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2891
Surgery for Aortic Stenosis in Elderly Patients
A Study of Surgical Risk and Predictive Factors
Y. Logeais, MD; T. Langanay, MD; R. Roussin, MD; A. Leguerrier, MD; C. Rioux, MD;
J. Chaperon, MD; C. de Place, MD; P. Mabo, MD; J.C. Pony, MD; J.C. Daubert, MD;
M. Laurent, MD; C. Almange, MD
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Background Aortic stenosis is the most common valvular
lesion occurring among elderly patients and has become
extremely frequent because of changing demographics in
industrialized countries. Surgical risk after the age of 70 has
increased. The increasing older age of patients having surgery
justifies an analysis of mortality predictive factors.
Methods and Results Between 1976 and February 1993, we
performed 2871 operations for aortic stenosis. This study
concerns 675 patients (278 men and 397 women) who were
275 years old. Mean age was 78.5 +3 years. Associated lesions
were found in 226 patients. A bioprosthesis was implanted in
632 patients (93.6%). Concomitant surgical procedures were
performed in 133 patients. Surgical mortality was 12.4% (84
deaths). A longitudinal analysis has been carried out over four
successive time periods to evaluate population evolution dur-
ing these 17 years. Statistical analysis was performed on 46
variables. Multivariate analysis found age (P<.0001), left
ventricular failure (P<.0001), lack of sinus rhythm (P<.01),
and emergency status (P<.02) to be presurgical independent
predictive factors of mortality.
Conclusions Risk-reducing strategy should both favor relatively early surgery to avoid cardiac failure and emergency
situations and pay careful attention to the use of myocardial
protection and cardiopulmonary bypass. Indications for surgery should remain broad since analysis failed to determine
specific high-risk groups to be eliminated, and surgery remains
the only treatment for aortic stenosis. (Circulation. 1994;90:
C hanging demographics in industrialized coun-
and analyzed by various programs. Multivariate analysis was
carried out with BMDP Statistical Software (BMDP Corp).
Cardiopulmonary bypass (CPB) was achieved using hemodilution (hematocrit from 22% to 27%) and moderate hypothermia (nasopharyngeal temperature at 28°C). Cold crystalloid
cardioplegia with single or multiple doses was carried out with
Bretschneider's solution. Cardioplegic solution was generally
administered via aortic access. Bioprostheses were implanted
in 93.6% of the patients (n=632).
Surgical mortality was defined as deaths occurring during
the first 30 postsurgical days or during hospitalization.
tries and the increasing incidence of aortic
stenosis (AS) in higher age groups'-3 are transforming this cardiopathy into an extremely frequent
lesion. Because it is generally recognized that surgical
risk increases with age,4-10 we analyzed our experience
to identify risk factors and select new criteria for better
indications and decreased risk.
Methods
All patients more than 75 years old who underwent surgery
for AS in our unit between August 1976, when this type of
surgery was begun in such elderly patients, and February 1993
were included in this study. There were no exclusion criteria
(concomitant diseases or surgical procedures). Among a total
of 2871 patients operated on for AS during this period, 675
(age range, 75 to 92 years) were included in this report,
representing 23.5% of all operations.
The 675 patients had been prospectively entered into a
computerized data base containing demographic data, functional class, associated diseases, hemodynamics, radiological
and echographic studies, and surgical and postsurgical data.
Data entered into Hewlett Packard 250 and then 260 and 9000
computers were extracted by QUERY HP language, transferred,
Received March 8, 1994; revision accepted July 27, 1994.
From the Clinic for Cardiovascular and Thoracic Surgery (Y.L.,
T.L., R.R., A.L., C.R.), Public Health Laboratory (J.C.), Division
of Cardiology A (C. de P., P.M., J.C.P., J.C.D.) and B (M.L.,
C.A.), University Hospital Center, Rennes, France.
Correspondence to Yves Logeais, MD, Clinic for Cardiovascular
and Thoracic Surgery, H6pital Pontchaillou, Rue Henri Le Guillou, 35000 Rennes, France.
© 1994 American Heart Association, Inc.
