Expectation and quality of life after aortic valve replacement over 85 years of age match those of the contemporary general population.

BACKGROUND: In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS. METHODS: Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics. RESULTS: Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population. CONCLUSIONS: Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

Biological and clinical outcomes in the elderly with left ventricular dysfunction: Are there differences between on-pump and off-pump coronary artery bypass grafting?

AIM: To compair biological and clinical outcomes after off-pump coronary artery bypass grafting (OPCABG) and conventional on-pump coronary artery bypass grafting (CCABG) in the elderly with left ventricular (LV) dysfunction. MATERIAL OF STUDY: We retrospectively reviewed 90 consecutive patients aged more than 75 years with preoperative left ventricular ejection fraction (LVEF) < 50% who underwent isolated coronary artery bypass grafting at our Institution between January 2000 and July 2009. According to operative technique, patients were categorized in to the OPCABG group (39 patients) or in to the CCABG group (51 patients). We compared postoperative CK, CK-MB, troponin T serum levels and major adverse cardiac and cerebrovascular events (MACCE). RESULTS: The overall in-hospital mortality was 2% (2/90) and was similar in both groups (p=0.8336). Mean troponin T levels at 6,24,48 hours after operation were significantly lower in the OPCABG group (p=0.0001; p=0.0021; p=0.0070, respectively). Overall survival was 77.6% at 10 years and no significant difference in MACCE was observed (p=0.3016). DISCUSSION: Our results show a lower incidence of myocardial injury in OPCABG group, but there aren't differences in term of MACCE in both groups. Recent studies have indicated the advantages of OPCABG in the elderly patients, reporting a reduction of postoperative morbidity and organ dysfunction. However these studies not analyzed the impact of LV dysfunction on early and late postoperative outcomes in high-risk patients. CONCLUSIONS: In the elderly with LV dysfunction, the OPCABG technique showed lower incidence of postoperative myocardial injury. However, at the follow-up, this does not reflect any significant differences in incidence of MACCE.

Coronary artery bypass grafting in the octogenarian. Is complete revascularization always necessary?

AIM: The aim of this study was to investigate whether the completeness of revascularization affects the outcomes in the octogenarian. MATERIAL OF STUDY: We retrospectively reviewed 130 consecutive octogenarians who underwent isolated coronary artery bypass grafting (CABG) between January 2003 and September 2010. According to operative technique, patients were categorized in Complete Revascularization (CRV) Group (96 patients) and in Incomplete Revascularization (IRV) Group (34 patients). Follow-up was 98% complete (mean: 30 ± 25 months). RESULTS: The overall in-hospital mortality was 13% and was similar in both groups (p=0.0553). Multivariate regression analysis identified preoperative left ventricular ejection fraction ≤ 40% (p= 0.0060; OR= 0.19) and NHYA class > II (p= 0.0042; OR= 0.17) as risk factor for in-hospital death. Cox regression analysis not identified incomplete revascularization as risk factor for early or late death (p= 0.1381 and p= 0.8865). No differences in 5-year survival and freedom from major adverse cardiac and cerebrovascular events (MACCE) was found between two groups (p=0.8865 and p=0.6283). DISCUSSION: CRV is important in young patients undergoing CABG, but this principle remains less absolute in elderly patients. In our study, the survival benefit of CRV was less in octogenarians. Probably, the major benefit of CRV was seen in patients less than 80 years of age. This makes sense because these patients have a longer expected survival, and there were more patients available to statistically confirm any difference in outcome. CONCLUSIONS: In octogenarians undergoing CABG, IRV does not affect survival and freedom from MACCE. Patients' preoperative conditions are important in determining short and long term outcomes.

Aortic valve replacement with smaller prostheses in elderly patients: does patient prosthetic mismatch affect outcomes?

BACKGROUND AND AIM OF THE STUDY: To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. METHODS: Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2)/m(2). Patients having IEOA < 0.75 cm(2)/m(2) and IEOA < 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. RESULTS: PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. CONCLUSIONS: PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up.

