Current hospital mortality of aortic valve replacement in octogenarians.

BACKGROUND AND AIM OF THE STUDY: The increasing incidence of cardiovascular disease with age, coupled to a constant extension of life expectancy in industrialized countries, is leading to an ever-increasing number of elderly patients being referred for aortic valve replacement (AVR). In light of advances in surgical technology and cardiac protection, the operative mortality and risk factors have been updated in order to specify surgical indications. METHODS: Between January 2000 and December 2004, a total of 442 patients (203 males, 239 females) aged > or =80 years (mean age 82.7 +/- 2.3 years) underwent AVR at the authors' institution. Surgery was either isolated (n = 344) or associated with coronary revascularization (n = 86), mitral valvuloplasty (n = 5) or aortic surgery (n = 7). Seventeen patients had undergone previous cardiac surgery. The EuroScore was calculated for each patient. RESULTS: Overall operative mortality was 7.5% (n = 33). Independent predictive factors of mortality were: aortic insufficiency (30%, p <0.004), NYHA class IV (20.5%, p < 0.001), left and right heart failure (11.5% and 19.4%, p <0.02), chronic renal insufficiency (18.5%, p <0.04), emergency (37.5%, p <0.001, OR = 4.7), left ventricular ejection fraction (21.1%, p <0.004, OR = 0.9), and redo surgery (35.3%, p <0.001, OR = 6). Mortality was also increased in case of associated coronary revascularization (11.6%), mitral or tricuspid surgery (20%) and ascending aorta procedure (25%). CONCLUSION: Patient functional improvement achieved after valve replacement at the cost of a rather low operative mortality justifies considering octogenarians for surgery. However, decisions should be taken on an individual basis. An earlier referral to surgery before the onset of altered cardiac function could lead to further reductions in hospital mortality.

Surgery for aortic stenosis in octogenarians: influence of coronary disease and other comorbidities on hospital mortality.

BACKGROUND AND AIM OF THE STUDY: Increasing life expectancy in industrialized countries and the high incidence of aortic stenosis (AS) in higher-age groups have led to wider indications for surgery in the elderly. The study aim was to re analyze operative risk factors, considering especially coronary status, for better patient selection and decreased risk. METHODS: Between 1978 and 2003, 771 patients (319 men, 452 women) aged > or =80 years (mean 82.9 years) underwent valve replacement (bioprosthesis in 760 cases; 99%) for AS. Preoperative coronary angiography (performed in 617 cases; 80%) found significant lesions in 203 patients (33%) of either single- (n = 122), double- (n = 54) or triple- (n = 27) vessel disease. In total, 112 patients underwent associated coronary revascularization (one graft in 80 patients, and two or three grafts in 32). RESULTS: Overall operative mortality was 10.1% (n = 78 patients). Predictive factors of mortality were left and right heart failure (p <0.001), emergency surgery (p <0.001), NYHA class IV (p <0.01), renal insufficiency (p <0.001), left ventricular ejection fraction (LVEF) <40% (p <0.01), atrioventricular block (p <0.01) and associated mitral valve replacement (p <0.01). Although no statistical difference was found, operative mortality increased according to the coronary status: no significant lesion 8.2%, single-vessel disease 11.5%, two-vessel 11.1%, and three-vessel 18.5%. If operative mortality is not influenced by single-vessel revascularization (10%), it becomes higher in multiple bypasses (18.8%). CONCLUSION: Surgery remains the only treatment for AS. Since analysis failed to identify any specific high-risk groups, indications should remain broad and decisions made on an individual patient basis. A combined strategy associating angioplasty and surgery should be evaluated in order to improve the preoperative coronary status and reduce operative risk.

Surgical treatment of acute traumatic rupture of the thoracic aorta a timing reappraisal?

OBJECTIVE: To report our experience with surgery of thoracic aortic rupture due to blunt trauma. METHODS: Between October 1976 and October 1999, 50 patients suffering from acute rupture of the thoracic aorta due to blunt trauma were operated on. On admission, 22 patients (44%) presented with hypovolemic shock and all but five (90%) sustained major associated injuries. Thirty-one patients (62%) underwent immediate operation for aortic repair, whereas the procedure was delayed from 6 to 60 days in ten patients because of late diagnosis or coexisting life-threatening lesions thought to largely worsen the operative risk. In 48 patients, the aortic repair was carried out with the aid of cardiopulmonary bypass (CPB) in order to maintain the distal perfusion and to prevent spinal cord injury. An inert 'Gott' shunt and the 'clamp-and-sew' technique were used in one patient each. RESULTS: The hospital mortality amounts to 18% (nine patients). Four patients (8%) died intraoperatively and five patients (10%) died in the postoperative course. In five patients (10%) death was caused by cerebral or pulmonary hemorrhage, possibly worsened by systemic heparinization during CPB. One case of postoperative paraplegia (2%) was observed in a patient operated on with the aid of CPB. There was neither aortic rupture nor sudden death in the group of patients in whom the surgical procedure was delayed. CONCLUSIONS: The immediate outcome of patients suffering from acute traumatic aortic rupture strongly depends on the associated injuries. In some cases, the emergency aortic repair must be favorably delayed because of the necessity of life-sustaining measures and management of major coexisting injuries, which could be worsened by the use of CPB. Conversely, the risk of paraplegia is significantly reduced by the use of CPB and distal perfusion during the time of aortic cross-clamping.