2891-2898.)
Key Words * aortic stenosis * valves * elderly mortality
Statistical Analysis
Continuous data are expressed as mean+SD and compared
using Student's t test and ANOVA. Qualitative variables are
expressed as a percentage and compared by x2 test and
Fisher's exact test.
All variables - before, during, and after surgery -were first
tested individually by univariate analysis. For continuous variables, critical threshold was determined by varying threshold
values. To evaluate independent factors of predictive mortality, 30 variables considered as significant by univariate analysis
were submitted to multivariate analysis and entered in a
step-by-step logistic regression analysis. A variable was evaluated as a significant independent factor when the P value
associated with X 2 improvement was <.05. Logistic regression
analysis concerned only preoperative variables. In a second
step, all preoperative, intraoperative, and postoperative data
were studied, retaining only preoperative factors previously
determined as significant and after proceeding to quantitative
criteria refining.
Preoperative Characteristics
Clinical preoperative data are listed in Table 1. Mean age
was 78.5 +±2.97 years, and female sex was predominant
2892
Circulation Vol 90, No 6 December 1994
TABLE 2. Preoperative Investigations
TABLE 1. Preoperative Clinical Data
No. of patients, %
Age, y
675 (100)
78.5±2.97
(range, 75 to 92)
278 (41.2)
397 (58.8)
200 (29.6)
18 (2.7)
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Male, n (%)
Female, n (%)
Systemic arterial hypertension, n (%)
Diabetes, n (%)
Associated diseases, n (%)
311
Total
226 (33.5)
No. of patients
75 (11.1)
Associated Al, n (%)
32 (4.7)
Associated mitral or tricuspid lesion, n (%)
52 (7.7)
Previous myocardial infarction, n (%)
NYHA class, mean±SD
2.82±0.67
38.4±51.7
Mean length of symptom, mo
605 (89.6)
Dyspnea, n (%)
334 (49.5)
Angina, n (%)
151 (22.4)
Syncope, n (%)
354 (52.4)
LV failure, n (%)
68 (10.1)
RV failure, n (%)
54 (8.0)
Emergency surgery, n (%)
Previous surgical history, n
1
Coronary
1
Valvular
Al indicates aortic insufficiency; NYHA, New York Heart Association; LV, left ventricular; and RV, right ventricular.
(58.8%). Systemic arterial hypertension was found in 200 cases
(29.6%), and associated diseases were found in 226 cases
(33.5%). Some patients had associated aortic insufficiency
(AI) (75 patients) or mitral or tricuspid anomaly (32 patients).
Dyspnea was the most frequent symptom (86.6%). Many
patients had left ventricular failure (LVF) (52.4%) or right
ventricular failure (RVF) (10.1%). Fifty patients (8.0%) underwent surgery on an emergency basis.
The results of the investigations are listed in Table 2.
Echocardiographic data confirmed severe stenosis, with a
mean orifice area of 0.6 cm2. Coronary arteriography was
carried out in 348 patients (51.6%), revealing significant
coronary lesions in 31.3% (109 patients).
Surgical Data
Surgical data are listed in Tables 3 and 4. Mechanical
prostheses (43 patients, 6.4%) were implanted in particular
reasons: repeated operation for altered bioprosthesis (one
case) or small aortic annulus associated with calcified aortic
root. Among concomitant surgical procedures, the most frequent were coronary artery bypass graft surgery (CABG) (79
patients), myotomy for subaortic septal hypertrophy (31 patients), and various procedures on the ascending aorta (30
patients). Table 4 describes myocardial protection techniques,
CPB, and aortic cross-clamp duration as well as hemodynamic
recovery at the end of CPB.
54.3±6.23
(range, 42 to 73)
441 (65.3)
Cardiothoracic ratio
ECG sinus rhythm, n (%)
Conduction disturbances (AVB, LBB, RBB),
n (%)
313 (46.4)
Echocardiography
LV ejection fraction, %
54.25±15.3
70.45±16.9
Maximum gradient, mm Hg
33.4±18.7
Mean gradient, mm Hg
Aortic area, cm2
0.6±1.7
Angiography
LV ejection fraction, %
58.3±17.3
348 (51.6)
Coronary arteriography performed, n (%)
109 (31.3)
Significant lesions, n (%)
AVB indicates atrioventricular block; LBB, left bundle-branch
block; RBB, right bundle-branch block; and LV, left ventricular.
