Significant Predictors Of Operative Mortality Research Articles

Surgical treatment and outcomes in aortic valve endocarditis and perivalvular abscesses.

Patients with aortic root abscesses experience increased morbidity and mortality compared to those without abscess in aortic valve infective endocarditis. The superior intervention for patients with aortic root abscess is not determined. This research investigates the degree to which increased morbidity and mortality of aortic root abscess, and to describe perioperative characteristics and outcomes of root operations versus root-sparing repairs of aortic root abscess. All patients who underwent surgical treatment of active aortic valve endocarditis between 2011 and 2022 at a single institution were reviewed, yielding 218 patients, of whom 64 had perivalvular abscess. Patients were treated with either simple (root-sparing) or complex (root replacement) techniques. Patients with abscess demonstrated significantly higher rates of previous cardiac surgery, redo endocarditis surgery, aortocavitary fistula, heart block, and prosthetic valve endocarditis. One quarter of abscesses were not detected on preoperative imaging. Presence of abscess was a significant predictor of operative mortality. Prosthetic valve endocarditis was a significant predictor of complex repair in patients with abscess. Five-year survival was similar between simple and complex repair groups in patients with abscess. Aortic root abscess confers significant morbidity and mortality, and measures should be taken to ensure early detection and treatment of this condition.

Predictors and Outcomes of Ischemic Stroke After Cardiac Surgery

Stroke is a major complication after cardiac surgery causing increased morbidity and mortality. There are limited data on outcomes of patients with large vessel occlusion after cardiac surgery. Patients who underwent index cardiac surgeries as defined by The Society of Thoracic Surgeons (STS) from 2010 to 2017 were reviewed from a prospectively maintained database. All patients with neurologic deficits were identified, and only patients with ischemic strokes were included. A total of 10,250 patients underwent cardiac surgical procedures. Postoperative stroke with neurologic deficits occurred in 221 patients (2.16%). Of these, 53 patients (24%) had large vessel occlusion. Patients who had a postoperative stroke were older and more likely to be female. These patients had higher STS predicted mortality and longer bypass time, cross-clamp time, total intensive care unit stay, and total hospital stay. Operative mortality was significantly higher for patients who had postoperative stroke (14.93% vs 2.15%, P < .001). Kaplan-Meier survival estimates demonstrated worse survival for the large vessel occlusion cohort at 1 year (54.72% vs 75%, P= .002). Predictors of stroke included increasing age, known cerebrovascular disease, diabetes mellitus, and emergent operative status. The most significant predictors of operative mortality included emergent operative status and New York Heart Association stage IV heart failure. There was no difference in 30-day, 1-year, and 5-year mortality between the intervention group and the medically managed patients in the large vessel occlusion cohort. Stroke is a devastating complication after cardiac surgery that increases operative morbidity and mortality. Stroke with large vessel occlusion was associated with worse survival. However, early intervention did not impart a survival benefit.

Characteristics and anatomic distribution of early vs late stroke after cardiac surgery.

The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality. Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis. The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001). Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality.

Assessment of Thoracic Endografting Operative Mortality Risk Score: Development and Validation in 2,000 Patients

In this study we derive and validate a composite risk index termed the Assessment of Thoracic Endografting Operative Mortality, or ATOM, risk score. All thoracic endovascular aortic repairs (TEVAR) in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) between 2005 and 2012 were identified. The primary outcome was operative mortality. After evaluating the association of over 60 preoperative variables and operative mortality in univariate analysis, a multivariable model was developed. Significant risk factors were assigned points equivalent to their odds ratio rounded to the nearest whole integer in the final multivariable model. Overall, 1,981 patients comprised the study population, including 1,486 (75.0%) in the derivation and 495 (25.0%) in the validation cohort. There were 173 (8.7%) operative mortalities. A 30-point risk score incorporating 10 risk factors was generated and found to be highly predictive of operative mortality in the derivation (odds ratio [OR] 1.36, p < 0.001) and validation cohorts (OR 1.24, p < 0.001). The models used to create and validate the ATOM score were robust (C indices 0.84 and 0.83, respectively). There was strong correlation between predicted mortality rates based on the derivation cohort and actual mortality rates in the validation cohort (r= 0.75, p < 0.001). Operative mortality based on low (ATOM < 5), moderate (ATOM 5 to 9), and high risk (ATOM ≥ 10) was 1.3%, 6.6%, and 24.0%, respectively (p < 0.001). Higher ATOM scores also correlated with higher complication rates and longer hospital stays. The ATOM score is a significant predictor of operative mortality in TEVAR and can be used for preoperative risk stratification.

