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Eur J Cardiothorac Surg 2005;28:83-87
© 2005 Elsevier Science NL

Is mitral valve surgery safe in octogenarians?

Jayan Nagendran a , * , Colleen Norris a , Andrew Maitland b , Arvind Koshal a , David B. Ross a

a University of Alberta Hospital, Edmonton, Alta., Canada
b University of Calgary Foothills Hospital, Calgary, Alberta, Canada

Received 14 September 2004; received in revised form 2 December 2004; accepted 13 December 2004.

* Corresponding author. Address: 2D4.37 Walter MacKenzie Center, Edmonton, Alta., Canada, T6G 2B7. Tel.: +1 780 407 8047; fax: +1 780 407 8054. (Email: jnagendr{at}ualberta.ca).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Objective: To evaluate the outcomes of mitral valve surgery in octogenarians. Methods: Data were collected prospectively from January 1996 to March 2004 at two surgical centers. Of 1386 consecutive patients with mitral valve surgery, 58 (4.2%) were aged ≥80 years. Survival data were analyzed using Cox proportional hazards modeling and Kaplan–Meier actuarial log rank statistics. Results: Octogenarians were similar to younger patients for the presence of pre-operative hypertension, hyperlipidemia, diabetes mellitus, and smoking history. Octogenarians had a higher incidence of cerebrovascular disease (19.0 versus 7.8%, P=0.003), urgent in-hospital surgery (55.2 versus 28.6%, P<0.001), and presence of ischemic disease requiring combined mitral valve plus revascularization surgery (72.4 versus 41.0%, P<0.001). Mitral valve repair was performed in a similar proportion of octogenarians and younger patients (44.8 versus 45.6%). Thirty-day mortality for octogenarians was significantly higher than younger patients (15.5 versus 5.6%, P=0.002), and actuarial survival of octogenarians was significantly decreased (P=0.009). However, 52.3% of the octogenarians were alive at 7-years following surgery. Independent predictors of mortality from multivariate risk adjusted modeling of the entire cohort were: emergency surgery (hazards ratio [HR]=2.94, P<0.001), combined mitral valve plus revascularization surgery (HR=2.27, P<0.001), mitral valve replacement (HR=1.85, P<0.01), and age ≥80 years (HR=1.80, P=0.02). Conclusions: Octogenarians undergoing mitral valve surgery have significantly greater incidence of urgent surgery, ischemic disease requiring combined revascularization surgery, and have decreased rates of survival. While caution is required when operating on these higher risk elderly patients, overall 52.3% of the octogenarians are alive at 7-years following surgery, which is greater than the survival of octogenarians in the community. The greatest survival benefit within octogenarians occurred when mitral valve repair was possible over replacement. Further study will more clearly define subgroups of octogenarians with potentially greater benefit from mitral valve surgery.

Key Words: Valve • Elderly • Survival


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
North America and Europe are experiencing an aging population. As there is an increasing number of people 80 years and older, there is a corresponding rise in the number of octogenarians undergoing cardiac surgical procedures [1]. There are studies which have shown that octogenarians derive benefit from coronary revascularization surgery [2]. It is also clear that octogenarians derive benefit from aortic valve surgery [3]. Survival has also been shown to be acceptable for combined aortic valve surgery and coronary surgery in selected patients with reasonable co-morbidities [4]. Studies have concluded that mitral valve replacement is associated with a worsened survival than mitral valve repair [5]. There is also evidence that more octogenarians are undergoing mitral valve surgery [6]. In an era of higher prevalence of ischemic mitral valve surgery [6], and increased number of octogenarians undergoing cardiac surgical procedures, the purpose of this study is to examine the safety of octogenarians undergoing mitral valve surgery. The study looks specifically at survival of octogenarians versus younger patients undergoing mitral valve surgery over the same time period.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 Appendix A. Conference...
 References
 
Data were collected from a combined cardiac surgery and cardiology database from January 1996 to March 2004. All patients who underwent any cardiac surgical procedure at the University of Alberta Hospital and the Calgary Foothills Hospital were registered in the database prospectively. The database used in at our institution is the APPROACH (Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease). Data were analyzed using the SPSS version 12 software for statistics.

