Minimally invasive aortic valve replacement in octogenarian, high-risk, transcatheter aortic valve implantation candidates.

OBJECTIVE Risk-stratifying algorithms are currently used to determine which patients may be at prohibitive risk for surgical aortic valve replacement, and thus candidates for transcatheter aortic valve implantation. Minimally invasive surgical approaches have been successful in reducing morbidity and improving survival after aortic valve replacement, especially in octogenarians. We documented outcomes after minimally invasive aortic valve replacement in high-risk octogenarians who may be considered candidates for percutaneous/transapical aortic valve replacement. METHODS From 1996 to 2009, minimally invasive aortic valve replacement was performed in 249 consecutive octogenarians. We used the modified European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons score to risk-stratify patients and characterize all early and late results. RESULTS The mean age at operation was 84±3 (range 80-95) years, and 111 patients (45%) were male. Twenty-one percent (n=52) had previous cardiac surgery. Operative mortality was 3% (n=8/249). The median modified European System for Cardiac Operative Risk Evaluation (11%; interquartile range, 6-14) and Society of Thoracic Surgeons score (10.5%; interquartile range, 7-17) were not predictive of 30-day mortality in this cohort of patients (European System for Cardiac Operative Risk Evaluation c-index=0.527, P=.74, Society of Thoracic Surgeons score c-index=0.67, P=.18). Despite their poor predictive power, the Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation were correlated with each other (r=0.40, P<.0001). Postoperative complications included stroke in 10 patients (4%), pneumonia in 3 patients (1%), renal failure requiring dialysis in 2 patients (1%), cardiac arrest in 2 patients (1%), pulmonary embolism in 1 patient (1%), and sepsis in 1 patient (1%). Follow-up was available for 238 patients (96%) and extended up to 12 years. Overall, long-term survival after minimally invasive aortic valve replacement at 1, 5, and 10 years was 93%, 77%, and 56%, respectively. There was no significant difference in long-term survival compared with that of a US age- and gender-matched population (standardized mortality ratio, 1.01; 95% confidence interval, 0.76-1.37; P=.88). A multivariate Cox-proportional hazards model indicated that increasing age (hazard ratio, 1.10; P=.008) and severe chronic obstructive pulmonary disease (hazard ratio, 2.52; P<.007) were significant predictors of survival. By using these factors, a clinical prediction model (P=.02) was developed and demonstrated that low-risk patients (first quartile prediction score) had 1-, 5-, and 8-year survival of 94%, 84%, and 67%, whereas high-risk patients (third quartile prediction score) had 1-, 5-, and 8-year survival of 89%, 74%, and 49%, respectively. CONCLUSIONS Patients thought to be high-risk candidates for surgical aortic valve replacement have excellent outcomes after minimally invasive surgery with long-term survival that is no different than that of an age- and gender-matched US population. These data provide a benchmark against which outcomes of transcatheter aortic valve implantation could be compared.

[1]  L. Cohn,et al.  Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. , 1997, Annals of surgery.

[2]  Alec Vahanian,et al.  Results of transfemoral or transapical aortic valve implantation following a uniform assessment in high-risk patients with aortic stenosis. , 2009, Journal of the American College of Cardiology.

[3]  J. Tijssen,et al.  Which elderly patients with severe aortic stenosis benefit from surgical treatment? An aid to clinical decision making. , 2004, The Journal of heart valve disease.

[4]  L. Svensson,et al.  Minimal-access "J" or "j" sternotomy for valvular, aortic, and coronary operations or reoperations. , 1997, The Annals of thoracic surgery.

[5]  F. Mohr,et al.  Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE. , 2009, The Annals of thoracic surgery.

[6]  T. Mihaljevic,et al.  One Thousand Minimally Invasive Valve Operations: Early and Late Results , 2004, Annals of surgery.

[7]  S. Nashef,et al.  Eurp-pean system for cardiac operative risk evaluation (Euro SCORE) , 1999 .

[8]  Philippe Ravaud,et al.  Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? , 2005, European heart journal.

[9]  J. Ennker,et al.  Aortic valve replacement in octogenarians: identification of high-risk patients. , 2010, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[10]  D. Malenka,et al.  Long-Term Survival of the Very Elderly Undergoing Aortic Valve Surgery , 2009, Circulation.

