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Ann Thorac Surg 2009;87:521-525. doi:10.1016/j.athoracsur.2008.09.030
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Redo Valvular Surgery in Elderly Patients

Manjula Maganti, MS, Vivek Rao, MD, PhD*, Susan Armstrong, Christopher M. Feindel, MD, Hugh E. Scully, MD, Tirone E. David, MD

Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital and the Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Accepted for publication September 11, 2008.

* Address correspondence to Dr Rao, Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General Hospital, 4N-464, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada (Email: vivek.rao{at}uhn.on.ca).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery.

Methods: A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 ± 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 ± 4 years and was 100% complete.

Results: Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% ± 5%. The freedom from valve-related mortality and morbidity was 86% ± 4% at 5 years. Mean intensive care eunit stay was 3.7 ± 4.5 days, and postoperative hospital stay was 15 ± 12 days.

Conclusions: Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The advent of minimally invasive and transcatheter valvular therapies has resulted in a reevaluation of the risks associated with conventional cardiac surgery [1]. Previous cardiac surgical intervention is often cited as the predominant reason why patients are referred for alternative therapies, particularly in the elderly population [2–7]. Various risk stratification scores have been developed to aid the clinician in decision-making and help the patient choose between conventional surgery and novel therapies. We reviewed our own institution's experience with redo valvular surgery in an elderly cohort to determine the risks of surgery in a contemporary, albeit highly selected, patient population.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
This study received approval from our institutional research ethics board to review patient-related data and to contact patients for follow-up assessments. A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 ± 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 ± 4 years and was 100% complete. Table 1 shows the clinical profile of patients. Table 2 provides the details of previous operations. Table 3 contains all the operative data.


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  		Table 1 Clinical Profile of Patients
 

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  		Table 2 Details of Previous Surgery
 

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  		Table 3 Details of Most Recent Surgery and Valve Disease Pathology
 
Conduct of surgery has been described previously in detail [7–9]. In general, most patients underwent redo median sternotomy and establishment of cardiopulmonary bypass by means of the ascending aorta and right atrium. The operative details are presented in Table 4. Cardioplegic arrest was achieved with either antegrade, retrograde, or combined cold-blood cardioplegia.


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  		Table 4 Operative Data
 
In patients receiving mechanical prostheses, intravenous heparin was instituted on the first postoperative day and continued until oral anticoagulation with warfarin achieved an international normalized ratio greater than 2. Similarly, all patients receiving a mitral prosthesis (tissue or mechanical) were routinely anticoagulated for a minimum of 3 months.

All statistical analyses were conducted with SAS 9.1 software (SAS Institute, Cary, NC). Categorical variables were analyzed using {chi}2 test and are expressed as percentages. Continuous variables were analyzed by Student's t test or nonparametric Wilcoxon rank-sum test and are reported as mean ± standard deviation. The Kaplan–Meier method was used to calculate estimates for long-term survival and event-free survival. All preoperative variables with a univariate probability value of less than 0.25 or those with known biologic significance but failing to meet this critical {alpha} level were submitted to the multivariable model for Cox regression analysis to determine the independent multivariable predictors of operative and late death.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
At their most recent operation, 112 patients underwent 155 valve procedures. Among the 155 valve procedures, 25 were valve repairs and 130 were valve replacements with implantation of 115 biologic valves and 15 mechanical valves. At previous operation, 124 valve procedures were done on 112 patients. Among the 124 valve procedures, 29 were valve repairs and 87 were valve replacements, which comprised 70 biologic valves and 17 mechanical valves. We are not able to find previous surgical information on 8 redo valve procedures. The clinical profile of patients who underwent reoperation is listed in Table 1.

Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant CABG at the time of their initial valve surgery. Further details of previous surgery are provided in Table 2.

At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (30%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (30%) required concomitant CABG, among which 14 patients had a previous CABG. Details of the most recent surgery and valve pathologic disease are listed in Table 3.

The operative mortality was 10.7% (12 patients). Operative mortality is defined as any death occurred within 90 days of surgery. The causes of operative mortality were multiorgan failure in 4 patients, myocardial failure in 2, postoperative hemorrhage in 1, heart failure in 2, arrest in 1, intracranial bleed in 1, and diaphragm bleed in 1. There were 2 deaths in 40 patients (5%) who underwent isolated aortic valve redo surgery, 2 deaths in 34 patients (5.8%) who underwent isolated mitral valve redo surgery, 4 deaths in 33 patients (12.1%) who underwent double valve redo surgery, and 2 deaths in 5 patients (40%) who underwent triple valve redo surgery. Early postoperative complications included reexploration for bleeding in 15 patients (5 died), stroke in 4 (2 died), low cardiac output syndrome in 16 (6 died), and insertion of permanent pacemaker in 19 patients. Duration of cardiopulmonary bypass time, aortic cross-clamp time, hours on ventilator, intensive care unit hours, and length of hospital stay in days are detailed in Table 4.