There were 1386 consecutive patients with mitral valve surgery at the two centers. Of the cohort of mitral valve surgery patients, 58 (4.2%) were octogenarians. Data were analyzed retrospectively. Chi squared analysis was used for association between independent variables. Kaplan–Meier actuarial log rank statistics was used to estimate survival curves for octogenarians and younger patients. A multivariate model using Cox proportional hazards modeling was employed to determine independent variables for mortality for the entire cohort.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 Appendix A. Conference...
 References
 
3.1. Demographics
The mean age of octogenarians was 82.4+1.8 years (range 80.0–86.9 years), whereas the mean age of younger patients was significantly lower at 61.8+12.4 years (range 18.7–79.9 years). There was an equal portion of women in both older and younger patients (40 versus 41%, respectively). In examining the pre-operative characteristics of the patients, the incidence of previous stroke was the only significantly different (P=0.003) pre-operative co-morbidity between the octogenarians and younger patients (Table 1 ). The incidence of renal dysfunction, congestive heart failure, type II diabetes mellitus, hypertension, hyperlipidemia, history of smoking, and history of myocardial infarction were not significantly different for older and younger patients.


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  		Table 1. Pre-operative co-morbidities
 
3.2. Interventions and urgency
Octogenarians and younger patients were similar in their history of previous thrombolysis (P=0.335) and previous percutaneous coronary intervention (angioplasty and stenting) (P=0.755). In reviewing the urgency of surgery, there are three categories: emergency surgery which is performed within 24h of admission to hospital, urgent surgery where a patient is admitted to hospital and has surgery done on the same admission in greater than 24h, and elective surgery where a patient is admitted from home for non-urgent surgery. The percentage of emergency surgery was low for both octogenarians and younger patients (1.7 versus 4.3%, P=0.268). Over half the octogenarians were operated on as urgent surgeries (Table 2 ), which was a significantly increased proportion compared to younger patients (55.2 versus 28.6%, P<0.001).


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  		Table 2. Interventions and urgency of surgery
 
3.3. Operations performed
Octogenarians were equally likely to have had a mitral valve repair as younger patients (45 versus 46%, Fig. 1 ). However, the majority of octogenarians undergoing mitral valve surgery had concomitant revascularization procedures while less than half the younger patients had combined bypass surgery (72 versus 41%, P<0.001, Fig. 2 ).



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  		Fig. 1. Proportion of Mitral Valve Repair.

 


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  		Fig. 2. Proportion of Combined Bypass Surgery.

 
3.4. Survival
Follow-up was 100% complete for the entire cohort, this is accomplished as the database is cross-linked to Vital Statistics Canada for complete mortality data on all Canadians. Survival data were analyzed using Kaplan–Meier log rank statistics. Octogenarians had a significantly decreased rate of survival compared to younger patients (P=0.009). The majority of the difference in survival is attributed to the operative mortality which was significantly higher for octogenarians (15.5 versus 5.6%, P=0.002). The curves are nearly parallel after the initial drop in survival of octogenarians (Fig. 3 ). At 7 years post-operatively, there is a 52.3% survival of octogenarians, which includes the operative mortality.



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  		Fig. 3. Survival Curves for Octogenarians and Younger Patients.

 
Mitral valve replacement and mitral valve repair were examined as cumulative survival over 7 years. Mitral valve replacement in octogenarians was associated with a significantly worse cumulative survival than younger patients (59.4 versus 79.7%, P=0.006). Mitral valve repair was associated with similar cumulative survival in octogenarians and younger patients (88.5 versus 89.6%, P=0.854). Within octogenarians, mitral valve repair had a significantly greater cumulative survival when compared to replacement (88.5 versus 59.4%).

Given the higher proportion of octogenarians undergoing combined procedures, a sub-group analysis of octogenarians for survival using Kaplan–Meier log rank statistics for mitral valve surgery versus combined mitral valve and CABG was performed. There was no statistically significant difference in survival for octogenarians undergoing isolated valve procedures or combined procedures (P=0.301) as seen by the survival curve in Fig. 4 . The overall survival for isolated mitral valve surgery was 62.5% and for combined mitral valve and CABG was 76.2%.



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  		Fig. 4. Survival Curves for Octogenarians with Isolated Mitral Valve Surgery versus Combined Mitral Valve and Coronary Artery Bypass Grafting Surgery.

 
3.5. Multivariate analysis
Cox proportional hazards modeling survival for the entire cohort of 1386 patients was employed. It was found that pre-operative history of stroke (P=0.62) and urgent surgery (P=0.30) were not significant independent risk factors for mortality. There were four significant independent risk factors for mortality which included: mitral valve replacement, combined mitral valve and bypass surgery, emergency surgery, and being an octogenarian (Table 3 ).


