Should Very Elderly Patients Be Offered The Same Surgical Options As Their Younger Counterparts? A Comparison Of Outcomes Among Patients Below And Over 80 Years Of Age Undergoing AVR With or Without CABG
Juan B. Grau1, Giovanni Ferrari2, Andrew W. C. Mak, MS3, Richard E. Shaw3, Mariano E. Brizzio1, Bruce Mindich1, Alex Zapolanski1
1Columbia University College of Physicians and Surgeons, The Valley Columbia Heart Center, Ridgewood, NJ, USA, 2Harrison Department of Surgical Research, The University of Pennsylvania School of Medicine, Glenolden, PA, 3The Valley Columbia Heart Center, Ridgewood, NJ, USA.
OBJECTIVE: Severe aortic stenosis carries an average survival of three years after the onset of symptoms. Referral of the very elderly (80 years of age or older) for surgical aortic valve replacement remains low in spite of continuous improvements in outcomes We retrospectively analyzed our institution’s results in all consecutive patients, both first time and redo AVR and AVR+CABG, and hypothesized that advanced age is not a significant independent predictor of postoperative mortality.
METHODS: From 2006 to 2010, 509 patients undergoing AVR or AVR + CABG were evaluated. The majority (N=266) underwent AVR + CABG. Using our STS database reporting system, outcomes were retrospectively analyzed dividing the patients into the following four groups 1) Group 1: Isolated AVR ≥ 80 years old (N=88); 2) Group 2: Isolated AVR < 80 years old (N=155); 3) Group 3: AVR + CAB ≥ 80 years old (N=105) and 4) Group 4: AVR + CAB < 80 (N=161).
RESULTS: The observed mortality for each of the different groups was significantly lower than the STS expected mortality. Most notably, the mortality in group 1 was 1.1% (expected was 6.4%), for group 2 it was 1.3% (expected was 2.7%), for group 3 it was 2.9% (expected was 8.6%), and for group 4 it was 1.2% (expected was 4.8%). The overall perioperative mortality rate was 1.6% without significant differences among the four groups (p=0.648). Table 1 summarizes the demographics and the outcomes in these four groups.
CONCLUSIONS: The 30-day mortality of all four groups was much lower than that predicted by the STS risk stratification system. In our series, advance age does not appear to significantly impact mortality in patients undergoing AVR or AVR+CABG. The low risk of AVR +/- CABG supports considering earlier surgical referral for patients who have a high likelihood of progression of their AS irrespective of age.
| AVR ≥ 80 | AVR < 80 | p-value | AVR+CABG ≥ 80 | AVR+CABG < 80 | p-value | |
| Male gender | 38.6% | 65.2% | <0.0001 | 49.5% | 67.7% | = 0.003 |
| NYHA class (III or IV) | 56.0% | 34.3% | = 0.060 | 48.0% | 47.5% | = 0.420 |
| Diabetes (n) | 29.5% | 21.3% | = 0.149 | 27.6% | 46.6% | = 0.002 |
| PVAD (n) | 9.1% | 9.0% | = 0.988 | 12.4% | 16.1% | = 0.396 |
| Chronic Lung Dis. | 13.6% | 11.0% | = 0.486 | 20.0% | 13.0% | = 0.108 |
| Previous CVA (n) | 6.8% | 4.5% | = 0.443 | 6.7% | 6.8% | = 0.958 |
| Reoperation | 19.3% | 16.1% | = 0.749 | 8.6% | 9.3% | = 0.836 |
| STS predicted mortality | 6.4% | 2.7% | <0.0001 | 8.6% | 4.8% | < 0.0001 |
| Observed mortality | 1.1% | 1.3% | = 0.917 | 2.9% | 1.2% | = 0.343 |
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