During the first year of follow-up, there were 3 additional deaths with a 1-year mortality rate of 13.4% (15 patients). At the most recent follow-up, there were a total of 59 deaths including the 12 operative deaths and 9 additional valve-related deaths, 21 cardiac-related deaths, and 17 of other causes. The survival at 2 and 5 years was 84% ± 4% and 67% ± 5%, respectively. Figure 1 shows the Kaplan–Meier estimates of survival in all patients. Peripheral vascular disease (hazard ratio, 3.6; 95% confidence interval, 1.5 to 8.4), left ventricular ejection fraction less than 0.40 (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.5), chronic obstructive pulmonary disease (hazard ratio, 2.8; 95% confidence interval, 1.2 to 6.3), and length of cardiopulmonary bypass time (hazard ratio, 1.01; 95% confidence interval, 1.003 to 1.015) were associated with increased mortality by multivariable Cox regression analysis.


Figure 1
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  		Fig 1. Kaplan–Meier estimates of survival.

 
Two patients had reoperations owing to paravalvular leak and survived reoperation. Three patients experienced subacute bacterial endocarditis and died. Six patients had major anticoagulant-related hemorrhagic complications and 5 died. Seven patients had thromboembolic complications and 5 died. The event-free survival at 2 and 5 years was 89% ± 3% and 66% ± 5%, respectively. Figure 2 shows the Kaplan–Meier estimates of event-free survival in all patients. Forty-nine patients (44%) were free from any valve-related morbidity.


Figure 2
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  		Fig 2. Freedom from event-free survival.

 
At recent follow-up, 53 patients were alive, and New York Heart Association functional class information was available on 51 patients; 20 were in New York Heart Association functional class I, 10 were in class II, 20 were in class III, and 1 was in class IV.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
An abundance of literature is available on primary valve surgery in the elderly population [2–7]. Similarly, many studies have examined outcomes of heart valve reoperations in a relatively younger patient group [10–12]. Although a few studies have exclusively investigated the outcomes of valve reoperations on octogenarians, the sample size was often less than 100 patients [13–15]. Thus the present study was undertaken with the aim of evaluating early and midterm outcomes after reoperative heart valve surgery in an elderly population older than the age of 75. Previous studies evaluating patients undergoing heart valve reoperations represented a heterogeneous group. They vary in terms of their previous valve surgery and preoperative risk factors. In the present series, all patients had previous intervention on the same valve of interest at reoperation.

Operative mortality in octogenarians undergoing valvular reoperations is reported to range from 13% to 32% [13, 15, 16]. Similarly, age older than 75 has been identified as an independent risk factor for early mortality in a large cohort of patients undergoing either aortic or mitral surgery for the first time [8, 17–20]. Also, operative mortality at valve reoperation is higher than at primary valve surgery [17], as reoperations are technically more demanding compared with primary surgery. Furthermore, prosthetic valve dysfunction or recurrent endocarditis can often lead to multiple valvular procedures in a single patient. In this series 55 patients were undergoing their third cardiac procedure, and 6 patients were undergoing a fourth cardiac procedure. Although the technical difficulties of valvular reoperations has been well described, it is also generally accepted that when complications do occur, they are less well tolerated in the elderly [11–13].

Our operative mortality for valve reoperations in this elderly series was 10.7%. Our results are similar to the outcomes published by Akins and associates (7.3%; [21]), Jones and coworkers (8.6%; [12]), Tyers and colleagues (11%; [22]), and Cohn and coworkers (10.1%; [23]) on valve reoperations in relatively younger patient populations. Also our operative mortality rates are comparable to the mortality rates reported on primary valve surgery in elderly patients: Milano and colleagues (7.6%; [3]), Urso and associates (8%; [4]), Bossone and colleagues (9.7%; [6]), and Kolh and coworkers (13%; [5]).

Owing to the relatively small sample size and few events, there were no preoperative predictors of operative mortality. However, we assume that the predictors of mortality in the elderly population are similar to those reported by our group in a larger, more generalized population [8].

We have also noticed that the 30-day operative mortality of the study group (8.9%) is not significantly different compared with the 30-day operative mortality of redo valve patients who are younger than 75 years (6.7%) or patients older than 75 years and undergoing primary valve surgery (5.4%) at our institution (Fig 3). Similarly, no significant difference in intensive care unit length of stay was noticed among the three groups. This observation is notable, especially in the age of increased efforts to limit health-care expenditure. However, hospital length of stay for the study group was significantly longer by 2 days compared with the other two groups mentioned above (Fig 4).


