Impact of New York Heart Association classification, advanced age and patient-prosthesis mismatch on outcomes in aortic valve replacement surgery

Abstract

OBJECTIVES More elderly patients (>80 years of age) are being referred for aortic valve replacement (AVR) with or without CABG. Current risk stratification models may not accurately predict the preoperative risk in these patients. We sought to determine which perioperative variables were relevant in determining short-term (30-day to in-hospital) outcomes in our intuition's series of consecutive AVR and AVR+CABG surgeries. We constructed a novel variable, patient-prosthesis mismatch (PPM) in the presence of diminished functional status (NYHA) classification, and studied its role as a predictor of mortality risk. METHODS From 2006 to 2010, 509 patients undergoing AVR or AVR+CABG were evaluated. We created four groups based on the age and procedure (AVR >80, AVR+CABG >80, AVR <80 and AVR+CABG <80). PPM was defined as a calculated effective orifice area index value of ≤ 0.85, and it was calculated from manufacturer-generated charts. In-hospital and 30-day outcomes were assessed using the Chi-square and logistic regression analyses. RESULTS Overall observed 30-day mortality for all groups was lower (n = 8, 1.6%) than the STS-predicted mortality. Reoperation and PPM+NYHA class III-IV were associated with short-term mortality, but age >80 years was not. Octogenarians referred for surgery often had advanced heart failure. CONCLUSIONS Overall, short-term outcomes after AVR with or without CABG were excellent and lower than predicted by the STS model. The low risk of AVR with CABG supports the consideration for earlier surgical referral and intervention for patients with a high likelihood of aortic stenosis progression before the onset of advanced heart failure ensues, regardless of the age. This should help further decrease the already very low mortality observed in these series. Efforts to avoid PPM in the setting of advanced heart failure may improve short-term results in this subset of patients.

Octogenarian patients’ sleep and delirium experiences in hospital and four years after aortic valve replacement: a qualitative interview study

“…Since degenerative aortic stenosis is associated with ageing, the need for aortic valve replacement (AVR) is increasing. 1 Age is no longer a contraindication for AVR via surgical aortic valve replacement (SAVR) or transcutaneous aortic valve replacement (TAVI). 2 Introduction of new knowledge enabling minimally invasive aortic treatments has led to a paradigm shift in cardiac healthcare for the elderly.…”

Perioperative predictors of midterm survival after aortic valve replacement

“…10 Our recent study on short-term postoperative outcomes and survival further underscores the low rates of mortality and adverse outcomes associated with AVR. 11 These results suggest that not only is AVR safe and effective, even for the very elderly, but that patients can expect favorable outcomes several years after the procedure. Naturally, we sought to investigate the midterm outcomes and survival of our series of AVR patients.…”

“…Our previous study and others have shown that AVR is a safe and effective procedure that confers a better quality of life and survival in the short term compared to published data on nonsurgically managed AS patients. [4][5][6][7][8][9]11 The majority of our patients are elderly (>70 years old) and have numerous comorbidities. Thus it is important to examine how age and other factors influence midterm postsurgical outcomes.…”

CARDIAC SURGERY Trends in mechanical aortic valve replacement surgery in a large, multi-surgeon, single hospital practice

“…and Jamieson et al . reported that PPM was related to early mortality after aortic valve replacement [ 15 , 16 ]. Conversely to the decrease in aortic root enlargement operations, this study observed a trend to choose larger aortic valves: size 21 was the one most frequently used in 1999, whereas size 23 was preferred in 2008 ( p < 0.05, Table VI ).…”