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Case Study - Survival of octogenarians following aortic
valve replacement surgery
The issue
Given the ageing population and the increasing prevalence of aortic
stenosis amongst elderly patients, aortic stenosis (AS; narrowing of the
exit of the left ventricle of the heart) represents a high and increasing
burden to the public health systems of many countries. The prevalence
of AS has increased up to 24-fold over the last 2 decades and over
40% of the patients receiving Aortic Valve Replacement (AVR) surgery
to treat the condition are aged 75 years or over. The management
difficulties associated with high-risk, elderly patients presenting for AVR
are, therefore, likely to become increasingly important in future clinical
practice.
AVR with cardiopulmonary bypass remains the “gold standard” of treatment, the survival benefits of which
have been firmly established as opposed to use of medications alone which shows consistently poor outcomes.
However, in elderly patients who have other medical issues, in the past medical professionals have chosen the
more conservative treatment options due to their high-risk status.
In more recent years with the development of new technologies such as the minimally invasive transcatheter
aortic valve implantation (TAVI) have provided more successful alternatives for those high-risk patients.
These new innovations, despite their inherent successes, are technically challenging, expensive and allow
a lower margin for error. As such, there is new impetus to more accurately define those patients who
would benefit most from TAVI. The authors in this study sought to address this question by evaluating the
surgical outcomes of octogenarian patients undergoing conventional AVR surgery over a five-year period.
Data collections involved
•
Clinical data from 117 patients undergoing AVR surgery in two hospitals (Royal Prince Alfred Hospital
and Strathfield Private Hospital, NSW) between August 2005 and February 2011.
•
Matched mortality data from the National Death Index
Data was linked by the Queensland Health Record Linkage Group.
POPULATION HEALTH RESEARCH NETWORK - CASE STUDY SERIES No 7
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Key findings of the study
•
46.2% of the cohort were females with the median age at the time of surgery was 83 years.
•
Cardiovascular risk factors including hypertension, hypercholesterolaemia and a history of
smoking.
•
The difference between subgroups for history of stroke was significant (p = .042).
•
The majority of surgical cases were elective, while 31.6% of cases were classified as urgent or
emergent (29.9% and 1.7% respectively).
•
Post-operative complications included pleural effusion (12.8%), new renal failure (4.3%) and
respiratory failure (4.3%) but the rate of major adverse events was extremely low, with no cases
of stroke.
•
Thirty-day mortality was low at 3.4% (all in patients aged 85-89) with these deaths attributed to
either cardiac causes or multisystem failure.
•
38.9% of patients were discharged home, 11.5% were transferred to another hospital and 38.9%
spent a period of time in a rehabilitation institution post discharge
•
In terms of long-term survival, the six-month, one-year and three-year survival was 95.6%,
87.6% and 58.4% respectively.
•
Apart from previous history of stroke and 30-day mortality, there were no differences between
subgroups of patients aged 80-84 and 85-89.
Implications/Future studies
•
The results from this study show that conventional AVR can be performed in octogenarians with
excellent short and long-term outcomes.
•
The mid- and long-term data point towards favourable patient quality of life and survival rates,
with almost 40% of patients fit to be discharged directly home and more than half of the cohort
alive at three years post discharge.
•
These results contribute to the emerging body of evidence in support of the safety and efficacy
of conventional AVR in potentially high-risk patient cohorts, indicating that they should not be
excluded from surgical intervention based on age alone
REFERENCE
Harris, R. S., Yan, T. D., Black, D., Bannon, P. G., Bayfield, M. S., Hendel, P.
N., . . . Vallely, M. P. (2013). Outcomes of surgical aortic valve replacement
in octogenarians. Heart Lung Circ, 22(8), 618-626. doi: 10.1016/j.
hlc.2013.01.008
PRIMARY CONTACT
Dr Michael P. Vallely, Cardiothoracic Surgical Unit, Royal Prince Alfred
Hospital, Sydney, Australia.
E-mail address: [email protected].
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