Improving early outcomes following hybrid procedure for patients with single ventricle and systemic outflow obstruction: defining risk factors†.

The hybrid procedure has become an accepted management strategy for patients with single ventricle and systemic outflow obstruction (SVSOO), particularly those considered at high risk for mortality following Stage I Norwood. We sought to refine patient selection by identifying clinical variables associated with early mortality. Single-centre review of all patients with SVSOO undergoing a hybrid procedure between January 2003 and December 2012. Demographic, clinical and outcome data were collected from the electronic medical record. The primary outcome was operative mortality (mortality within 30 days of the operation or prior to hospital discharge). Thirty-four patients underwent hybrid palliation at a median age of 5 days (IQR 3-8.5) and a median weight of 2.5 kg (IQR 2.2-2.9). Aortic atresia was present in 13 of 34 patients. Emergency banding for resuscitation was performed in 8 cases. Subsequent procedures included Stage I Norwood in 14, combined Stage I and II Norwood in 8, biventricular repair in 3 and cardiac transplantation in 2. Median cardiac intensive care unit length of stay was 54 days (IQR 27-92). Seven patients had no subsequent procedure. There were 11 operative deaths. Non-modifiable patient-related factors had a significant association with operative mortality, including weight under 2.0 kg (OR 18; 95% CI 1.8-188.3, P = 0.0008) and aortic atresia (OR 6.1; 95% CI 1.2-30.1, P = 0.026). Most significant was the interaction between aortic atresia and weight under 2.0 kg on early mortality (OR 13.1; 95% CI 1.9-92 P = 0.0039). The multivariate analysis demonstrated that the presence of aortic atresia (OR 13.4; 95% CI 1.2-151) and a birthweight of 2.0 kg or less (OR 51; 95% CI 2.4-999) were also significant predictors of operative mortality. Non-modifiable patient-related factors have a profound effect on early survival following a hybrid procedure for SVSOO. Outcomes for patients under 2.0 kg with aortic atresia remain very poor. Risk stratification should inform management decisions.

Management of cirrhotic patients with blunt abdominal trauma: Analysis of risk factor of postoperative death with the Model for End-Stage Liver Disease score

IntroductionThe aim of this retrospective study is to analyse the risk factors of mortality in cirrhotic patients with blunt abdominal trauma (BAT) underwent laparotomy and the value of the Model for End-Stage Liver Disease (MELD) score to predict postoperative death is determined. Materials and methodsFrom July 1993 to June 2005, 34 cirrhotic patients with BAT were reviewed. Data are presented as mean±standard deviation (SD), frequency (percentage), or Pearson correlation coefficient. Predictors were compared by uni- and multiple logistic regression analysis and results were considered statistically significant if P<0.05. The prognostic value of the MELD score in predicting postoperative death was assessed using receiver operating characteristic (ROC) curve analysis. ResultsOf the 34 patients (27 men, 7 women; mean age, 49 years), the Injury Severity Score (ISS) ranged from 4 to 43 (mean: 14). Of the 34 patients, 12 were treated with nonoperative management (NOM) initially and 4 succeeded and 30 patients (88.2%) eventually required laparotomy. Of the 30 operative patients, 7 died of haemorrhagic shock and the other 6 died of multiple organ failure with a 43.3% mortality rate. Of the 17 survivors after laparotomy, 4 developed intra-abdominal complication, and 3 developed extra-abdominal complication with a 41.2% morbidity rate. On univariate analysis, the significant predictors of surgical mortality were shock at emergency department, damage control laparotomy, ISS and MELD score. On multiple logistic regression analysis, the significant predictors of operative mortality were shock at ED (P=0.021) and MELD score (P=0.012). Analysis by ROC curve identified cirrhotic patients with a MELD score equal to or above 17 as the best cut-off value for predicting postoperative death. ConclusionsLiver cirrhosis with BAT has a high operative rate, low salvage rate of NOM, high surgical mortality and morbidity rate. The MELD score can accurately predict postoperative death and a MELD score equal to or above 17 of our data is at high risk of postoperative death.

