HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Philippe Kolh Raymond Limet Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kolh, P. Articles by Limet, R. Search for Related Content PubMed PubMed Citation Articles by Kolh, P. Articles by Limet, R.

Eur J Cardiothorac Surg 1999;16:68-73
© 1999 Elsevier Science NL

Aortic valve replacement in the octogenarians: perioperative outcome and clinical follow-up

^a Cardiothoracic Surgery Department, University Hospital of Liège, B 35 Sart Tilman, 4000 Liège, Belgium
^b Department of Biostatistics, University of Liège, Liège, Belgium

Corresponding author. Tel.: +32-4-3667163; fax: +32-4-3667164
e-mail: philippe.kolh{at}chu.ulg.ac.be

	Abstract

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
Objectives: To determine long-term results of aortic valve replacement (AVR) in patients 80 years old or older, and assess the factors influencing perioperative outcome. Methods: Data were reviewed on 83 consecutive octogenarians, undergoing aortic valve replacement between 1992 and 1997. There were 66 women and 17 men (mean age: 82.8 years). Fifty-seven patients (69%) were in New York Heart Association (NYHA) class III–IV and six had previous myocardial infarction. Three patients had previous percutaneous aortic valvuloplasty. There were 19 urgent procedures (23%). Coronary artery bypass grafting (CABG) was performed on 21 patients (25%). Possible influence of preoperative and operative variables on early and late mortality was performed with univariate and multivariate statistical analysis, and survival was estimated with the Kaplan–Meier method. Results: Operative mortality was 13% (9% for AVR, 24% for AVR-CABG). Postoperative complications were respiratory failure in 19 patients, atrial fibrillation in 19, hemodialysis in four, myocardial infarction in four and stroke in two patients. Five patients required pacemaker insertion for permanent atrioventricular block. Median hospital stay and intensive care unit stay were 19.8±12.2 days and 7.9±3.4 days, respectively. Multivariate predictors of hospital death (P<0.05) were percutaneous aortic valvuloplasty, NYHA class IV, and urgent procedure. Mean follow-up was 26.5 months. Survival at 1, 2, and 5 years was 98.5±1.4% (63 patients at risk), 93.4±3.2% (47 patients at risk), and 78.2±6.9% (six patients at risk), respectively. Preoperative myocardial infarction and urgent procedure were independent predictors of late death. At most recent follow-up, 91% were angina free and 81% were in class I–II. Conclusions: Aortic valve replacement in octogenarians can be performed with acceptable mortality. These results stress the importance of early operation on elderly patients with aortic valve disease. Both long-term survival and functional recovery are excellent.

Key Words: Aortic valve • Cardiac surgery • Octogenarians • Quality of life

	1. Introduction

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
The increase in life span of European and American populations over the past decades has resulted in a significant increase in the number of people aged over 80 years. Based on statistical data derived from population studies, life expectancy varies from an average of approximately 8.1 years at the age of 80 years to 6 years at the age of 89 years [1].

With this ageing of the population and the greater use of non-invasive diagnostic techniques, particularly echocardiography with two-dimensional Doppler ultrasonography, the diagnosis of symptomatic aortic valve disease, particularly aortic stenosis, is becoming increasingly common [2]. Recent reports reveal that cardiac operations for selected elderly individuals who have otherwise good physical and mental health can improve mortality, morbidity and quality of life [3–6]. However, the outcomes remain not completely defined, especially for valve procedures.

To analyse these issues further, we have reviewed our early and long-term results in patients aged 80 years and over who underwent aortic valve replacement (AVR) at our institution, between January 1992 and November 1997.

	2. Methods

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
2.1. Patients
Records of 83 patients who underwent AVR, with or without concomitant procedures, were reviewed. A total of 46 preoperative, operative and postoperative variables were recorded. Follow-up information was obtained from all hospital survivors through clinic visits and annual letters, and was 100% complete. Mean follow-up was 26.5 months, and cumulative follow-up was 206 patient-years. Between February and March 1998, all known survivors were questioned to determine general health status, presence or absence of chest pain, dyspnea or angina pectoris, postoperative New York Heart Association (NYHA) functional class and quality of life.