Figure 3
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  		Fig 3. Hospital mortality.

 

Figure 4
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  		Fig 4. Mean length of stay in the intensive care unit and the hospital.

 
Peripheral vascular disease, poor left ventricular ejection fraction, chronic obstructive pulmonary disease, and length of cardiopulmonary bypass time significantly predicted late mortality. Left ventricular dysfunction was reported as a predictor of late deaths in reports published by Luciani and associates [10]. The unfavorable effect of length of cardiopulmonary bypass time on late deaths was also noticed in the findings of Milano and coworkers [3] in elderly patients who underwent aortic valve surgery. Likely, intraoperative technical factors influenced cardiopulmonary bypass time and may have also influenced intraoperative decisions such as the perceived need to construct an additional bypass graft or to enlarge an aortic root. It is conceivable that these inherent biases during an already complicated operation may have had a detrimental effect on long-term survival.

Our study is limited by the fact that it is retrospective in nature and reflects the experience of a single institution. However, our very recent experience with percutaneous valve replacement in a largely elderly population has demonstrated similar perioperative mortality and morbidity (unpublished data). In the series reported by Eitchaninoff and colleagues [24] of 36 patients followed to 3 years, there were 6 procedure-related deaths (17%) and 10 overall deaths within 6 months (28%), yielding a 2-year survival of 72%, which is less than our survival rate of 84%. Although we concede that the present series of patients were highly selected, they all required reintervention on a valve previously repaired or replaced. The individual selection criteria varied among the surgeons, but clearly the presence of significant comorbidities influenced the decision to offer surgery. The advent of percutaneous technologies to replace degenerative prostheses (valve in a valve replacement) has underscored the need to understand the contemporary results of conventional surgery in this high-risk population [25]. Our results would suggest that advanced age and the need for reoperation in and of itself is not a contraindication to conventional surgical intervention.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Lichtenstein SV, Cheung A, Ye J, et al. Transapical transcatheter aortic valve implantation in humans: initial clinical experience Circulation 2006;114:591-596.[Abstract/Free Full Text]
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  3. Milano A, Guglielmi C, De Carlo M, et al. Valve-related complications in elderly patients with biological and mechanical aortic valves Ann Thorac Surg 1998;66(6 Suppl):S82-S87.[Medline]
  4. Urso S, Sadaba R, Greco E, et al. One-hundred aortic valve replacements in octogenarians: outcomes and risk factors for early mortality J Heart Valve Dis 2007;16:139-144.[Medline]
  5. Kolh P, Kerzmann A, Honore C, Comte L, Limet R. Aortic valve surgery in octogenarians: predictive factors for operative and long-term results Eur J Cardiothorac Surg 2007;31:600-606Epub 2007 Feb 20.[Abstract/Free Full Text]
  6. Bossone E, Di Benedetto G, Frigiola A, et al. Valve surgery in octogenarians: in-hospital and long-term outcomes Can J Cardiol 2007;23:223-227.[Medline]
  7. Chukwuemeka A, Borger MA, Ivanov J, Armstrong S, Feindel CM, David TE. Valve surgery in octogenarians: a safe option with good medium-term results J Heart Valve Dis 2006;15:191-196.[Medline]
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  10. Luciani N, Nasso G, Anselmi A, et al. Repeat valvular operations: bench optimization of conventional surgery Ann Thorac Surg 2006;81:1279-1283.[Abstract/Free Full Text]
  11. Lytle BW, Cosgrove DM, Taylor PC, et al. Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958–1984 Ann Thorac Surg 1986;42:632-643.[Abstract/Free Full Text]
  12. Jones JM, O'Kane H, Gladstone DJ, et al. Repeat heart valve surgery: risk factors for operative mortality J Thorac Cardiovasc Surg 2001;122:913-918.[Abstract/Free Full Text]
  13. Kirsch M, Nakashima K, Kubota S, Hotel R, Hillion ML, Loisance D. The risk of reoperative heart valve procedures in octogenarian patients J Heart Valve Dis 2004;13:991-996.[Medline]
  14. Ghosh P, Holthouse D, Carroll I, Larbalestier R, Edwards M. Cardiac reoperations in octogenarians Eur J Cardiothorac Surg 1999;15:809-815.[Abstract/Free Full Text]
  15. Blanche C, Khan SS, Chaux A, et al. Cardiac reoperations in octogenarians: analysis of outcomes Ann Thorac Surg 1999;67:93-98.[Abstract/Free Full Text]
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  17. Bridges CR, Edwards FH, Peterson ED, Coombs LP, Ferguson TB. Cardiac surgery in nonagenarians and centenarians J Am Coll Surg 2003;197:347-357.[Medline]
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