OBJECTIVE: The objective of this study was to examine the fate of the native aortic root after replacement of the ascending aorta to treat acute type A aortic dissection. METHODS: Between June 1985 and January 2010, 319 consecutive patients (mean age, 63 ± 11 years) with acute type A aortic dissection underwent replacement of the ascending aorta with preservation of the aortic root. The aortic valve was also replaced in 21 of these patients (7%). The intervention was extended to the aortic arch in 210 patients (66%), of whom 173 (54%) underwent hemiarch replacement, and 37 (12%), total arch replacement. RESULTS: There were 109 (34%) in-hospital deaths. Of the 210 discharged patients, survival was 95%, 58%, and 27% at 1, 10, and 23 years, respectively. Freedom from reoperation on the proximal aorta was reported by 97%, 92%, and 82% patients at 5, 10, and 23 years, respectively. Twelve patients were reoperated for aortic root dilatation and 2 died during reoperation. Univariate and multivariate Cox regression analyses revealed that significant risk factors for proximal reoperation were age <60 years (P = .005; relative risk, 1.94) and Marfan syndrome (P = .011; relative risk, 2.76). At follow-up, 15 patients (11%) had an aortic root diameter of >45 mm, but they were not reoperated. CONCLUSIONS: For acute type A aortic dissection, replacement of the ascending aorta with root preservation shows long-term effectiveness with low reoperation and aortic root dilatation rates.

Outcomes after surgical treatment for type A acute aortic dissection in octogenarians: a multicenter study.

BACKGROUND: Management of octogenarian patients with acute type A acute aortic dissection is controversial. This study analyzed the surgical outcomes to identify patients who should undergo operations. METHODS: Beginning January 2000, we established a registry including all octogenarian patients operated on for type A acute aortic dissection. We evaluated 57 consecutive patients enrolled up to December 2006. Their median age was 82 (range, 80 to 89 years). Compassionate indication operations were attempted in 2 moribund patients and in 5 presenting with shock associated with neurologic symptoms or renal failure, or both. Operations followed the standard procedure recommended in younger patients. Follow-up was 100% complete (mean, 3.9 +/- 2 years; range, 5 months to 8 years). RESULTS: There were 26 (45.6%) in-hospital and 6 late deaths. Multivariate analysis identified compassionate indication (p < or = 0.0001) and total arch replacement (p = 0.0060) as risk factors for in-hospital mortality. Postoperative complications occurred in 36 patients (69.2%) and were associated with a higher mortality (p = 0.0001). Overall survival was 51% at 1 year and 44% at 5 years. Excluding patients with compassionate indication and those who underwent total arch replacement, or both, overall survival was 66% at 1 year and 57% at 5 years. CONCLUSIONS: Surgical treatment for type A acute aortic dissection in octogenarians shows satisfactory midterm results among survivors. However, the high mortality rate imposes a requirement for better perioperative management. Compassionate cases should be managed medically. A less aggressive approach should improve outcomes of surgical treatment.

Fate of the aortic valve after root reconstruction in type A aortic dissection: a 20-year follow up.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the fate of the aortic valve after root reconstruction in acute type A aortic dissection. METHODS: Between 1982 and 2006, a total of 373 consecutive patients underwent emergency surgery for acute type A aortic dissection at the authors' institution. Of these patients, 298 (mean age 63 +/- 11 years; range: 22-85 years) underwent replacement of the supracoronary aorta with root reconstruction. The mean follow up period was 6.9 +/- 5.2 years (range: 2 months to 23 years), and was 98% complete. Aortic valve function was assessed by the incidence of aortic valve reoperation and transthoracic echocardiography. RESULTS: The 30-day mortality was 27% (82/298). Survival was 80%, 57% and 49% at five, 10 and 15 years, respectively. For survivors at the latest follow up, freedom from moderate or severe aortic regurgitation (AR) was 93%, 84% and 72% at five, 10 and 15 years, respectively. Four patients had severe AR but were not reoperated on. Among 200 patients discharged, 13 (6.5%) were reoperated on for severe AR, with an operative mortality of 15% (n = 2). Freedom from aortic valve replacement was 97%, 92% and 84% at five, 10 and 15 years, respectively. Cox regression analysis identified age < or = 59 years (p = 0.0201) and 'low-volume surgeon' (p = 0.0004) as risk factors for recurrent moderate or severe AR. CONCLUSION: The study results showed that, when the aortic dissection involves the aortic root, supracoronary replacement of the ascending aorta with a root reconstruction allows preservation of the aortic valve in the majority of patients, with a satisfactory long-term outcome.

