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Eur J Cardiothorac Surg 2005;27:276-280
© 2005 Elsevier Science NL

Valvular surgery in octogenarians: operative risks factors, evaluation of Euroscore and long term results

Service de Chirurgie cardiaque, Hopital de la Timone, 246 rue St Pierre, 13385 Marseille cx 05, France

Received 16 July 2004; received in revised form 13 October 2004; accepted 25 October 2004.

^* Corresponding author. Tel.: +33 4 91 38 57 17; fax: +33 4 91 85 41 40. (E-mail: fcollart{at}univ-aix.fr).

	Abstract

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

 
Objectives: In the last decade, cardiac surgery in octogenarians is becoming a routinely performed procedure in our Western countries. The functional benefit of this surgery had already been proved. The aim of this study was to evaluate operative mortality, to identify pre- and post-operative risk factors of early and late mortality, to assess the Euroscore count in this high-risk group of patient and to evaluate late results of this surgery. Methods: We reviewed 215 consecutive patients with a mean age of 83±2 years having undergone valvular surgery. There were 127 female patients (57.1%) and 88 males (42.9%). One hundred and fifty-nine patients (74%) underwent aortic valve replacement 42 (19.5%) mitral surgery and 14 (6.5%) double valve surgery. There were 32 (14.9%) re-operative cases. Twenty-seven patients (12.6%) were operated on in emergency. There were 32 re-operations (14%). The EuroSCORE was used to assess predicted operative risk. Mean Euroscore additive count was 9.5±2.3 and mean logistic Euroscore was 15.1%. Results: Operative mortality was 8.8% (19 patients). Left ventricular dysfunction was the only pre-operative significant risk factors of mortality (P=0.05). Low cardiac output (P<0.001), gastrointestinal complications (P=0.03) and surgical reexploration (P=0.001) were significant risk factors of mortality. Mean survival was 84% after one year and 56% after 5 years. Conclusions: Valvular surgery in octogenarians is a safe and low risk procedure compared to functional benefit and long-term survival. Our data how that logistic Euroscore overestimates the mortality in this high-risk group of patients.

Key Words: Valvular surgery • Octogenarian • Euroscore

	1. Introduction

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

 
The increased life expectation in Western countries has led to a significant increase in the number of people aged over 80 [1]. The prevalence of cardiovascular pathologies is higher in octogenarians than in younger population and can go up to 40% [2]. Moreover, progress made over the past few years with a significant lower operative mortality have contributed to a broader indication for valvular surgery in octogenarians. Many scientific papers have evidenced the benefits of surgery in these patients, with a functional improvement comparable to younger age groups [3,4]. Compared to younger group of patients valvular surgery represents a higher proportion in octogenarians. The object of this study is to assess all the pre- and post-operative morbidity factors in octogenarian patients who benefited from valvular surgery. We also calculated the EuroSCORE to see whether it satisfactorily fitted with operative risk evaluation in such patients. The aim of our study was also to assess long-term results of this surgery in old patients [5,6].

	2. Methods

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

 
Since 1986, operative and post-operative data of all patients operated on in our institution are prospectively collected in the computer supported data base of the adult cardiac surgery of the ‘Hôpital de la Timone’ in Marseille. Analysis of this database made it possible to list all octogenarian patients who had valvular surgery between January 1993 and December 2003. Data on 215 successive patients were extracted from the database to perform this study. The whole of demographic data, pre-operative risk factors, surgical procedures and post-operative complications were reviewed.

All patients operated on an elective manner had received a cardiac catheterization and coronography pre-operatively.

The operating technique was identical for all patients. Following general anaesthesia a median sternotomy was performed together with standard canulation from right atrium and ascending aorta. Extra-corporeal circulation was set up under moderate hypothermia with non-pulsating flow. Myocardial protection was ensured by intermittent cold blood cardioplegia.

Emergency was defined as a procedure carried out on referral before the beginning of the next working day and critical status was any one or more of the following: ventricular tachycardia or fibrillation or aborted sudden death, pre-operative cardiac massage, pre-operative ventilation before arrival in the anaesthetic room, pre-operative inotropic support, intraaortic balloon counterpulsation or pre-operative acute renal failure (anuria or oliguria<10ml/h).