Coronary artery disease was defined as a reduction of vessel diameter by at least 50% in one view on coronary angiography. Stenosis to this degree in the left anterior descending system, circumflex system, or right coronary system was used for the criterion of single, double, or triple vessel disease. Urgent operations were defined as operative procedures performed in patients whose accelerated symptoms prompted urgent hospital admission for evaluation and who were judged to be too unstable for discharge before surgery. Operative mortality was any death occurring within 30 days of the operation or death during the same hospital admission as the operation. Postoperative course was followed up in terms of bleeding, cardiac and renal status, assisted ventilation duration and neurological events. Congestive heart failure was determined by the presence of pulmonary congestion or opacities consistent with oedema on chest roentgenograms. Perioperative myocardial infarction was defined as either a new Q wave or the elevation of the myocardial fraction of creatinine kinase in association with persistent ST segment changes or a new conduction abnormality. Stroke was defined as any neurologic deficit lasting longer than 24 h, even if the deficit resolved before hospital discharge.

Anaesthesiological protocol was the same throughout this period, extracorporeal circulation was performed with a membrane oxygenator, and myocardial protection used cold crystalloid cardioplegia solution added to topical cooling.

2.2. Statistical analysis
Distribution for all relevant variables was expressed either as percentages or as mean±SD. The effects of nominal risk factors, such as the presence of angina, on early mortality were evaluated univariately with ² test or Fisher's exact test. The effects of continuous variables, such as age, were univariately evaluated with two-sample t-tests or with Wilcoxon rank sum tests when necessary. Combinations of risk factors were multivariately evaluated with multiple logistic regression models. Survivorship to death, for all patients and for all hospital survivors, was estimated with the Kaplan–Meier method. To assess separately those risk factors related to late survival as distinct from operative deaths, we analysed only hospital survivors. Nominal risk factors for survival were assessed with log-rank tests. Continuous measurable risk factors, such as age, and combinations of risk factors, both nominal and continuous, were evaluated with Cox's proportional hazard models. A P value <0.05 was considered statistically significant.

	3. Results

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
3.1. Patient population
The population consisted of 83 consecutive patients ranging in age from 80 to 89 years who underwent AVR, either alone or in combination with other procedures. Clinical characteristics of these patients are listed in Table 1. Most common presenting symptoms were dyspnea on exertion in 70 patients (84%), congestive heart failure in 51 patients (61%), angina in 48 patients (58%), and syncope in 21 patients (25%).

Aortic stenosis was the predominant valvular lesion in 64 patients (77%), followed by combined aortic stenosis and insufficiency in 18 patients (22%) and aortic insufficiency in one patient. Valvular disease involved calcified lesions in 80 patients (96%), bicuspid valve in 12 patients (14%), myxomatous degeneration in seven patients (8%), rheumatic disease in two patients (2%), and endocarditis in one patient.

Stented bioprostheses were implanted in 74 patients (89%), stentless bioprostheses in seven patients (8%), and mechanical valves in two patients (2%). Average valve size was 21.1 mm. Additional CABG was performed in 21 patients (25%), respectively for one-vessel disease in 10 (11%), two vessels disease in eight (10%), and three vessels disease in three (4%). Mean cardiopulmonary bypass time was 103.5±40.5 min, and mean aortic cross clamp time was 66.0±21.4 min.

3.2. Postoperative complications
Early postoperative complications are listed in Table 2. Arrhythmias occurred in 22 patients (26.5%), of whom 19 had atrial fibrillation or supraventricular tachycardia, and three had ventricular tachycardia. Among 19 patients (23%) requiring prolonged (>2 days) mechanical ventilation, 13 (15%) had pneumonia. Two patients (2.4%) developed cerebrovascular accident, of which one completely recovered before hospital discharge. Thirty patients (36%) had no postoperative complications. Length of hospital stay averaged 19.8±12.2 days, including two patients with stays longer than 50 days.