[Hospital mortality at a cardiosurgical unit in Torino: international comparisons and time trend]. / Mortalità ospedaliera in una unità di cardiochirurgia di Torino: confronti internazionali e andamento temporale.

OBJECTIVE: To compare hospital mortality in a cardiac surgery unit with external data and to assess changes in time (patients undergoing surgery in two different periods). MATERIALS AND METHODS: Data on risk factors for hospital mortality were collected from clinical records (retrospectively for the first period and prospectively for the second) for all patients undergoing open heart surgery at the Heart Surgery Unit of the University of Turin (Italy) during 1991 and 1995 (n = 1794) and 1999 (n = 892). Comparisons of in-hospital mortality, expressed as Standardized Mortality Ratios (SMR), were adjusted for risk factors defined according to EuroSCORE (European System for Cardiac Operative Risk Evaluation). RESULTS: In the first and second period, complete information on all the 17 EuroSCORE items was available for 58.3% and 89.6% patients respectively. After exclusion of patients with one or more missing data, observed and expected numbers of death were found to be very similar, with SMRs ranging between 0.82 (isolated bypass in the second period) and 1.06 ("other" surgery in the first period). Mortality was higher among patients with missing data, but at least in 1999 the latter had a limited impact on the overall estimates. Compared to the first period, mortality was reduced during 1999 (from 5.9% to 5.4%), in particular for isolated bypass (from 4.4% to 3.4%). CONCLUSIONS: In the unit under investigation, hospital mortality following heart surgery was similar to that predicted from EuroSCORE and seemed to be lower in 1999 than in 1991-95, particularly for isolated bypass. Incompleteness of data on individual risk factors may have been a source of bias, especially when data were collected retrospectively.

Comparison of polymerase chain reaction and pp65 antigen test for early detection of human cytomegalovirus in blood leukocytes of cardiac transplant recipients.

OBJECTIVE: To establish whether polymerase chain reaction (PCR) for cytomegalovirus deoxyribonucleic acid (DNA) can provide clinical information for the management of the infection. METHODS: Leukocytes in 30 heart transplant recipients were monitored by pp65 antigen testing and PCR for 82 to 365 days after transplantation. RESULTS: Of the 30 patients, 26 developed cytomegalovirus infection, nine of whom were symptomatic. Altogether, 300 leukocyte samples were examined. The concordance between PCR and pp65 antigen test was 82.6%. In symptomatic patients after surgery, PCR detected cytomegalovirus infection after 38 plus minus 16 days and the pp65 antigen test, after 48 plus minus 15 days. Symptomatic infection correlated with a higher number of pp65-positive leukocytes than did asymptomatic infection: 310 plus minus 356 vs 24 plus minus 35 (p < 0.005)/200,000 examined, respectively. Clearance of virus was observed by PCR after 125 plus minus 73 days (range 29 to 225) in symptomatic, and after 82 plus minus 70 days (range 16 to 301) in asymptomatic, cases of infection. CONCLUSIONS: The positive predictive value of PCR for symptomatic infection was 34.6%. Our findings correlate with previous reports and show that the qualitative detection of cytomegalovirus DNA is not associated with overt disease whereas quantitation of pp65-positive leukocytes closely correlate with symptom onset. Insofar as the results are not quantitative, PCR is not a marker of clinically apparent infection. Careful monitoring of cytomegalovirus infection based on quantitative pp65 antigen assay can fulfill all clinical needs for early diagnosis and proper management of the infection