Combined Valve and Coronary Artery Bypass Procedures in Septuagenarians and Octogenarians: Results in 120 Patients

doi:10.1016/S0003-4975(10)64608-5

The Annals of Thoracic Surgery

Volume 42, Issue 6, December 1986, Pages 681-684

https://doi.org/10.1016/S0003-4975(10)64608-5 Get rights and content

Abstract

A consecutive series of 96 septuagenarians (mean age, 74) and 24 octogenarians (mean age, 83) underwent coronary artery bypass (CAB) and valve operations using hypothermia and hyperkalemic cardioplegia in a 45-month period; there was a mean of 2.6 grafts per patient. Most patients were in New York Heart Association (NYHA) class IV (57% of the septuagenarians and 88% of the octogenarians) preoperatively. The early deaths were 19% for septuagenarians and 37% for octogenarians; late deaths were 9% and 6%, respectively, after a mean of 25 months. Of 92 survivors, 78% of the septuagenarians and 87% of the octogenarians improved by one or more NYHA class postoperatively. Of 58 patients with combined CAB and aortic valve replacement, 12 (21%) died; of 38 with combined CAB and mitral valve replacement 19 (50%) died; 2 of 9 (22%) with combined CAB and double valve replacement died; and 2 of 11 (18%) with CAB and MV repair died. In comparison, of patients with isolated valve replacement in the same period, 2 of 30 (7%) in the AVR group died, 5 of 17 (29%) died in the MVR group, 2 of 7 (33%) in the DVR group died.

The risk of combined valve procedures and bypass surgery was significantly increased in the elderly and may warrant a less aggressive procedure, especially in the mitral position.

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Cited by (59)