View larger version (11K): [in this window] [in a new window]   Fig. 1. Survival curve of all 83 patients and of 72 hospital survivors aged 80 years and older undergoing AVR.

At the time of follow-up, NYHA functional class and activity level also were assessed. The majority of patients were in NYHA class I (41/61, 67%) and class II (15/61, 25%). Patient activity level was rated as heavy, defined as running or lifting heavy objects; moderate, defined as ability to do cleaning; light, defined as activities of daily living; and bedridden. Patients often rated their activity level as heavy (13/61, 21%), or moderate (29/61, 48%). Among the 61 long-term survivors, 92% believed that having heart surgery after age 80 years was a good choice, and similarly 88% felt as good as, or better than they had preoperatively.

	4. Discussion

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 
The elderly population continues to expand in western countries, and acquired heart disease is a leading cause of death among the elderly [7]. Because aortic valvular disease remains a common problem in the elderly, increasing numbers of elderly patients are presenting for surgical evaluation of symptomatic valve disease. Controversy continues to exist as to whether aortic valve replacement represents a prudent expenditure of health-care resources in this population [5,8,9].

The natural prognosis of severe aortic stenosis is ominous: 90% of patients with angina and syncope died within 3 years of the onset of symptoms and if heart failure was present, death occurred within 2 years [10]. Balloon aortic valvuloplasty has been proposed as an alternative to operation in the treatment of aortic valve stenosis [11]. Nevertheless, published hospital mortality ranged from 3 to 10% [12,13], and hospital morbidity from 10 to 25%. Furthermore, immediate restenosis (within 72 h) occurred in 25% of patients, and 66% had restenosis within 6 months [13]. Survival curves showed less than 80% survival at 1 year, and functional improvement did not occur in all patients [13].

Early reports of AVR in elderly patients showed high operative mortality rates; however, recent reports have shown mortality rates of 2–10% for isolated AVR [14,15]. In a recent study by Akins et al. [14], hospital mortality in 105 octogenarians who had isolated AVR was 7.6%. Similarly, Tseng et al. [16] reported a 6.1% operative mortality among 247 elderly patients (70–89 years old) who underwent isolated AVR.

Our hospital mortality for 62 patients who underwent isolated AVR was 9%. These results show that AVR can be performed with an acceptable risk in patients older than 80 years of age. Significant improvement in surgical outcome has been ascribed to advances in myocardial protection, anaesthesia and postoperative critical care.

We sought to define risk factors that would be predictors of early death in this elderly population. Multivariate logistic regression analysis showed that the only preoperative risk factors associated with operative mortality were NYHA functional class IV, previous percutaneous valvuloplasty, and urgent procedure. After surgery, myocardial infarction was harbinger of a poorer outcome. Poor left ventricular function was also predictive of hospital death in two series, respectively from the Texas Heart Institute [15] and from the John Hopkins Hospital [16]. Elayada et al. [15] also found hypertension and concomitant surgical procedures to be associated with early mortality. Galloway et al. [17] showed emergency operation, isolated aortic regurgitation and previous cardiac operation to be predictive of operative mortality. It is important to note that in our experience, previous aortic valvuloplasty was an independent factor predicting operative mortality. However, it is possible that those patients were initially felt to be poor surgical candidates.

In our series, age itself was not a predictor. Similarly, age was not a predictor in the recent study by Tseng et al. [16].

