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Aortic Valve Replacement in Octogenarians: Is it Time to Abandon the Standard Operation?

Benjamin Medalion, Ariel Farkash, Eitan Snir, Erez Sharoni, Ram Sharoni, Philip Biderman, Eyal Porat.
Rabin Medical Center, Petach Tiqva, Israel.


OBJECTIVE: Increasing number of elderly patients require AVR. With the growing experience of transcatheter valve implantation it is important to evaluate the current surgical outcome of octogenarians after AVR
METHODS: All patients 80 years or older (range, 80 to 92 years) (n = 191) who underwent AVR alone (n = 73) or AVR and CABG (n=118), between October 2003 and September 2009 were reviewed according to logistic EuroSCORE risk stratification. Surgical risk was defined as low risk (score 10% [n = 43]), medium risk (10% < score < 20% [n = 79]), and high risk (score 20% [n = 69]). Predicted survival of the general population of similar age and sex was calculated from tables published by the national central bureau of statistics. Quality of life (QOL) was assessed by a questionnaire.
RESULTS: Mean EuroSCORE predicted risk of perioperative mortality was 8.3% ± 1.2% (low risk), 14.5% ± 2.9% (medium risk), and 37% ± 14.5% (high risk; p < 0.001). Actual perioperative mortality was 4.7% (low risk), 5.1% (medium risk), and 21.7% (high risk; p = 0.002) for all patients. It was 0 (low risk), 3.3% (medium risk), and 18.5% (high risk; p = 0.045) for isolated AVR. Five years survival was 64%, 40%, and 37% (p = 0.006), for low-, medium-, and high-risk patients, respectively for all patients. It was 70%, 63%, and 53% (p = 0.23), for low-, medium-, and high-risk patients, respectively for isolated AVR. Expected 5 year survival of the general population of similar age and sex was calculated to be 60%. Independent predictors for perioperative mortality were severe LV dysfunction and COPD. Cox regression predictor of medium-term survival was severe LV dysfunction. In the QOL assessment, 82% expressed improvement in QOL, and 78% feel better than prior the operation.
CONCLUSIONS: Octogenarians with low and medium risk have excellent short- and long-term results after open AVR. High risk patients carry high early mortality. However, survivors, even in this high risk group, have life expectancy approaching that of age matched general population. Decisions regarding surgical intervention in patients requiring AVR should not be based on age alone.
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