Results
Overall surgical mortality was 12.4% (84 patients).
Causes of death are listed in Table 5. In most instances,
TABLE 3. Surgical Data (1)
Mechanical prostheses, n (%)
Bjork-Shiley
43 (6.4)
17
21
5
632 (93.6)
460
149
4
19
133 (19.7)
St Jude Medical
Carbomedics
Bioprostheses, n (%)
Carpentier-Edwards
Medtronic Intact
Biocor
lonescu-Shiley
Concomitant surgery, n (%)
Coronary bypass (1=47, 2=24,
79
3=7; endarterectomy 1)
LV myotomy
31
MVR
12
4
MVR+tricuspid annuloplasty
MVR+CABG
1
MVR+tricuspid
1
annuloplasty+CABG
LA thrombectomy
1
Carotid endarterectomy
4
Ascending aorta surgery, n (%)
30 (4.4)
Reduction
6
Tube
5
Bentall
2
17
Endarterectomy
LV indicates left ventricular; MVR, mitral valve replacement;
LA, left atrial; and CABG, coronary artery bypass graft (surgery).
Logeais et al Surgical Risk of AS in the Elderly
TABLE 4. Surgical Data (2)
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Myocardial protection, n (%)
506 (75.0)
Cold crystalloid cardioplegia via aortic access
132 (19.6)
Aortic cardioplegia+ice slush
29 (4.3)
Cardioplegia via coronary sinus
6 (0.9)
Cardioplegia via coronary arteries
133 (19.7)
Reperfusions (1 to 3)
73±55
CPB duration, mean min
50.6±30
Aortic cross-clamp, mean min
Defibrillation, n (%)
231 (34.2)
Spontaneous
352 (52.1)
One shock
87 (12.9)
Several shocks
Hemodynamic recovery, n (%)
583 (86.4)
Excellent
92 (13.6)
Average or poor
135 (20.0)
Stimulation for temporary AV block
Circulatory support
27 (4.0)
Sustained CPB
3 (0.4)
IABCP
CPB indicates cardiopulmonary bypass; AV, atrioventricular;
and IABCP, intra-aortic balloon counterpulsation.
permission for autopsy was not obtained. Myocardial
causes were predominant (43 deaths, 51%), including
low cardiac output (29 patients), myocardial infarction
(8 patients), and ventricular dysrhythmias (6 patients).
TABLE 5. Surgical Mortality for 84 of 675
Patients (12.4%)
Cause of Death
Myocardial
Low cardiac output
Myocardial infarction
Ventricular dysrhythmias
Tamponade
Valve related
lonescu-Shiley thrombosis
Cerebral embolism
Infection
Cerebrovascular stroke
Respiratory insufficiency
Renal insufficiency
Digestive and abdominal complications
Coagulation disorders
Surgical technique
Intensive care failure
Total
No. of Patients
43
29
8
6
4
3
2
1
2
5
5
3
11
2
4
2
84
%
51
5
4
2
6
6
4
13
2
5
2
100
2893
Gastrointestinal complications were the second leading cause of death (11 deaths, 13%), mostly mesenteric
infarction.
Effect of Year of Surgery on Presurgical and
Surgical Characteristics
The population (Table 6) was divided into four
groups over the study period, and the number of
patients operated on increased significantly over the
years. Apart from the 1976 through 1980 period, which
is nonsignificant because of the small number of patients (10 patients and 0 deaths), there was no significant variation in surgical mortality.
Preoperative data showed two opposite trends in
relation to surgical risk. One was a relative improvement in cardiac status: New York Heart Association
(NYHA) functional class, LVF and RVF, cardiothoracic ratio, and associated Al. The second was a regular
increase in age (mean from 76.4 to 79 years, P<10`7)
and in incidence of associated diseases represented by
the percentage of patients and penetration index (ratio
of number of diseases to number of patients).