Our postoperative complication rate was somewhat high (64%). Pulmonary insufficiency or infection was one of the leading causes of postoperative morbidity. In these elderly patients, we are now having encouraging results with partial sternotomies, early extubation (less than 6 h postoperatively) and more vigorous pulmonary toilet. Among the 22 patients who developed postoperative arrhythmias, 19 had atrial fibrillation or supraventricular tachycardia that was rapidly treated with either intravenous antiarrhythmic agents or cardioversion. The incidence of other postoperative complications such as stroke, dialysis, myocardial infarction, or reoperation, was comparable with other recent reports [14,16].

For hospital survivors, survival at 1, 2, and 5 years was 98.5±1.4%, 93.4±3.2%, and 78.2±6.9%, respectively. These survival rates are comparable with other studies and show good long-term survival despite advanced age [15,16,18].

In our study, previous myocardial infarction and urgent procedure were preoperative risk factors predictive of late mortality, by multivariate analysis. These results suggest that elderly patients should be referred for operation as early as possible to prevent urgent operations or advanced stage disease. Urgent operation also was predictive of late mortality in other recent studies [13,19]. When survival was stratified based on urgency of operation, our survival for elective surgery was 98.1±1.9%, 96.0±2.8% and 87.1±6.5% at 1, 2, and 5 years, respectively, as compared with 92.8±6.9%, 83.6±10.8% and 42.7±16.7% at 1, 2, and 5 years, respectively, for urgent operations. Clearly, referral of elderly patents before end-stage disease requiring urgent operations is paramount to long-term survival.

Of at least equal importance to the elderly as survival, is quality of life. In this study, 92% of long-term survivors believed in retrospect that having decided to have cardiac surgery after age 80 years had been a good choice. Furthermore, at a mean follow-up of 26.5 months postoperatively, 72% of survivors were still living at home or with their families. Finally, we did not experience valve-related complications, such as bleeding events, thromboembolism, prosthetic valve endocarditis, structural failure or reoperation.

We currently believe the bioprosthetic valve is the safest cardiac valve substitute in the octogenarians. A report by Jamieson et al. [20] states that structural deterioration of tissue valves is limited in the elderly population. Because systemic anticoagulation is rarely required, bioprosthetic valves have a reduced incidence of haemorrhagic and thrombotic complications compared with mechanical valves [21]. Furthermore, the use of stentless valves allows for implantation of larger prostheses, which in our study has beneficial effects on long-term survival, however, without reaching statistical significance.

Aortic valve replacement combined with coronary artery bypass grafting resulted in a 24% early- and a 12.5% late-mortality. This is noticeably higher than the 6.3% early mortality recently reported by Akins et al. [14], but comparable to the 28% early and 40% late mortality reported by Fiore et al. [22], which, however, is a somewhat older series. Our higher operative mortality could, in part, be explained by the significant preponderance of women (4:1). In other reports, female sex has been an independent predictor of both early and late mortality in the elderly, both for isolated AVR [23], and for AVR with CABG [24].

Conventional practice suggests that revascularization should be performed at the time of aortic valve replacement if major coronary artery stenosis is present, regardless of the presence or absence of angina [25]. Reports [26] in younger patient populations indicate that myocardial revascularization does not increase the operative mortality of valve replacement, and the functional result may be improved by relieving the symptoms of angina and providing improved myocardial protection. This aggressive approach requires prolonged ischemic time and may not be appropriate in the octogenarians. We now tend to believe that in octogenarians, only those with critical (>80%) coronary lesions or severe angina should undergo concomitant coronary bypass grafting. Less than complete revascularization may be an acceptable alternative in this elderly subset of patients when congestive heart failure is a primary indication for operation.

In summary, AVR can be performed in patients 80 years or older with acceptable mortality, good long-term results and good quality of life. Preoperative risk factors associated with early mortality involve previous percutaneous valvuloplasty and NYHA functional class IV, whereas myocardial infarction was a predictor of late mortality. Urgent procedure was an independent predictor of both early and late mortality.

We believe octogenarians with aortic valve disease should not be denied the benefits of surgery if they are reasonably good surgical candidates, are physiologically and mentally able to withstand the stress of surgery and have good motivation for an improved life style.