Post-operative death was defined as hospital mortality (death within any time interval after operation if the patient is not discharged from the hospital and include patients dying in the operating room).

All post-operative complications were recorded. Low cardiac output was defined as a post-operative inotropic support for more than 24h. Infection included any post-operative infectious complication requiring antibiotic therapy. Pulmonary complications comprised all those leading to prolonged mechanical ventilation.

The additive and logistic EuroSCORE ratings were calculated to assess the post-operative risk.

For distance follow-up, a telephone study was made for all survivors at the time of the study (early 2004). The follow-up study utilized a specific questionnaire aimed at acquiring information about the patients' post-operative functional and social status, new hospitalization and quality of life of each survivor. In case of death during follow-up, the cause of death was assumed whenever possible to be on the basis of a declaration from the referring physician. Post-operative functional capacity was ranked according to the NHYA classification system. A non-symptomatic patient was defined as one who, during follow-up, did not experience angina pectoris, dyspnea, edema or palpitations. Autonomy and degree of dependency were quantified by scoring the collected data with both the OMS performance ladder (minimum 0 for normal life with no restriction, maximum 4 for a totally dependent bedridden patient) and the Karnofsky dependency category (minimum 10 for bedridden patients, maximum 100 for normal lifestyle). Social integration was monitored by the following items: a need for occasional or permanent assistance; living at home; living with relatives; and living in an institution. Finally the patients were asked in retrospect, and taking into consideration all suffering during hospitalization for surgery and the benefits they felt subsequently, whether they would agree to undergo surgery again.

Statistical analysis was performed through the SPSS software (SPSS, Inc., Chicago, IL, USA). For comparison of qualitative variables, Chi square or Fisher's Exact tests were used and in order to compare the medians and averages of variables the Mann–Whitney test were implemented as well as the Cox model for multivariate analysis. A 0.05 threshold was considered significant. Survivals were estimated through the Kaplan–Meyer's method and compared through the Log Rank test.

	3. Results

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

 
Out of the 215 patients in the study, there were 127 females (59.1%) and 88 males (40.9%). Average age was 83±2.3 years within a 80–90 years range. Average NYHA rating of patients stood at 2.6. Patients' characteristics and pre-op risk factors are given in Table 1 and surgical data in Table 2. Most patients had elective surgery, 11.2% emergency and three critical conditions. In 32 cases (15%), surgery was re-operation (31 cases of anterior valvular surgery and one myocardial revascularization). In 29 cases redux surgery and tridux in three patients was involved. The mean additive EuroSCORE was 9.54±2.33 [min 7–max 19] and the logistic EuroSCORE 14.9%. Minimum EuroSCORE was seven points (five points for patients over 80 years of age and 2 for valve surgery) which places the patients in the high-risk group. We divided the patients into three sub-groups on the basis of the EuroSCORE (low risk, EuroSCORE<9; moderate risk, between 9 and 10; and high risk, EuroSCORE>10). Aortic valve replacement was the most frequent surgical procedure (74%). Tight calcific aortic stenosis accounted for 73% of aortic pathologies and mitral insufficiency for 74% of mitral valve pathologies. Triscupid plasty was required in four patients.

Operating mortality was 8.8% (19 patients) for an additive EuroSCORE predicted mortality of 9.54 and a logistic EuroSCORE of 15.1%. Table 4 shows both actually observed mortality and EuroSCORE predicted mortality for each sub-group of patients. The main cause for post-operative death was cardiogenic shock. In univariate analysis, no single post-operative death cause emerged as mortality significant and in multivariate analysis, the moderate alteration in the left ventricle ejection fraction (between 30 and 50%) stood out as the only pre-operative predictive factor (P=0.05). Mortality was not significantly higher in re-operations, in emergency surgery cases or those having had associated myocardial revascularization. Mortality predictive post-op complications were: low output (P<0.001), digestive complications (P=0.03), need for surgical re-intervention and mechanical ventilation for over 24h (P<0.001).

Return home was possible for 77% of patients and 38% could live on their own. If surgery needed to be done again, 78% of patients would agree to it.

Regarding the quality of life and autonomy, more than 65% of patients have and OMS performance ladder of 0 or 1 (Fig. 1) and 79% of patient a Karnofsky count of 60 or more.