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  		Table 3. Cox proportional hazards modeling survival
 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
Appendix A. Conference...
 References
 
This study examined the safety of mitral valve surgery in octogenarians, specifically by looking at long-term survival compared to younger patients. It was found that octogenarians were different than younger patients undergoing mitral valve surgery in that octogenarians were more likely to have a history of stroke, require urgent surgery, and have combined mitral valve and coronary artery bypass surgery. The increased history of cerebrovascular accidents in octogenarians is consistent with previous findings by Alexander and colleagues [7]. The higher proportion of urgent surgery versus elective surgery for octogenarians is also consistent with previous studies as per Fruitman and associates [8]. There was a large difference in percentage of octogenarians undergoing combined mitral valve and bypass surgery compared to younger patients (72 versus 41%, P<0.001). Thus, it is not unexpected that octogenarians had decreased survival rates as combined procedures have been shown to an independent risk factor for mortality [9].

Octogenarians do have a significantly lower survival (P=0.009) than younger patients, as seen by the Kaplan–Meier log rank statistics survival curves. The majority of the difference in the two survival curves can be attributed to the operative mortality of octogenarians being significantly higher than younger patients. Octogenarians had a three-fold increased rate of operative mortality compared to younger patients (15.5 versus 5.6%, respectively), which is expected rates of mortality as described by Nowicki and colleagues [10] where age over 80 had a odds ratio of 3.54 for association to in-hospital mortality after mitral valve surgery in a univariate analysis of 3150 patients. Once the initial drop in octogenarian survival is subtracted, the two survival curves nearly overlap. In spite of the lower survival of octogenarians, the 7-year survival was 52.3%, which is greater than the overall aged matched population of Canada which is less than 50% at 7-years. 1 .

The multivariate Cox proportional hazards modeling survival of the entire cohort showed that history of cerebrovascular accident and urgent surgery were not independent risk factors for mortality. This is in contrast to results observed by Kolh and associates [11], who found that both cerebrovascular accident and urgent surgery were independent risk factors for mortality in a multivariate analysis.

There were four independent risk factors for mortality from our multivariate analysis. First, mitral valve replacement was inferior to repair, a finding consistent with others [5]. The risk factor of emergency surgery is also a well documented independent risk factor for all cardiac valvular surgery [10]. The finding of combined mitral valve and revascularization surgery adding increased risk has too been previously described by others [12]. Thourani and associates [12] not only showed the benefit to mitral valve repair over replacement, they also demonstrated decreased survival associated with advanced age and combined valve and bypass surgery. Finally, there is the risk associated with being an octogenarian.

In conclusion, although age greater than or equal to 80 years is an independent risk factor for mortality in this study, as previously mentioned the overall survival of octogenarians undergoing mitral valve surgery was comparable and indeed greater than the survival of octogenarians in the community during long-term follow-up. Octogenarians undergoing mitral valve surgery do pose a significant operative risk, yet the long-term survival benefit justifies the high (15.5%) in-hospital mortality. Urgent surgery is not predictive of a poorer outcome, only emergency surgery is predictive of a worsened outcome. Patients who are suitable for mitral valve repair in both younger and older cohorts derive greater survival benefit, and the difference is far greater in the octogenarian group. Isolated mitral valve procedures and combined mitral valve and coronary artery bypass surgery in octogenarians was not found to show significant survival difference; however, in the entire cohort with younger patients this was found to be an independent risk factor for mortality. Thus, we should operate on octogenarians requiring mitral valve surgery, even in the urgent setting or requiring combined revascularization procedures. The greatest benefit to octogenarians occurs when mitral valve repair can be performed and should be the goal for this higher risk group of elderly patients.

4.1. Limitations
This study used data that was collected in a prospective database, though a retrospective analysis of the data was performed. In spite of showing acceptable long-term survival rates of octogenarians, there is no post-operative quality of life and functional status data for these patients, which would further validate the benefits of mitral valve surgery in octogenarians if quality of life remained acceptable. Also, we have not gone back to the individual charts and ascertain mitral valve pathology from the pre-operative trans-esophageal echocardiograms for this entire cohort, thus, we are unable to analyze etiology of mitral valve disease as a predictor of mortality. Through our prospectively collected database, there is no scoring system linked for estimating peri-operative mortality. Finally, with an octogenarian sample size of 58, it is difficult to sub-analyze this group to determine subgroups which may derive potentially greater benefit from mitral valve surgery, which makes interpretation of the survival curves in Fig. 4 even more tenuous.