Left ventricular catheterization, coronary arteriography, and femoral retrograde route were not considered
to be risk-free factors in these elderly patients. During
the first years of this series, invasive investigations were
performed selectively in patients showing clinical signs
of coronary insufficiency. Since 1990, the routine use of
coronary arteriography was adopted regardless of patient age. A total of 348 patients were studied; 239
(68.7%) presented with either normal arteries (165) or
insignificant lesions (74). Among 109 patients (31.3%)
with significant lesions (50% stenosis of the main trunk
or 70% stenosis of the branches), CABG was performed
in 79 patients (72.5%) and appeared to be impossible in
30 patients (27.5%) because of vessel thrombosis or
poor run-off.
An increasing incidence in overall concomitant surgery
was also observed. CPB and aortic cross-clamp times
decreased, whereas postoperative bleeding increased.
Factors Determining Surgical Mortality
The variables found to be significant by univariate or
multivariate analysis are given in Table 7. Age was
extremely significant compared with 2196 patients with
AS who were <75 years old and were operated on
during the same period (145 of 2196 deaths, 6.6%;
P<.0001). In our overall series of 2871 cases, surgical
mortality varied from 2.2% to 12.4% depending on the
age group (Fig 2). However, among the 675 elderly
patients, mortality did not increase after age 80.
Multivariate analysis also confirmed the role of LVF
(P<.0001); atrial fibrillation (P<.01), usually indicating
a long history and poor tolerance; and the need for
emergency surgery (P<.02).
NYHA functional grade, cardiomegaly, associated
Al, RVF, and tricuspid insufficiency, which were found
to be significant by univariate analysis, were not confirmed by multivariate analysis. The same result was
obtained for four intraoperative variables found to be
significant by univariate analysis: hemodynamic recovery at the end of CPB, associated tricuspid annulo-
2894
Circulation Vol 90, No 6 December 1994
TABLE 6. Demographic Data for 1976 Through 1993
No. of cases
Death, %
Age, mean y
Associated diseases, %
Associated diseases, n/No. of
patients
NYHA, mean
LVfailure, %
CT ratio, mean
Associated Al
Coronary arteriography, %
Significant coronary lesions, %
CPB, min
Aortic cross-clamp, min
1980
10
0
76.4
30
1985
84
11.9
77
22.6
1990
245
13.9
78.5
39.2
1993
336
12
79
32.1
P
...
NS
10-7
.05
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0.50
0.47
.05
2.8
2.8
.001
46
49
10-9
53.8
54.4
10-4
9.8
9
10-6
32
79
10-9
...
33.3
30.6
NS
67
75
105
10-7
69
46
53
10-6
0
7.4
18
10-4
CABG,%
11
0
20
27
.001
Associated surgery (overall), %
1.2
8.6
2.7
0
.002
LV myectomy
1.2
1.2
1.13
1.15
.01
Hemodynamic recovery, 1 to 4
...
527
mL
690
780
10-7
24
Bleeding h,
LV indicates left ventricular; RV, right ventricular; NYHA, New York Heart Association; Al, aortic
insufficiency; CPB, cardiopulmonary bypass; and CABG, coronary artery bypass graft surgery.
During the time frame, the following variables were found to be nonsignificantly different: surgical -RV failure, cardiac rhythm, previous myocardial infarction, mitral insufficiency, tricuspid insufficiency, LV ejection fraction, and emergency; during surgery-mitral valve replacement; tricuspid
annuloplasty, and ascending aorta surgery; and after surgery-low cardiac output, myocardial
infarction, repeated operation for tamponade, sustained respiratory support, and renal failure.
0.30
3.2
100
56.5
60
...
plasty, mitral valve replacement, or overall associated
surgery.
Inversely, all of the postoperative variables-except
for renal failure -were confirmed by multivariate analysis: low cardiac output, sustained respiratory support,
myocardial infarction, and repeated operation for
tamponade.