View larger version (25K): [in this window] [in a new window]   Fig. 1. OMS autonomy score (0 for normal life with no restriction, 4 for a totally dependent bedridden patient).

The late mortality predictive risk factors are age, over 85 at the date of surgery (P=0.001), diabetes (P=0.025) and renal insufficiency (P=0.04). Long-term survival rates are, respectively, 84, 76, 68, 65, and 56% at 1–5 years. Fig. 2 gives the survival curve plotted against that of the general population of the same age.

View larger version (18K): [in this window] [in a new window]   Fig. 2. Actuarial survival curve compared with same age general population.

	4. Discussion

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

The demographic data in the study show that women accounted for the majority of octogenarians who had valvular surgery, this data being comparable to other publications such as Akins et al. [9]. Higher life expectancy in women is the likely cause of this data trend. The incidence of the pre-operative risk factors is similar to what is found in younger patients, apart from the diabetes percentage (5%), which remains low, as life expectancy is poorer in diabetic patients. The study made by Avery et al. [10] presents similar results.

Many publications in the literature report a 10% higher surgical mortality in octogenarians [4,8,10–12]. More recent studies have reported a figure of 7.6% mortality rate for patients operated on with isolated valve replacement [9]. In our series, the 8.8% global operative mortality is comparable to that of these more recent publications. In the 32 re-intervention group, operative mortality was 9.3%, comparable to that published by Blanche and coll. [13]. In the group of double valvular replacements, mortality was higher (14.3%), but not significantly so on account of the small number considered but it still remained very much lower than figures given in other reports [14]. Contrary to what has been published in other studies, the need to add myocardial revascularization procedure in some patients did not increase operative mortality [7,9,11], which was even lower in this group (4.7%), although non-significant.

Operative mortality is slightly lower than the predictive value from the additive EuroSCORE (9.54%). But is it markedly lower than mortality predicted by the logistic EuroSCORE which is supposed to be more performing for assessing surgical risk in high-risk patients [15]. It would seem that the logistic EuroSCORE is not suited to assess surgical risk in such patients. The division into three groups (low, moderate or high risk) by the EuroSCORE did not give any evidence of an increase in operative mortality for higher risk patients.

Operative mortality was not higher in surgical emergency patients, contrary to other studies [11,12]. The only significant pre-operative risk factor evidenced was a lower ejection fraction <50%. A larger patient population may have evidenced a number of pre-operative risk factors. In the literature, renal insufficiency [16], COPD [9], pulmonary arterial hypertension [11] or an NHYA >2 [11] status stand out as risk factors.

The study of post-operative complications shows that the main mortality risk factor is post-op cardiogenic shock as showed in most literature reports. The fragility of these patients and the difficulty in considering circulatory assistance, even of short duration, in octogenarians may explain these results. Our re-operation incidence is comparable to other studies with variations ranging from 5.6 to 13% [7–11]. The need for re-operation, which is usually accompanied by an increase in transfusions required, with infectious and respiratory risk leads to a significant increase in mortality. Other major complications such as digestive ischemia have most serious consequences for such fragile patients with 50% mortality in our series. Post-operative atrial fibrillation was the most frequent complication, but less so than in Avery's report who gave 55.3% post-op predictive AF rate in octogenarians [10].

The distance results for surgery are excellent, and confirm the major benefits surgery offers such patients. Functional gains are confirmed by many reports [3,7,8].

Long-term survival too is good with over half of the patients having 5 years survival, considering that average age on surgery was 83 years.

Long-term survival is parallel to that of the same general population age group.

Long-term mortality, functional status, OMS and karnofsky count were not different in the three subgroups op patients. Patients with a high pre-operative Euroscore count did not have a poor long-term outcome compared to low risk patients.

The results of the study evidence that valvular surgery can be performed with low operative risk on octogenarians. The presence of associated risk factors leading to a higher EuroSCORE does not lead to any increase in operative mortality according to our study. Considering these results, it would seem logical to consider the overall condition, level of autonomy and life expectancy of octogenarian patients before considering surgery including on patients with a higher operative risk level. The Euroscore did not predict long-term outcome in high risk operative patients.

	References

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

 

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