Aortic valve replacement in geriatric patients: determinants of in-hospital mortality

Bloomstein, Larry Z; Gielchinsky, Isaac; Bernstein, Arthur; Parsonnet, Victor; Saunders, Craig R.; Karanam, Ravi; Graves, Bette

doi:10.1016/s0003-4975(00)02326-2

Cited by 91 publications

(51 citation statements)

References 10 publications

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“…Operative risk is increased in the setting of comorbidities such as advanced age and others. [23][24][25][26][27] In our patients, judged poor candidates for routine surgery with an estimated logistic Euroscore mortality of 35Ϯ26%, a 30-day mortality rate of 14% is encouraging.…”

Section: Discussionmentioning

confidence: 94%

Transapical Transcatheter Aortic Valve Implantation in Humans

et al. 2006

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Background-Aortic valve replacement with cardiopulmonary bypass is currently the treatment of choice for symptomatic aortic stenosis but carries a significant risk of morbidity and mortality, particularly in patients with comorbidities. Recently, percutaneous transfemoral aortic valve implantation has been proposed as a viable alternative in selected patients. We describe our experience with a new, minimally invasive, catheter-based approach to aortic valve implantation via left ventricular apical puncture without cardiopulmonary bypass or sternotomy. Methods and Results-A left anterolateral intercostal incision is used to expose the left ventricular apex. Direct needle puncture of the apex allows introduction of a hemostatic sheath into the left ventricle. The valve prosthesis, constructed from a stainless steel stent with an attached trileaflet equine pericardial valve, is crimped onto a valvuloplasty balloon. The prosthetic valve and balloon catheter are passed over a wire into the left ventricle. Positioning within the aortic annulus is confirmed by fluoroscopy, aortography, and echocardiography. Rapid ventricular pacing is used to reduce cardiac output while the balloon is inflated, deploying the prosthesis within the annulus. Transapical aortic valve implantation was successfully performed in 7 patients in whom surgical risk was deemed excessive because of comorbidities. Echocardiographic median aortic valve area increased from 0.7Ϯ0.1 cm 2 (interquartile range) to 1.8Ϯ0.8 cm 2 (interquartile range). There were no intraprocedural deaths. At a follow up of 87Ϯ56 days, 6 of 7 patients remain alive and well. Conclusions-This

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Section: Discussionmentioning

confidence: 94%

Transapical Transcatheter Aortic Valve Implantation in Humans

et al. 2006

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“…Operative risk is increased in the setting of comorbidities, such as advanced age. [22][23][24][25][26] A prior publication from our institution reported aortic valve surgery carried a risk of early mortality of 15.1% for patients 80 to 84 years of age and 17.8% for patients 85 years of age. 27 Mortality at 30 days in this initial percutaneous series of patients with a mean age of 82 years was 11%, which was favorable compared with the Logistic EuroSCORE-predicted surgical mortality rate of 26%.…”

Section: Alternative Therapiesmentioning

confidence: 99%

Percutaneous Aortic Valve Implantation Retrograde From the Femoral Artery

et al. 2006

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Background-Percutaneous aortic valve implantation by an antegrade transvenous approach has been described but is problematic. Retrograde prosthetic aortic valve implantation via the femoral artery has potential advantages. Percutaneous prosthetic aortic valve implantation via the femoral arterial approach is described and the initial experience reported. Methods and Results-The valve prosthesis is constructed from a stainless steel stent with an attached trileaflet equine pericardial valve and a fabric cuff. After routine aortic balloon valvuloplasty, a 22F or 24F sheath is advanced from the femoral artery to the aorta. A steerable, deflectable catheter facilitates manipulation of the prosthesis around the aortic arch and through the stenotic valve. Rapid ventricular pacing is used to reduce cardiac output while the delivery balloon is inflated to deploy the prosthesis within the annulus. Percutaneous aortic prosthetic valve implantation was attempted in 18 patients (aged 81Ϯ6 years) in whom surgical risk was deemed excessive because of comorbidities. Iliac arterial injury, seen in the first 2 patients, did not recur after improvement in screening and access site management. Implantation was successful in 14 patients. After successful implantation, the aortic valve area increased from 0.6Ϯ0.

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“…significant risk to the elderly with multiple medical problems, rendering these patients poor operative candidates. 4 Patients may also be nonsurgical candidates due to marked aortic calcification or previous cardiac surgery. in these individuals, percutaneous AV replacement may become an alternative in the management of aortic stenosis.…”

Section: Discussionmentioning

confidence: 99%

“…2 Surgical aortic valve (AV) replacement is effective in prolonging life and improving symptoms; however, the procedure can be associated with significant perioperative risk, especially in the elderly with decreased functional reserve and multiple co-morbidities. 3,4 Surgery may also carry an unacceptable risk due to extensive calcification of the ascending aorta. Whereas balloon valvuloplasty represents an alternative therapeutic option, the reduction in stenosis is modest and temporary.…”

Section: éLéments Cliniques : Une Fois Le Consentement Du Comité D'étmentioning

confidence: 99%

Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients

Ree

Bowering

Schwarz

2008

Can J Anesth/J Can Anesth

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Purpose: To describe both the evolution and the main associated complications in the anesthetic management of the initial 40 patients at our centre who underwent percutaneous retrograde aortic valve replacement, a novel technique utilizing a catheterguided femoral artery approach. Clinical features:With institutional Research Ethics Board approval, we retrospectively reviewed the medical records of the first 40 patients who underwent percutaneous retrograde aortic valve replacement between January 2005 and March 2006. Information obtained included patient characteristics, anesthetic management, details of the procedure, and complications. All procedures were scheduled to be performed in the cardiac catheterization laboratory. The first four patients received monitored anesthesia care, and the subsequent 36 underwent general anesthesia. There were no anesthesia-related adverse events. The prosthetic valve was placed successfully in 33/40 patients (83%). Median anesthetic time was 3.5 hr (range, 1.25-7.25 hr). Thirty-two/40 patients required vasopressor support. The most common, serious procedural complications were myocardial ischemia and arrhythmia following rapid ventricular pacing, hemorrhage from vascular injury secondary to the placement and removal of the large-bore sheath in the ilio-femoral artery, aortic rupture, and prosthetic valve maldeployment; 30-day mortality was 13% (n = 5/40). Conclusions:Percutaneous retrograde aortic valve replacement is a novel procedure that presents the anesthesiologist with unique challenges. Careful preoperative assessment, intraoperative monitoring appropriate for a major vascular procedure, and meticulous management of hemodynamics are imperative for a successful outcome. Serious complications, including major hemorrhage from vascular injury as well as arrhythmia and myocardial ischemia following rapid ventricular pacing, must be anticipated and managed in an expeditious fashion.

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Aortic valve replacement in geriatric patients: determinants of in-hospital mortality

Cited by 91 publications

References 10 publications

Transapical Transcatheter Aortic Valve Implantation in Humans

Transapical Transcatheter Aortic Valve Implantation in Humans

Percutaneous Aortic Valve Implantation Retrograde From the Femoral Artery

Case series: anesthesia for retrograde percutaneous aortic valve replacement — experience with the first 40 patients

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