Discussion
The rewarding results of cardiac surgery on elderly
patients over the past years has been responsible for the
increasing development of geriatric cardiac surgery.11-14
We also experienced such changes (Fig 1) in our series
of patients with AS, which was one of the largest
reported.15-22 There is no reason to question the decision to perform surgery in more elderly patients, since
medical treatment remains largely ineffective when AS
becomes symptomatic23 and balloon dilatation does not
provide successful results and cannot be retained as a
truly competitive alternative. The result is that valve
replacement is recognized as the sole curative treatment.3 In some instances, the success of surgery has led
to a discussion of prophylactic indications in symptomfree or mildly symptomatic patients who are candidates
for another type of surgery (hip arthroplasty, etc). In
accepting this change, we should ask whether there is a
relative shift in indications. Are "lesser cardiac and
0.27
2.8
80
56.8
18
5
25
80
53
0
older patients" operated on? If observed, such a shift in
indications would not only reduce the duration and
quality of surgical results but also increase the already
high economic cost and result in an ethical discussion
that is topical. Surgical technique brought to its extreme
would reach its limit through a progressive decrease in
its benefit.
We carried out this study to evaluate severity factors
and avoid, if possible, high-risk patients to retain the
best indications that would guarantee good results and
tolerable risk. Statistical analysis has confirmed a heavy
incidence of age.24-30 In our overall experience of 2871
patients with AS of all ages who were operated on
during the same period (Fig 2), risk was low (from 2.2%
to 2.9%) at less than age 60, increased between age 60
and 70 (6.2%), and eventually leveled off after age 70
(11.2%). The studied series of 675 elderly patients with
AS did not reveal any significant increase between age
75 and 90. A near-equal risk situation was reached after
age 70.
Left ventricular dysfunction, functional class, emergency surgery, aortic regurgitation, and cardiomegaly
were also found to be predictive risk factors. The logistic
regression curve (Fig 3) displays the role of these
factors when held concurrently. Risk reaches 40% when
the five factors are combined. Lack of sinus rhythm is
also considered as generally referring to an advanced
Logeais et al Surgical Risk of AS in the Elderly
TABLE 7. Surgical Risk Factors
Univarlate
P<
Multivarlate
P<
X2 Im-
provement
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Preoperative variables
Age >80y
NS
NS
...
<75 y
.001
10-4
53.2
NYHA class
.03
NS
...
LV failure
.0001 10-4
15.9
RV failure
.01
NS
...
CT ratio
.002
NS
...
ECG rhythm
.0005
.01
6.6
EF (echocardiography)
.03
NS
...
Associated Al
.005
...
NS
TI
.02
NS
...
Emergency
.002
.02
5.3
Operating surgeon
.0005
NS
...
lntraoperative variables
Hemodynamic recovery
10-5
NS
...
Tricuspid annuloplasty
.009
NS
...
MVR
.02
NS
...
Associated surgery (overall)
.05
...
NS
Postoperative variables
Low cardiac output
1 o-8
10-4
69
Sustained respiratory support 1 Q-8
10-4
30
10-6
Myocardial infarction
.001
10.7
Reoperation for tamponade
.001
.02
5.2
Renal failure
10-4
NS
...
NYHA indicates New York Heart Association; LV, left ventricular; RV, right ventricular; CT, cardiothoracic; EF, ejection fraction; Al, aortic insufficiency; TI, tricuspid insufficiency; and MVR,
mitral valve replacement.
2895
state of the disease. Less significant are right-side heart
failure and tricuspid insufficiency, although they are
orientation factors. The surgeon is also a perceptible
factor in univariate analysis, but this would lead to a
discussion of series homogeneity.
The presence of coronary artery lesions with or
without revascularization was not found to be a determining factor. First, surgical mortality in the group with
coronary arteriography (41 of 348, 11.8±1.7%) was not
significantly different from that of the group without (43
of 327, 13.1±1.9%). Likewise, the difference was not
significantly affected by the presence (17 of 109,
15.6±3.5%) or absence (24 of 239, 10±1.9%) of coronary lesions. When significant coronary lesions were
present, surgical mortality was higher (14 of 79,
17.7±4.3%) in patients who had associated coronary
bypass grafts than in those who did not, because of poor
run-off (3 of 30, 10±5.5%). Again, the difference was
not statistically significant.