	Footnotes

 
Presented at the 20th Annual Meeting of the European Society of Cardiology, Vienna, Austria, August 23, 1998.

	References

Top Abstract 1. Introduction 2. Methods 3. Results 4. Discussion References

 

1. Statistical Abstract of the United States: 1991 (111th Ed). Washington DC, Department of Commerce, US Bureau of the Census, 1991:81.
2. Roger V., Tajik A., Reeder G., Hayes S.N., Mullany C.J., Bailey K.R., Seward J.B. Effect of Doppler echocardiography on utilization of hemodynamic cardiac catheterization in the preoperative evaluation of aortic stenosis. Mayo Clin Proc 1996;71:141-149.[Medline]
3. Freeman W.K., Schaff H.V., O'Brien P.C., Orszulak T.A., Naessens J.M., Tajik A.J. Cardiac surgery in the octogenarian: perioperative outcome and clinical follow-up. J Am Coll Cardiol 1991;18:29-35.[Abstract]
4. Tsai T.P., Nessim S., Kass R.M., Chaux A., Gray R.J., Khan S.S., Blanche C., Utley C., Matloff J.M. Morbidity and mortality after coronary artery bypass in octogenarians. Ann Thorac Surg 1991;51:983-986.[Abstract]
5. Culliford A.T., Galloway A.C., Colvin S., Grossi E.A., Baumann F.G., Esposito R., Ribakove G.H., Spencer F.C. Aortic valve replacement for aortic stenosis in patients aged 80 years and over. Am J Cardiol 1991;67:1256-1260.[Medline]
6. Kleikamp G., Minami K., Breymann T., Samar U., Luth J.U., Reichelt W., Gleichmann U., Körfer R. Aortic valve replacement in octogenarians. J Heart Valve Dis 1992;1:196-200.[Medline]
7. Statistical Abstract of the United States: 1994 (114th Ed). Washington DC, Department of Commerce, US Bureau of the Census, 1994:84.
8. Iskandrian A.S., Segal B.L. Should cardiac surgery be performed in octogenarians?. J Am Coll Cardiol 1991;18:36-37.[Medline]
9. Culliford A.T., Galloway A.C., Colvin S. Cardiac surgery in octogenarians: do the risks exceed the benefit?. Am J Geriatr Cardiol 1992;1:15-25.[Medline]
10. Frank S., Johnson A., Ross J. Natural history of valvular aortic stenosis. Br Heart J 1973;35:41-46.[Free Full Text]
11. Cribier A., Savin T., Saoudi N., Rocha P., Berland J., Letac B. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement. Lancet 1986;330:63-67.
12. McKay R.G. Balloon aortic valvuloplasty in 285 patients: initial results and complications. Circulation 1988;78(Suppl. 2):594.
13. Robicsek F., Harbold N.B.J., Daugherty H.K., Cook J.W., Selle J.G., Hess P.J., Gallagher J.J. Balloon valvuloplasty in calcified aortic stenosis: a cause for caution and alarm. Ann Thorac Surg 1988;45:515-525.[Abstract]
14. Akins C.W., Daggett W.M., Vlahakes G.J., Hilgenberg A.D., Torchiana D.F., Madsen J.C., Buckley M.J. Cardiac operations in patients 80 years old and older. Ann Thorac Surg 1997;64:606-615.[Abstract/Free Full Text]
15. Elayada M.A., Hall R.J., Reul R.M., Alonzo D.M., Gillette N., Reul G.J., Jr, Cooley D.A. Aortic valve replacement in patients 80 years and older: operative risks and long-term results. Circulation 1993;88(Part II):11-16.[Abstract/Free Full Text]