Surgical repair for acute type a aortic dissection in octogenarians
2015, Annals of Thoracic Surgery
Citation Excerpt :
The population in the United States will include more than 25 million people older than 80 years in 2050 [16]. That increased age is associated with adverse outcome after cardiovascular interventions [17–19], including operations for AAD, is common sense and has been demonstrated in various publications [20–22]. With no doubt AAD is one of the most lethal emergencies in cardiovascular surgery, especially in the elderly.
Despite limited data, the necessity for immediate surgical intervention in octogenarians with acute type A aortic dissection (AAD) has recently been questioned because the surgical risk may outweigh its potential benefits. At the same time, evolving stent graft technologies are pushing in the market for pathology within the ascending aorta, even for treatment of AAD. Against this background, we analyzed our institutional experience in this patient cohort during the last 8 years.
Between October 2005 and October 2013, 39 patients aged older than 80 years (82 ± 2 years) underwent surgical repair for AAD, of which 29 patients (74%) were men. Owing to patient age and comorbidities, we aimed to limit the operation to supracoronary hemiarch replacement whenever possible. Clinical data were prospectively entered into our institutional database. Late follow-up was 3.6 ± 2.8 years and was 100% complete.
Hemiarch replacement was performed in 32 patients (82%), and full arch replacement was necessary in the remaining 7. In 31 patients (79%), the aortic root could be glued and reconstructed or remained untouched. The remaining 8 patients (21%) underwent the bio-Bentall procedure. Mean ventilation time was 46 ± 23 hours, and the intensive care unit stay was 5 ± 9 days. We observed new postoperative permanent neurologic deficits in 2 patients (5%) and transient neurologic deficits in 3 (8%). The 30-day mortality was 26% (n = 10). Kaplan-Meier estimates for late survival were 46% ± 16% at 5 years.
Given the guidelines regarding the predicted risk of death in patients with untreated AAD, current data suggest a survival benefit with immediate open surgical intervention even in octogenarians. Similarly to the early days of transcatheter-based aortic valve implantation, open surgical reference data are warranted to set the bar for upcoming endovascular treatment of AAD in octogenarians.
Aortic wrapping for stanford type a acute aortic dissection: Short and midterm outcome
2014, Annals of Thoracic Surgery
Conventional surgical treatment of Stanford type A acute aortic dissection (AAD) is associated with considerable in-hospital mortality. As regards very elderly or high-risk patients with type A AAD, some may meet the criteria for less invasive surgery likely to prevent the complications associated with aortic replacement.
We have retrospectively analyzed a cohort of patients admitted to our center for Stanford type A AAD and having undergone surgery between 2008 and 2012. The outcomes of the patients having had an aortic replacement under cardiopulmonary bypass (group A) have been compared with the outcomes of the patients who underwent off-pump wrapping of the ascending aorta (group B).
Among the 54 patients admitted for Stanford type A AAD, 15 with a mean age of 77 years [46 to 94] underwent wrapping of the aorta. Regarding the new standard European system for cardiac operative risk evaluation (EuroSCORE II), the median result in our group B patients was 10.47 [5.02 to 30.07]. In-hospital mortality was 12.80% in group A and 6.6% in group B (p = 0.66). For patients who underwent external wrapping of the ascending aorta, follow-up mortality rate was 13.3% with a median follow-up of 15 months [range 0 to 47].
The gold standard in cases of Stanford type A AAD consists of emergency surgical replacement of the dissected ascending aorta. In some cases in which the aortic root is not affected a less invasive surgical approach consisting of wrapping the dissected ascending aorta can be suggested as an alternative.
Role of age in acute type A aortic dissection outcome: Report from the International Registry of Acute Aortic Dissection (IRAD)
2010, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
IRAD confirmed that AAD is more common during the seventh and eighth decades, although the condition is not uncommon during the fifth and sixth decades. Previous studies, as well as reports of IRAD, have shown that increased age is associated with increased short- and long-term mortality rates after cardiovascular interventions,7-10 including AAD surgery.11,12,14 In this report, we confirmed that increased age is an independent predictor of in-hospital mortality, and we further investigated outcomes of patients with AAD after surgical and medical management in different age groups.
The increasing life expectancy of the population will likely be accompanied by a rise in the incidence of acute type A aortic dissection. However, because of an increased risk of cardiac surgery in an elderly population, it is important to define when, if at all, the risks of aortic repair outweigh the risk of death from unoperated type A aortic dissection.
We analyzed 936 patients with type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection from 1996 to 2004. Patients with type A aortic dissection were categorized according to patient age by decade and by surgical versus medical management, and outcomes of both management types were investigated in the different age groups.
The rate of surgical aortic repair decreased progressively with age, whereas surgical mortality significantly increased with age. Age 70 years or more was an independent predictor for mortality (38.2% vs 26.0%; P < .0001, odds ratio 1.73). The in-hospital mortality rate was significantly lower after surgical management compared with medical management until the age of 80 years. For patients aged 80 to 90 years, the in-hospital mortality appeared to be lower after surgical management (37.9% vs 55.2%; P = .188); however, this failed to reach clinical significance owing to the limited patient number in this age group.
Although the surgical mortality significantly increased with increased age, surgical management was still associated with significantly lower in-hospital mortality rates compared with medical management until the age of 80 years. Surgery may decrease the in-hospital mortality rate for octogenarians with type A aortic dissection and might be considered in all patients with type A aortic dissection regardless of age.
Discussion
2010, Annals of Thoracic Surgery
