Is it worthwhile to perform surgical aortic valve replacement in elderly patients with symptomatic aortic valve disease and malignancy: a short and long-term study in 2,500 patients

Abstract

Abstract Introduction Malignancy (all types) can be considered as limiting factor for the outcome of surgical aortic valve replacement (SAVR). Purpose How does the referral pattern evolve over time for patients with previously malignancy, referred for SAVR What is their early and long-term outcome after SAVR? Patients and methods This is a retrospective file study of 2,500 patients referred for SAVR with a biological prosthesis between 1987 and 2017. Mechanical valves and valve prosthesis in another position were excluded. A chi-square analysis was used to compare patients with and without cancer with respect to age, gender, era of referral (2008, the year of introduction of transcatheter aortic valve implantation, TAVI), preoperative cardiovascular (parameters for ventricular function, severity of valve disease, coronary disease, arrhythmias and conduction defects) and non-cardiac (pulmonary, renal, diabetes, cerebral) comorbid conditions, operative variables (bypass time, associated CABG and mitral valve repair), need for resources (blood products, stay on ICU) and early postoperative mortality, cardiac and non-cardiac events. A Kaplan-Meier (log-rank) analysis was used to evaluate the effect of malignancy on long-term outcome. Results Of the 2,500 patients, 388 (15.5%) patients had a documented prior malignancy There was a total of 18.917 patient-years for follow-up. For cancer patients, this was 2,489 patient-years. The referral of patients increased after 2008 (from 9.1% to 17.7%, p=0.006). Cancer patients had more chronic pulmonary (14.6% vs. 17.9%, p=0.044) and kidney (15.5% vs. 21.5%, p=0.009) disease, more prior CVA (14.8% vs. 19.8%, p=0.038) and permanent pacemaker implant (14.9% vs. 24/19%, p=0.044). Obesity was less present (18.4% vs. 14.2%). Cardiovascular and operative parameters were comparable for both groups. Postoperative cardiac and non-cardiac adverse events, need for resources and especially mortality (5.0% vs. 6.9%, p=0.105) were comparable. Long-term survival was significantly reduced in patients with malignancy (p<0.001), but this was acceptable: a mean survival time of 105 (98–113) months vs. 121 (118–125) months. Five-year survival was 70.0±2.4% vs. 76.6±0.9% Ten-year survival was 38.6%±1.3% vs. 48.9±2.9% Fifteen-year survival was 14.1±2.7% vs. 20±1.3% In a Cox' proportional hazard analysis, malignancy ranks 8th of 10 independent predictors for mortality (odds ratio 1.26). Conclusion Even after the introduction of TAVI, the number of valve patients with prior malignancy referred for SAVR increased significantly. Nevertheless, only non-cardiac preoperative factors differed significantly. Operative variables, use of resources and early outcome did not differ significantly. Malignancy reduces long-term survival in a significant but acceptable degree. Funding Acknowledgement Type of funding sources: None.