16. Tseng E.E., Lee C.A., Cameron D.E., Stuart R.S., Greene P.S., Sussman M.S., Watkins L., Gardner T.J., Baumgartner W.A. Aortic valve replacement in the elderly: risk factors and long-term results. Ann Surg 1997;225:793-804.[Medline]
17. Galloway A.C., Solvin S.B., Grossi E.A., Baumann F.G., Sabban Y.P., Esposito R., Ribakove G.H., Culliford A.T., Slater J.N., Glassman E., Harty S., Spencer F.C. Ten-year experience with aortic valve replacement in 482 patients 70 years of age or older: operative risk and long-term results. Ann Thorac Surg 1990;49:84-93.[Abstract]
18. Straumann E., Kiowski W., Langer I., Grädel E., Stulz P., Buckhardt D., Pfisterer M., Burkart F. Aortic valve replacement in elderly patients with aortic stenosis. Br Heart J 1994;71:449-453.[Abstract/Free Full Text]
19. Chocron S., Etievent J.P., Viel J.F., Meneveau N., Clement F., Schipman N., Taberlet C., Alman K. Aortic valve replacement in the elderly: a comparative assay of potential risk factor modification. J Heart Valve Dis 1995;4:268-273.[Medline]
20. Jamieson W., Burr L.H., Munro A.I., Miyagishima R.T., Gerein A.N. Cardiac valve performance in the elderly: clinical performance of biologic prostheses. Ann Thorac Surg 1989;48:173-185.[Abstract]
21. Borkon A.M., Soule L.M., Baughman K.L., Baumgartner W.A., Gardner T.J., Watkins L., Gott V.L., Hall K.A., Reitz B.A. Aortic valve selection in the elderly patient. Ann Thorac Surg 1988;46:270-277.[Abstract]
22. Fiore A.C., Naunheim K.S., Barner H.B., Pennington D.G., McBride L.R., Kaiser G.C., Willman V.L. Valve replacement in the octogenarian. Ann Thorac Surg 1989;348:104-108.
23. Azariades M., Fessler C.L., Ahmad A., Starr A. Aortic valve replacement in patients over 80 years of age: a comparative standard for balloon valvuloplasty. Eur J Cardio-thorac Surg 1991;5:373-377.[Abstract]
24. Aranki S.F., Rizzo R.J., Couper G.S., Adams D.H., Collins J.J., Jr, Gildea J.S., Kinchla N.M., Cohn L.H. Aortic valve replacement in the elderly. Effect of gender and coronary artery disease on operative mortality. Circulation 1993;88(5Pt2):II17-II23.
25. Kouchoukos N.T., Lell W.A., Rogers W.J. Combined aortic valve replacement and myocardial revascularization. Ann Thorac Surg 1983;197:721-727.
26. Lytle B.W., Cosgrove D.M., Loop F.D., Taylor P.L., Gill C.C., Golding L.A., Goormastic M., Groves L.K. Replacements of aortic valve combined with myocardial revascularization: determinants of early and late risk for 500 patients. Circulation 1983;68:1149-1162.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. P. Dal-Bianco, B. K. Khandheria, F. Mookadam, F. Gentile, and P. P. Sengupta Management of Asymptomatic Severe Aortic Stenosis J. Am. Coll. Cardiol., October 14, 2008; 52(16): 1279 - 1292. [Abstract] [Full Text] [PDF]