[11]  Fabian Nietlispach,et al.  Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. , 2010, Journal of the American College of Cardiology.

[12]  F. Biancari,et al.  Is it possible to improve the accuracy of EuroSCORE? , 2009, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[13]  Assaf Bash,et al.  Percutaneous Transcatheter Implantation of an Aortic Valve Prosthesis for Calcific Aortic Stenosis: First Human Case Description , 2002, Circulation.

[14]  R. Salamon,et al.  Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. , 1999, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[15]  M. Pasque,et al.  Aortic valve replacement in octogenarians: risk factors for early and late mortality. , 2007, The Annals of thoracic surgery.

[16]  P. Pibarot,et al.  Feasibility and initial results of percutaneous aortic valve implantation including selection of the transfemoral or transapical approach in patients with severe aortic stenosis. , 2008, The American journal of cardiology.

[17]  Daniel R Wong,et al.  Transapical transcatheter aortic valve implantation: 1-year outcome in 26 patients. , 2009, The Journal of thoracic and cardiovascular surgery.

[18]  L. Cohn,et al.  Reoperative minimal access aortic valve surgery: minimal mediastinal dissection and minimal injury risk. , 2008, The Journal of thoracic and cardiovascular surgery.

[19]  R. Bansal,et al.  Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: Results from a cohort of 277 patients aged > or =80 years. , 2006, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[20]  W. Baumgartner,et al.  EuroSCORE Predicts Short‐ and Mid‐Term Mortality in Combined Aortic Valve Replacement and Coronary Artery Bypass Patients , 2009, Journal of cardiac surgery.

[21]  L. Cohn,et al.  Early and late outcomes of 1000 minimally invasive aortic valve operations. , 2008, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[22]  Lukas Altwegg,et al.  Percutaneous Transarterial Aortic Valve Replacement in Selected High-Risk Patients With Aortic Stenosis , 2007, Circulation.

[23]  S. Lemeshow,et al.  European system for cardiac operative risk evaluation (EuroSCORE). , 1999, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[24]  M. Kamler,et al.  Society of Thoracic Surgeons score is superior to the EuroSCORE determining mortality in high risk patients undergoing isolated aortic valve replacement. , 2009, The Annals of thoracic surgery.

[25]  David Collett Modelling Survival Data in Medical Research , 1994 .

[26]  T. Sundt,et al.  Is the European System for Cardiac Operative Risk Evaluation model valid for estimating the operative risk of patients considered for percutaneous aortic valve replacement? , 2008, The Journal of thoracic and cardiovascular surgery.

[27]  M. Mack,et al.  Reliability of risk algorithms in predicting early and late operative outcomes in high-risk patients undergoing aortic valve replacement. , 2008, The Journal of thoracic and cardiovascular surgery.

[28]  K. Zou,et al.  Receiver-Operating Characteristic Analysis for Evaluating Diagnostic Tests and Predictive Models , 2007, Circulation.

[29]  Mirko Doss,et al.  Transapical Minimally Invasive Aortic Valve Implantation: Multicenter Experience , 2007, Circulation.

[30]  D. Cosgrove,et al.  Minimally invasive approach for aortic valve operations. , 1996, The Annals of thoracic surgery.

[31]  Sean M. O'Brien,et al.  The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2--isolated valve surgery. , 2009, The Annals of thoracic surgery.

[32]  T. Sundt,et al.  Quality of Life After Aortic Valve Replacement at the Age of >80 Years , 2000, Circulation.

[33]  Thomas Walther,et al.  Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome. , 2007, Journal of the American College of Cardiology.

[34]  M. Kamler,et al.  The EuroSCORE - still helpful in patients undergoing isolated aortic valve replacement? , 2010, Interactive cardiovascular and thoracic surgery.

[35]  Fabian Nietlispach,et al.  Transcatheter Aortic Valve Implantation: Impact on Clinical and Valve-Related Outcomes , 2009, Circulation.

[36]  Alona Muzikansky,et al.  Re: Selective Inhibition of Her2-positive Breast Cancer Cells by the Hiv Protease Inhibitor Nelfinavir Notes Erratum: " Comparing Survival of a Sample to That of a Standard Population " , 2022 .