An analysis of other intraoperative variables revealed
that concomitant procedures had little or no effect; this
was confirmed by the lack of a role for aortic crossclamp duration during CPB between the limits of 110
and 65 minutes. It is interesting to note that the date of
surgery over the entire 17-year period did not influence
surgical risk. Age increase as well as associated disease
may have counterbalanced the progress achieved in
surgical technique and postoperative care.
As mentioned, postoperative variables represent a
recognition of poor prognosis more than they are truly
predictive factors. They, however, underline the role of
myocardial protection and surgical hemostasis since
repeated surgery for tamponade is an important risk
factor, and many have observed increased postoperative
bleeding that is attributed to coagulation defect.
An analysis confirmed the severity of advanced cases
with left- and right-side heart failure, although left
ventricular dysfunction is not always considered a determining factor of surgical mortality,12'14'28 whereas it is
generally accepted as a predictor of long-term outcome.
Accordingly, left ventricular dysfunction should not be
considered a contraindication to surgery.
In searching for the best surgical indications, we
thought it would be interesting to retrospectively ana-
100
FIG 1. Bar graph of yearly incidence. The
number of patients 75 years and older who
were operated on per year for aortic stenosis
has been increasing since 1976.
60
40
0
197
1980
1985
1990
1993
FEB
2896
Circulation Vol 90, No 6 December 1994
14 T
12,4
12
4
10
4
11,2
FIG 2. Bar graph of surgical risk analysis according to age (mortality in percent). Studied group (75
years or older, mortality 12.4%) is compared with
other age groups who were operated on during the
same period (1976 through February 1993). Overall mortality of 2871 cases series was 7.97% (229
deaths). Before 70 years, surgical mortality was
4.9% (80 of 1614) (P<.0001).
8-
62
6-
4.
28
2-
0-
-I
)60
50
40
75
70
90
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lyze how much removing high-risk cases, as indicated by
the univariate analysis, would have contributed to improved results. Fig 4 shows that the elimination of
emergency surgery, aortic regurgitation, NYTHA class
IV, and concomitant surgical procedures did not provide a statistically significant decrease in risk. Improvement was obtained only by discarding a larger number
of cases with cumulative suppression of the abovementioned groups. Reducing the number of patients
from 675 to 420 would have lowered the risk to 8.3%.
An additional improvement can be accomplished by the
cumulative elimination of patients with coronary artery
lesions, cardiomegaly, and left ventricular insufficiency.
The final group has a low risk of 3.2%, obtained only by
this severe and unrealistic selection (154 of the initial
675 cases). As a consequence, based on our analysis
there would be no easy way to improve results, either by
searching for severity factors or by eliminating high-risk
cases.
An analysis of the causes of death (Table 5) revealed
two important groups. The group with myocardial
causes had 43 deaths (51%) from low cardiac output,
myocardial infarction, and ventricular dysrythmias. This
underlines the role of myocardial protection. One could
also question the role of mechanical support in the
treatment of myocardial complications. We did not
00%
consider it desirable to cross this limit due to the
investment required and because we wanted to keep the
treatment within "reasonable" limits.
Gastrointestinal complications, including mesenteric
infarction (11 deaths, 13%), formed a second significant
group of causes of death. The effect of associated low
cardiac output and inotropic drugs must not be overlooked as they may aggravate mesenteric ischemia.
Standard CPB at 28°C is questionable because hypothermia can reduce blood flow in the mesenteric area. A
routine policy of hypothermia deserves to be challenged
in favor of normothermia under the condition of adequate arterial pressure during CPB.
The study of other causes of death underlines the
importance of patient preparation (respiratory training)
and rigorous surgical technique. Aortic annulus decalcification must be performed with great care because
even repaired annulus wounds may provoke myocardial
hemorrhagic dissection and hematomas, which are always poorly tolerated.