				B. Chenuel, M. Poussel, P.-L. Nguyen Thi, J.-P. Villemot, and P. Haouzi Arterial oxygen partial pressure and cardiovascular surgery in elderly patients Interactive CardioVascular and Thoracic Surgery, October 1, 2008; 7(5): 819 - 824. [Abstract] [Full Text] [PDF]

				A. Sinhal, L. Altwegg, S. Pasupati, K. H. Humphries, M. Allard, P. Martin, A. Cheung, J. Ye, C. Kerr, S. V. Lichtenstein, et al. Atrioventricular Block After Transcatheter Balloon Expandable Aortic Valve Implantation J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 305 - 309. [Abstract] [Full Text] [PDF]

				N. Piazza, Y. Onuma, E. Jesserun, P. P. Kint, A.-M. Maugenest, R. H. Anderson, P. P. T. de Jaegere, and P. W. Serruys Early and Persistent Intraventricular Conduction Abnormalities and Requirements for Pacemaking After Percutaneous Replacement of the Aortic Valve J. Am. Coll. Cardiol. Intv., June 1, 2008; 1(3): 310 - 316. [Abstract] [Full Text] [PDF]

				G. Silvay, J. G. Castillo, J. Chikwe, B. Flynn, and F. Filsoufi Cardiac Anesthesia and Surgery in Geriatric Patients Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2008; 12(1): 18 - 28. [Abstract] [PDF]

				S. Dawkins, A. R. Hobson, P. R. Kalra, A. T.M. Tang, J. L. Monro, and K. D. Dawkins Permanent Pacemaker Implantation After Isolated Aortic Valve Replacement: Incidence, Indications, and Predictors Ann. Thorac. Surg., January 1, 2008; 85(1): 108 - 112. [Abstract] [Full Text] [PDF]

				Y. S. Tjang, Y. van Hees, R. Korfer, D. E. Grobbee, and G. J.M.G. van der Heijden Predictors of mortality after aortic valve replacement Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 469 - 474. [Abstract] [Full Text] [PDF]

				L. A. Cuniberti, P. G. Stutzbach, E. Guevara, G. G. Yannarelli, R. P. Laguens, and R. R. Favaloro Development of Mild Aortic Valve Stenosis in a Rabbit Model of Hypertension J. Am. Coll. Cardiol., June 6, 2006; 47(11): 2303 - 2309. [Abstract] [Full Text] [PDF]

				F. Collart, H. Feier, F. Kerbaul, A. Mouly-Bandini, A. Riberi, T. G. Mesana, and D. Metras Valvular surgery in octogenarians: operative risks factors, evaluation of Euroscore and long term results Eur. J. Cardiothorac. Surg., February 1, 2005; 27(2): 276 - 280. [Abstract] [Full Text] [PDF]

				V. D. Bello, D. Giorgi, P. Viacava, T. Enrica, C. Nardi, C. Palagi, M. G. D. Donne, F. Verunelli, M. A. Mariani, J. Grandjean, et al. Severe Aortic Stenosis and Myocardial Function: Diagnostic and Prognostic Usefulness of Ultrasonic Integrated Backscatter Analysis Circulation, August 17, 2004; 110(7): 849 - 855. [Abstract] [Full Text] [PDF]

				J. Bergler-Klein, U. Klaar, M. Heger, R. Rosenhek, G. Mundigler, H. Gabriel, T. Binder, R. Pacher, G. Maurer, and H. Baumgartner Natriuretic Peptides Predict Symptom-Free Survival and Postoperative Outcome in Severe Aortic Stenosis Circulation, May 18, 2004; 109(19): 2302 - 2308. [Abstract] [Full Text] [PDF]

				J. Ennker, U. Rosendahl, I. C. Ennker, S. Bauer, and I. Florath Risk in Elderly Patients After Stentless Versus Stented Aortic Valve Surgery Asian Cardiovasc Thorac Ann, March 1, 2003; 11(1): 37 - 41. [Abstract] [Full Text] [PDF]

				K. Manku, P. Bacchetti, and J. M. Leung Prognostic Significance of Postoperative In-Hospital Complications in Elderly Patients. I. Long-Term Survival Anesth. Analg., February 1, 2003; 96(2): 583 - 589. [Abstract] [Full Text] [PDF]

				R. Rosenhek, G. Maurer, and H. Baumgartner Should early elective surgery be performed in patients with severe but asymptomatic aortic stenosis? Eur. Heart J., September 2, 2002; 23(18): 1417 - 1421. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Philippe Kolh Raymond Limet Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kolh, P. Articles by Limet, R. Search for Related Content PubMed PubMed Citation Articles by Kolh, P. Articles by Limet, R.