   Appendix A. Conference discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 Appendix A. Conference...
References
 
Dr D. Unic (Zagreb, Croatia): You have shown us the cohort of your patients and the multivariate analysis which shows only that the age over 80 years is an independent risk factor. Do you have maybe a multivariate or univariate analysis pertaining to just those 58 patients, only the octogenarians? And do you have the data for cardiopulmonary bypass and the type of mitral valve pathology, which I think is very important in these patients?

Dr Nagendran : This study is a pilot study and soon to be multicenter study across the nation and the east coast of Canada as well. We have not done a univariate analysis on the subgroup of octogenarians, which would be performed as the study grows in size.

In terms of the etiology of mitral valve pathology, that is an excellent question. And I may speculate that based on the requirement of concomitant coronary surgery that the majority of octogenarians undergoing mitral valve procedures are ischemic in nature, though I do not have that precise data with me, which will be included in the larger study.

Dr J. Tsai (Pingtung, Taiwan): Up to 10 years after operation, in your 52 cases, did you find any AV groove laceration compared before 80 years old, the incident of these two groups, any incident of AV groove laceration?

Dr Nagendran : There were two patients who had AV groove dissociation and they were both in younger patients. Neither of them were in the octogenarian population.

Dr Tsai : You mean 80 years old age, two?

Dr Nagendran : No, younger patients.

Dr Tsai : Younger patients.

Dr Nagendran : None in the octogenarian population.

Dr Tsai : Okay.


   Footnotes
 
{star} Presented at the joint 18th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 12th Annual Meeting of the European Society of Thoracic Surgeons, Leipzig, Germany, September 12–15, 2004.

1 Canada Health Survey, 1978–1989. www.statcan.ca Back


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

  1. Craver J, Puskas J, Weintraub W, Shen Y, Guyton R, Gott J, Jones E. 601 Octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg 1999;67:1104-1110.[Abstract/Free Full Text]
  2. Dalrymple-Hay M, Alzetani A, Aboel-Nazar S, Haw M, Livesey S, Monro J. Cardiac surgery in the elderly. Eur J Cardiothorac Surg 1999;15:61-66.[Abstract/Free Full Text]
  3. Chiappini B, Camurri N, Loforte A, Di Marco L, Di Bartolomeo R, Marinelli G. Outcome after aortic valve replacement in octogenarians. Ann Thorac Surg 2004;78:85-89.[Abstract/Free Full Text]
  4. Herlitz J, Brandrup-Wognsen G, Caidahl K, Haglid M, Karlsson B, Karlsson T, Albertsson P, Lindelow B. Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery early and late results. Eur J Cardiothorac Surg 1997;12:836-846.[Abstract]
  5. Enriquez-Sarano M, Schaff H, Orszulak T, Tajik A, Bailey K, Frye R. Valve repair improves the outcome of surgery for mitral regurgitation: a multivariate analysis. Circulation 1995;91:1022-1028.[Abstract/Free Full Text]
  6. Nowicki E, Weintraub R, Birkmeyer N, Sanders J, Dacey L, Lahey S, Leavitt B, Clough R, Quinn R, O'Connor G. Mitral valve repair and replacement in northern New England. Am Heart J 2003;145:1058-1062.[CrossRef][Medline]
  7. Alexander K, Anstrom K, Muhlbaier L, Grosswald R, Smith P, Jones R, Peterson E. Outcomes of cardiac surgery in patients age ≥80 years: results from the national cardiovascular network. J Am Coll Cardiol 2000;35:731-738.[Abstract/Free Full Text]
  8. Fruitman D, MacDougall C, Ross DB. Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg 1999;68:2129-2135.[Abstract/Free Full Text]
  9. Mehta R, Eagle K, Coombs L, Peterson E, Edwards F, Pagani F, Deeb G, Bolling S, Prager R. Influence of age on outcomes in patients undergoing mitral valve replacement. Ann Thorac Surg 2002;74:1459-1467.[Abstract/Free Full Text]
  10. Nowicki E, Birkmeyer N, Weintraub R, Leavitt B, Sanders J, Dacey L, Clough R, Quinn R, Charlesworth D, Sisto D, Uhlig P, Olmstead E, O'Connor G. Multivariable prediction of in-hospital mortality associated with aortic and mitral valve surgery in northern New England. Ann Thorac Surg 2004;77:1966-1977.[Abstract/Free Full Text]
  11. Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R. Cardiac surgery in octogenarians. Eur Heart J 2001;22:1235-1243.[Abstract/Free Full Text]
  12. Thourani V, Weintraub W, Guyton R, Jones E, Williams W, Elkabbani S, Craver J. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. Circulation 2003;108:298-304.[Abstract/Free Full Text]



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