Conclusions
This series of elderly patients with AS, which is one of
the largest reported, confirms that surgical risk is increased after age 70, which is in agreement with most
series reporting a risk of > 10%.3,17,20
Probability of death
90
80
70
60
50
40
---
30
20
.
10
0:
Emergency
Al
CTR
LVF
NYHA
.
.
.
.
.
.
.
.
01 0 1
O0 1 0
1 2 1 12 1 1
0 0 1 11 0 0
3 3 4 24 2 4
.
,
.
0
0
0 0 0 0 0 0
1
001
0
0
0
0
1 0 0
0
001
1
1 1 2
0
0
2 3 2
0
0
0-
1 2
1 1
3 4
1
221
2
1
111
1
3
234
3
,
10 0
0 1 1
12 1
11 1
4 4 3
l
100
101
222
100
443
1
0
2
1
3
FIG 3. Logistic regression analysis of preoperative mortality factors (in percent). Vertical lecture indicates the risk of each group.
Additive effect is observed on the curve
(number of patients becomes too low to
validate the curve above a 25% risk) (emergency: 0, no; 1, yes; Al: associated aortic
insufficiency: 0, absent; 1, present; LVF: left
ventricular failure: 0, absent; 1, present;
NYHA: New York Heart Association: functional class; CTR: cardiothoracic ratio, 0,
below 0.6; 1, above 0.6.
Logeais et al Surgical Risk of AS in the Elderly
700
675
600-
500
600
,,
61
529
-
400-
T
E
T
M
A
L
R
05
AII
G
E
N
C
Y
300-
200
100-
1
1
ASS I
H
SURG
A
I
0
N
1AX1
2
3-
2
3
.15
A
ALL
Iv
4
10,7
.
.01
23
CO
LES
4
154
10,9
6
-4-
.001
emR
> 0.59
5
6.
7+
8
5
6
7
9
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An analysis of risk factors proved that left ventricular
dysfunction, lack of sinus rhythm, and emergency surgery are independent predictive factors of surgical
mortality. However, there is no easy way to discern
low-risk subgroups. Therefore, surgical indications must
remain broad. Respiratory preparation, myocardial protection, and probably normothermic CPB are methods
of improving prognosis as valvular replacement remains
the only curative treatment for AS.
4.
5.
6.
7.
Appendix: Variables Entered Into the Analyses
Before Surgery
8.
Variables were sex, age (>80 or <75 years), NYHA class,
LVF, RVF, cardiothoracic ratio, associated diseases, cardiac
rhythm, left ventricular ejection fraction (angiography, echocardiography), coronary arteriography, coronary artery lesions,
associated valve malfunctions (aortic insufficiency, mitral insufficiency, tricuspid insufficiency), duration of symptoms, angina,
dyspnea, syncope, conduction disturbances (atrioventricular
block, left bundle-branch block, right bundle-branch block),
previous myocardial infarction, emergency surgery, preoperative intra-aortic balloon counterpulsation, and year of surgery.
9.
10.
11.
12.
During Surgery
Variables were duration of CPB and aortic cross-clamping,
type of prosthesis, associated surgery (mitral valve replacement, tricuspid annuloplasty, CABG, ascending aorta, septal
myectomy, and overall associated surgery), hemodynamic recovery after CPB, ABCP, and surgeon.
13.
14.
After Surgery
15.
Variables were atrial and ventricular arrhythmias, conduction disturbances, low cardiac output, myocardial infarction,
repeated operation (tamponade or hemorrhage), pacemaker
insertion, blood loss, sustained respiratory support, intestinal
hemorrhage, abdominal complications, and renal failure.
16.
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17.
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3,2
2897
FIG 4. Bar graph of search for "ideal
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is obtained by suppressing risk factors
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Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive
factors.
Y Logeais, T Langanay, R Roussin, A Leguerrier, C Rioux, J Chaperon, C de Place, P Mabo, J
C Pony and J C Daubert
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Circulation. 1994;90:2891-2898
doi: 10.1161/01.CIR.90.6.2891
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