Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study

Abstract

ObjectivesAn increasing number of octogenarians are referred to undergo mitral valve surgery for degenerative disease, and percutaneous approaches are being increasingly used in this subgroup of patients. We sought to determine the survival and its predictors after Mitral Valve Surgery in Octogenarians (MiSO) in a multicenter UK study of high-volume specialized centers.MethodsPooled data from 3 centers were collected retrospectively. To identify the predictors of short-term composite outcome of 30 days mortality, acute kidney injury, and cerebrovascular accident, a multivariable logistic regression model was developed. Multiple Cox regression analysis was performed for late mortality. Kaplan–Meier curves were generated for long-term survival in various subsets of patients. Receiver operating characteristic analysis was done to determine the predictive power of the logistic European System for Cardiac Operative Risk Evaluation.ResultsA total of 247 patients were included in the study. The median follow-up was 2.9 years (minimum 0, maximum 14 years). A total of 150 patients (60.7%) underwent mitral valve repair, and 97 patients (39.3%) underwent mitral valve replacement. Apart from redo cardiac surgery (mitral valve repair 6 [4%] vs mitral valve replacement 11 [11.3%], P = .04) and preoperative atrial fibrillation (mitral valve repair 79 [52.6%] vs mitral valve replacement 34 [35.1%], P < .01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was lower in the mitral valve repair group (10.2 ± 11.8 vs 13.7 ± 15.2 in mitral valve replacement; P = .07). No difference was found between groups for duration of cardiopulmonary bypass and aortic crossclamp times. The 30-day mortality for the whole cohort was 13.8% (mitral valve repair 4.7% vs mitral valve replacement 18.6%; P < .01). No differences were found in terms of postoperative cerebrovascular accident (2% vs 3.1%; P = .9), acute kidney injury requiring dialysis (6.7% vs 13.4%; P = .12), and superficial or deep sternal wound infection (10% vs 16.5%, P = .17; 2% vs 3.1%, P = .67, respectively). The final multiple regression model for short-term composite outcome included previous cardiac surgery (odds ratio [OR], 4.47; 95% confidence interval [CI], 1.37-17.46; P = .02), intra-aortic balloon pump use (OR, 4.77; 95% CI, 1.67-15.79; P < .01), and mitral valve replacement (OR, 7.7; 95% CI, 4.04-14.9; P < .01). Overall survival for the entire cohort at 1, 5, and 10 years was 82.4%, 63.7%, and 45.5% (mitral valve repair vs mitral valve replacement: 89.9% vs 70.7% at 1 year, 69.6% vs 54% at 5 years, and 51.8% vs 35.5% at 10 years; P = .0005). Cox proportional hazard model results showed mitral valve replacement (hazard ratio, 1.88; 95% CI, 1.22-2.89; P < .01) and intra-aortic balloon pump use (hazard ratio, 2.54; 95% CI, 1.26-5.13; P < .01) to be independent predictor factors affecting long-term survival. Logisti...

Surgical Treatment of Degenerative Mitral Valve Regurgitation in the Elderly: Comparison of Early and Long-Term Outcomes Using Propensity Score Matching Analysis

“…After propensity score matching, the preoperative demographic data were similar between the 2 groups. Despite the concerns that have been raised in this regard, CPB and ACC times were not significantly longer in the MV repair group before or after propensity score matching, which is similar to previous studies [3–6]. The CPB and ACC times (199±76.5 minutes and 127±50.9 minutes, respectively) were markedly longer than those reported in previous studies [3–8].…”

“…However, the feasibility and efficacy of MV repair in the elderly population is still debated. Although some retrospective observational studies and meta-analyses have suggested that MV repair might have favorable results in early and long-term outcomes even in the elderly population [3–10], data obtained from administrative American databases showed a low rate of MV repair (<50%) in those older than 65 years [13,14]. Some operators, especially young surgeons, still considered older patients to be poor surgical candidates for MV repair for multiple reasons: (1) MV repair requires longer CPB and ischemic times, which can affect early and long-term clinical outcomes; (2) elderly patients tend to have a more friable or calcified leaflet and annulus, making repair technically more difficult, increasing the possibility of failure and reoperation; and (3) the shorter life expectancy of elderly patients may decrease the benefit of MV repair over MV replacement [5,8,9,15].…”

“…Current European and American guidelines recommend mitral valve (MV) repair as the treatment of choice for primary degenerative mitral regurgitation (MR) in the general population [1,2]. However, controversy exists regarding whether MV repair provides the same advantages as MV replacement in terms of operative mortality, long-term survival, and valve-related complications in the elderly population [3–10]. The aim of this study was to compare the early and long-term clinical outcomes of MV repair and MV replacement in elderly patients.…”

Learning curve predictors for minimally invasive mitral valve surgery; how far should the rabbit hole go?

“…[5][6][7] A high logistic Euroscore II (LES) resulted in a higher incidence of postoperative complications. 8,9 Furthermore, the actual clinical retrospective studies assess only the learning curve without considering the impact of a high BMI and LES in the learning curve. [10][11][12][13][14][15] While the increased demand for MIMVS leads surgeons to venture in minimally invasive programs, there are still controversies regarding the appropriate timing to introduce high-risk patients in their clinical practice.…”

Conventional mitral surgery in octogenarians: The “μισο” study against skepticism

“…1 However, there are some operative factors that could have contributed to overbalance the results in favor of MVr in the study by Chivasso and colleagues. 2 For example, it is unknown if the mitral valve apparatus was spared during surgery and not clear why 18 patients received a small-sized prosthesis (23 and 25 mm).…”