Outcomes of Surgical Aortic Valve Replacement in High-Risk Patients: A Multiinstitutional Study

Abstract

The introduction of transcatheter aortic valves has focused attention on outcomes after open aortic valve replacement (AVR) in very high-risk patients. This study analyzes the short-term and midterm outcomes of AVR in this patient cohort in the current surgical era. A retrospective review was performed on 159 patients who underwent isolated, primary AVR with a STS PROM (Society of Thoracic Surgeons predicted risk of mortality) of 10% or greater from January 2002 to December 2007 at four US academic institutions. Patients with previous valve operations were excluded. A multivariable model was constructed to determine predictors of in-hospital mortality. Estimates of the cumulative event rate mortality were calculated by the Kaplan-Meier method. The mean age of all patients was 76.1±11.2 years, most were men (92 of 159, 57.9%), and mean STS PROM was 16.3%±7.3%. Significant preoperative factors included the following: peripheral vascular disease, 33.3% (53 of 159); stroke, 23.3% (37 of 159); renal failure, 50.3% (80 of 159); New York Heart Association class III-IV heart failure, 78.0% (124 of 159); and previous coronary artery bypass grafting, 39.0% (62 of 159). Mean ejection fraction was 0.461±0.153 and median implanted valve size was 23 mm. Postoperative complications included the following: stroke, 4.4% (7 of 159); heart block, 5.0% (8 of 159); multisystem organ failure, 6.9% (11 of 159); pneumonia, 7.5% (12 of 159); and dialysis, 8.2% (13 of 159). Postoperative length of stay was 12.6±11.0 days and in-hospital mortality was 16.4% (26 of 159). One-, three-, and 5-year survival was 70.9%, 56.8%, and 47.4%, respectively. In the current era, high-risk surgical patients undergoing open AVR have respectable short and mid-term survival. These results should serve as a benchmark for evaluating outcomes of transcatheter aortic valve implantation.