Citation Excerpt :
In the past, many elderly patients have been denied cardiac surgery on the basis of perceived risk of poor outcomes. Although elderly patients have more medical comorbidities and often tolerate complications poorly owing to limited functional reserve, recent studies have shown both good short-term and long-term outcomes after cardiac surgery in the elderly [3–15]. The present study focused on the outcomes of elderly patients undergoing reoperative isolated valve surgery.
Elderly patients requiring reoperative cardiac surgery for valve disease are considered high risk for immediate outcomes, but little is known about their long-term survival. It is often conjectured that medical therapy provides equivalent late survival in this population, which may dissuade both patient and surgeon from considering reoperation. We analyzed a cohort of such patients undergoing reoperative valve surgery to determine their long-term survival.
From 1992 through 2007, 363 patients aged 75 years or more underwent reoperative isolated valve surgery; 211 (58%) had aortic valve replacement and 152 (42%) had mitral valve surgery. Mean age was 80.5 years. Hospital outcomes were prospectively recorded. Survival from all-cause death was determined from the Social Security Death Index.
Hospital mortality was 13.8% (12.8% for aortic and 15.1% for mitral valve operations; p = 0.52). Multivariable predictors of hospital death were New York Heart Association functional class III or IV heart failure (odds ratio = 3.19, p = 0.012), dialysis (odds ratio = 15.63, p = 0.003), and more than one reoperation (odds ratio = 2.59, p = 0.058). At 5 years, overall survival was 62% ± 3% for all patients (66% ± 4% for aortic and 56% ± 4% for mitral valve patients). For aortic valve patients aged 80 years or more, 5-year survival was 60% ± 0.6%. Life expectancy table analysis predicted a 5-year survival of 57% for an age-matched and sex-matched comparison group.
Reoperative surgery for elderly patients with isolated aortic or mitral valve pathology is associated with excellent long-term survival, particularly when treating aortic valve disease. While in-hospital mortality is higher among the elderly than among younger patients, specific predictors of poor outcome can be identified preoperatively to risk stratify these patients.
Reoperative valve surgery in the elderly: Predictors of risk and long-term survival
2010, Annals of Thoracic Surgery
Citation Excerpt :
In the past, many elderly patients have been denied cardiac surgery on the basis of perceived risk of poor outcomes. Although elderly patients have more medical comorbidities and often tolerate complications poorly owing to limited functional reserve, recent studies have shown both good short-term and long-term outcomes after cardiac surgery in the elderly [3–15]. The present study focused on the outcomes of elderly patients undergoing reoperative isolated valve surgery.
Elderly patients requiring reoperative cardiac surgery for valve disease are considered high risk for immediate outcomes, but little is known about their long-term survival. It is often conjectured that medical therapy provides equivalent late survival in this population, which may dissuade both patient and surgeon from considering reoperation. We analyzed a cohort of such patients undergoing reoperative valve surgery to determine their long-term survival.
From 1992 through 2007, 363 patients aged 75 years or more underwent reoperative isolated valve surgery; 211 (58%) had aortic valve replacement and 152 (42%) had mitral valve surgery. Mean age was 80.5 years. Hospital outcomes were prospectively recorded. Survival from all-cause death was determined from the Social Security Death Index.
Hospital mortality was 13.8% (12.8% for aortic and 15.1% for mitral valve operations; p = 0.52). Multivariable predictors of hospital death were New York Heart Association functional class III or IV heart failure (odds ratio = 3.19, p = 0.012), dialysis (odds ratio = 15.63, p = 0.003), and more than one reoperation (odds ratio = 2.59, p = 0.058). At 5 years, overall survival was 62% ± 3% for all patients (66% ± 4% for aortic and 56% ± 4% for mitral valve patients). For aortic valve patients aged 80 years or more, 5-year survival was 60% ± 0.6%. Life expectancy table analysis predicted a 5-year survival of 57% for an age-matched and sex-matched comparison group.
Reoperative surgery for elderly patients with isolated aortic or mitral valve pathology is associated with excellent long-term survival, particularly when treating aortic valve disease. While in-hospital mortality is higher among the elderly than among younger patients, specific predictors of poor outcome can be identified preoperatively to risk stratify these patients.
Valve Structure and Survival in Septuagenarians Having Aortic Valve Replacement for Aortic Stenosis (±Aortic Regurgitation) With Versus Without Coronary Artery Bypass Grafting at a Single US Medical Center (1993 to 2005)
2007, American Journal of Cardiology
The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in septuagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed valve structure in 424 septuagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 254 (60%) with and 170 (40%) without simultaneous CABG. Of the 424 patients, 8 (2%) had a congenitally unicuspid aortic valve, 179 (42%), a congenitally bicuspid aortic valve, 235 (55%), a 3-cuspid valve, and in 2 patients (1%) the valve structure was indeterminate. Survival data were available in 418 of the 424 patients: 23 (5.5%) died within 30 days of AVR and 9 other patients from 31 to 60 days after AVR (7.7% 60-day mortality). Sixty-day mortality was not affected by congenital valve abnormality (unicuspid/bicuspid 8.5% vs tricuspid 7.0%). In contrast, late survival (up to 13-year follow-up) was affected by valve structure: it was longer in the unicuspid/bicuspid valve structure group than in the tricuspid valve structure (hazard ratio 0.54, 95% confidence intervals 0.36 to 0.81). The hazard ratio was estimated after adjusting for concomitant CABG. In conclusion, aortic valve structure affected late, but not early survival in septuagenarians undergoing AVR for AS.

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Combined Valve and Coronary Artery Bypass Procedures in Septuagenarians and Octogenarians: Results in 120 Patients

Abstract

Ann Thorac Surg

Am J Cardiol

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Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

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J Am Coll Cardiol