Long-term survival of the very elderly undergoing aortic valve surgery.

BACKGROUND: Increasing numbers of the very elderly are undergoing aortic valve procedures. We describe the short- and long-term survivorship for this cohort. METHODS AND RESULTS: We conducted a cohort study of 7584 consecutive patients undergoing open aortic valve surgery without (51.1%; AVR) or with (48.9%; AVR + CABG) concomitant coronary artery bypass graft surgery between November 10, 1987 through June 30, 2006. Patient records were linked to the Social Security Administration's Death Master File. Survivorship was stratified by age and concomitant CABG surgery. During 39 835 person-years of follow-up, there were 2877 deaths. Among AVR, there were 3304 patients <80 years of age, 419 patients 80 to 84 years, and 156 patients > or =85 years (24 patients >90 years). Among AVR+CABG patients, there were 2890 patients <80 years of age, 577 patients 80 to 84 years, and 238 patients > or =85 years (22 patients >90 years). Median survivorship for patients undergoing isolated AVR was 11.5 years (<80 years), 6.8 years (80 to 84 years), 6.2 years (> or =85 years); for patients undergoing AVR+CABG, median survivorship was 9.4 years (<80 years), 6.8 years (80 to 84 years), and 7.1 years (> or =85 years). Among both procedures, adjusted survivorship was significantly different across strata of age (P<0.001). These findings are similar to life expectancy of the general population from actuarial tables: 80 to 84 years (7 years) and > or =85 years (5 years). CONCLUSIONS: Survivorship among octogenarians is favorable, with more than half the patients surviving more than 6 years after their surgery. Concomitant CABG surgery does not diminish median survivorship among patients >80 years of age.

Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in Northern New England.

BACKGROUND: Predicting risk for aortic and mitral valve surgery is important both for informed consent of patients and objective review of surgical outcomes. Development of reliable prediction rules requires large data sets with appropriate risk factors that are available before surgery. METHODS: Data from eight Northern New England Medical Centers in the period January 1991 through December 2001 were analyzed on 8943 heart valve surgery patients aged 30 years and older. There were 5793 cases of aortic valve replacement and 3150 cases of mitral valve surgery (repair or replacement). Logistic regression was used to examine the relationship between risk factors and in-hospital mortality. RESULTS: In the multivariable analysis, 11 variables in the aortic model (older age, lower body surface area, prior cardiac operation, elevated creatinine, prior stroke, New York Heart Association [NYHA] class IV, congestive heart failure [CHF], atrial fibrillation, acuity, year of surgery, and concomitant coronary artery bypass grafting) and 10 variables in the mitral model (female sex, older age, diabetes, coronary artery disease, prior cerebrovascular accident, elevated creatinine, NYHA class IV, CHF, acuity, and valve replacement) remained independent predictors of the outcome. The mathematical models were highly significant predictors of the outcome, in-hospital mortality, and the results are in general agreement with those of others. The area under the receiver operating characteristic curve for the aortic model was 0.75 (95% confidence interval [CI], 0.72 to 0.77), and for the mitral model, 0.79 (95% CI, 0.76 to 0.81). The goodness-of-fit statistic for the aortic model was chi(2) [8 df] = 11.88, p = 0.157, and for the mitral model it was chi(2) [8 df] = 5.45, p = 0.708. CONCLUSIONS: We present results and methods for use in day-to-day practice to calculate patient-specific in-hospital mortality after aortic and mitral valve surgery, by the logistic equation for each model or a simple scoring system with a look-up table for mortality rate.

A multicenter comparison of intraaortic balloon pump utilization in isolated coronary artery bypass graft surgery.

BACKGROUND: Single-center studies suggest substantial variation in intraaortic balloon pump (IABP) utilization. Our purpose is to examine IABP utilization over time and across medical centers. METHODS: This was a prospective cohort of 29,961 consecutive patients undergoing isolated coronary artery bypass graft surgery, between 1995 and 2000, at 10 centers (eight in northern New England and two in Canada). RESULTS: A total of 2,678 (8.9%) patients received an IABP. The rate of preoperative IABP insertion was 6.3%, and that of intra- or postoperative insertion was 2.6%. During the 6 years, IABP use increased from 7.0% to 10.3% (p(trend) <0.001). Preoperative IABP insertion increased from 5.4% to 7.8% (p(trend) < 0.001). There was no significant increase in intra-/postoperative IABP insertion 1.7% to 3.4% (p(trend) = 0.34). Adjustment for changes in patient and disease characteristics did not substantially alter these results. The rate of IABP use varied substantially by center, from 5.9% to 16.4% (p < 0.001). Adjustment for patient and disease characteristics resulted in variation from 4.8% to 12.8% across the 10 centers (p < 0.001). The adjusted rates of preoperative IABP insertion varied from 3.6% to 13.7% (p < 0.001), and the rates of intra-/postoperative IABP insertion ranged from 1.0% to 5.2% (p < 0.001). There was no significant correlation between the rates of preoperative and intra-/postoperative IABP use (r(s) = 0.085, p = 0.815). CONCLUSIONS: During the 6 years, there was a 47% increase in the rate of IABP utilization. Even after adjustment, there was almost threefold variation in IABP use across centers. This variation likely reflects lack of consensus on the appropriate use of the IABP in CABG patients.

Long-term survival of the very elderly undergoing coronary artery bypass grafting.

BACKGROUND: Increasing numbers of the very elderly are undergoing coronary artery bypass graft surgery (CABG). Short-term results have been studied, but few data are available concerning long-term outcomes. METHODS: We conducted a cohort study of 54,397 consecutive patients undergoing primary, isolated CABG surgery between July 1, 1987, and June 30, 2006. Patient records were linked to the Social Security Administration's Death Master File. RESULTS: During 390,871 person-years of follow-up, there were 17,352 deaths. There were 51,149 patients younger than 80 years, 2,661 patients aged 80 to 84 years, and 587 patients aged 85 or more years who underwent isolated CABG surgery. Crude in-hospital survival was 97.2% for those less than 80 years, 98.3% for those aged 80 to 84 years, and 87.6% for those aged 85 or more years. Patients aged 80 or more years were more likely to be female (46.9%), more likely to be emergency priority (10.2%), and more likely to have associated comorbidities than younger patients. Patients aged 85 or more years were more likely to have intraoperative and postoperative morbid events. Among patients younger than 80, median survival was 14.4 years with an annual incidence of death of 4.2%. Among patients 80 to 84 years old, median survival time was 7.4 years, with an annual incidence rate of death of 10.3%. Among patients aged 85 or more years, median survival was 5.8 years, and the annual incidence of death was 13.7%. CONCLUSIONS: Although very elderly CABG patients have more comorbidities and more acute presentation than younger patients and their in-hospital mortality rate is high, their long-term survival is surprisingly good.