Revista argentina de cardiología
versión On-line ISSN 1850-3748
PICCININI, Fernando et al. Aortic Valve Replacement in Octogenarian Patients: Evaluation, Operative Risk and Mid-Term Outcomes. Rev. argent. cardiol. [online]. 2010, vol.78, n.6, pp. 476-484. ISSN 1850-3748.
Background The indications and benefits of aortic valve replacement have been clearly established, even for elderly populations with high prevalence of comorbidities. However, concern arises about the indication of aortic valve replacement in this population due to manipulation of aortic atheromas, use of cardiopulmonary bypass and cross clamping of the aorta, cardiac arrest and decalcification that are related with this procedure, and their eventual consequences. Objectives To report morbidity and mortality of the procedure in octogenarians and validate the usefulness of the risk scores most frequently used. Material and Methods A total of 87 octogenarian patients undergoing isolated aortic valve replacement were included; preoperative, operative and postoperative variables were analyzed, and EuroSCORE was estimated; the population was divided into three groups of risk (low, moderate and high) for logistic EuroSCORE analysis. A conventional surgical technique was used. The medical records were analyzed and/or telephone contact was used for follow-up. Results Median age was 83±2.5 years (range: 80 to 89). Sixty percent of the population were women. Indications for aortic valve replacement were aortic stenosis 92%, active endocarditis 4.6% and combined aortic valve disease 3.4%. History: hypertension 71%, smoking habits 31%, dyslipemia 39%, diabetes 11.5%, COPD 10%, CKF-dialysis 2.3%, stroke 11.5%, previous MI 8%, atrial fibrillation 16%, reoperation 15%. Clinical presentation: absence of symptoms 3.45%, chronic stable angina 10.3%, unstable angina 11%, CHF 13.8%, dyspnea FC III-IV 60%, moderate to severe left ventricular dysfunction 18.3%, logistic EuroSCORE risk 12.4%±15%. Average operative time was 200±61.7 min, CBP time 86±32.5 min and aortic-cross clamp time 65±18.2 min. Complications: medical bleeding 17.2%, reoperation due to bleeding 5.7%, low cardiac output syndrome 13.8%, requirement of inotropic agents > 48 hours 32.1%, intraaortic balloon pump 1.2%, atrial fibrillation 32.2%, transient pacemaker 20.7%, permanent pacemaker 5.7%, pulmonary complications 3.4%, stroke with consequences 3.4%, oliguric/anuric AKF 27.6%, dialysis 5.7%, sternum infection 1.2%, ICU stay 3±5.2 days, hospital stay 8±9.6 days, overall mortality 10.34%, elective surgery mortality 9.5%, non elective surgery mortality 12.5%. Mortality in low, moderate and high risk groups was l7.14%, 15.38% and 5%, respectively. Postoperative low cardiac output syndrome was identified as a predictor of mortality at 30 days (OR 7, p=0.011). Seventy one patients (91%) completed median follow-up of 1023 days (51 to 3927). Survival rate was 98.6% at 1 year, 87.65% at 3 years, 77.3% at 5 years and 48.6% at 7 years, regardless of the preoperative score. Quality of life improved in 72% of patients, while 21% did not report any changes and was worse in 7%. We did not find predictors during follow-up. Conclusions Aortic valve replacement is a safe, long-lasting procedure that confers proved functional benefit and a long-tem survival that is comparable to that of the general population. The use of preoperative scores should undergo revision as they overestimate the operative risk.
Palabras llave : Aortic Valve Stenosis; Elderly; Chest Surgery; Aortic Valve; Heart Valve Prosthesis.