Socioeconomic Status and Surgical Mortality in the Elderly

Although racial disparities in the quality of surgical care are well described, the impact of socioeconomic status on operative mortality is relatively unexplored. We used Medicare data to identify all patients undergoing 1 of 6 common, high risk surgical procedures between 1999 and 2003. We constructed a summary measure of socioeconomic status for each US ZIP code using data from the 2000 US Census linked to the patient's ZIP code of residence. We assessed the effects of socioeconomic status on operative mortality rates while controlling for other patient characteristics and then examined the extent to which disparities in operative mortality could be attributed to differences in hospital factors. Socioeconomic status was a significant predictor of operative mortality for all 6 procedures in crude analyses and in those adjusted for patient characteristics. Comparing the lowest quintile of socioeconomic status to the highest, the adjusted odds ratios (OR) and 95% confidence intervals (CI) ranged from OR = 1.17; 95% CI: 1.10-1.25 for colectomy to OR = 1.39; 95% CI: 1.18-1.65 for gastrectomy. After further adjustment for hospital factors, the odds ratio associated with socioeconomic status for coronary artery bypass (OR = 1.14; 95% CI: 1.09-1.19), aortic valve replacement (OR = 1.13; 95% CI: 1.04-1.23), and mitral valve replacement (OR = 1.11; 95% CI: 1.00-1.23) were diminished, and those for lung resection (OR = 0.93; 95% CI: 0.81-1.07), colectomy (OR = 1.04; 95% CI: 0.98-1.12), and gastrectomy (OR = 1.11; 95% CI: 0.90-1.38) were reduced and also were no longer statistically significant. Within hospitals, there were only small differences in adjusted operative mortality by patient socioeconomic status. Patients with lower socioeconomic status have higher rates of adjusted operative mortality than patients with higher socioeconomic status across a wide range of surgical procedures. These disparities in surgical outcomes are largely attributable to differences between the hospitals where patients of higher and lower socioeconomic status tend to receive surgical treatment.

Aortic Valve Replacement in Octogenarians: Is Biologic Valve the Unique Solution?

This study analyzed morbidity, mortality, and quality of life after aortic valve replacement with mechanical and biologic prostheses in octogenarian patients. A retrospective analysis was performed in 345 consecutive patients, mean age of 82 +/- 2 years (range, 80 to 92), who had aortic valve replacement from May 1991 to April 2005. A bioprosthesis (group I) was used in 200 patients (58%), and 145 (42%) received a mechanical prosthesis (group II). Associated cardiac procedures were done in 211 patients (61%), of which 71% were coronary artery bypass grafting. Patients had symptomatic aortic stenosis (84.3%) or associated aortic insufficiency; 88% were in New York Heart Association (NYHA) class III or IV. The mean preoperative aortic valve gradient was 62 +/- 16 mm Hg (range, 25 to 122 mm Hg). The mean left ventricular ejection fraction was good (0.52 +/- 0.12); 30 patients (8.7%) had an ejection fraction of less than 0.30. The in-hospital mortality rate was 7.5% (26 patients); 17 (8.5%) in group I and 9 (6.2%) in group II (p = 0.536) Significant predictors of operative mortality were preoperative renal insufficiency (blood creatinine > 2.00 mg/mL) and need for urgent operation. Mean follow-up, complete at 100%, was 40 +/- 33 months (range, 1 to 176 months). Long-term follow-up, using Kaplan-Meier analysis, showed an overall survival of 61% at 5 years and 21% at 10 years; survival by type of prosthesis was significantly higher with mechanical prostheses (log-rank p = 0.03). Freedom from cerebrovascular events (thromboembolic/hemorrhagic) at 5 and 10 years was 89% and 62% in the mechanical group and 92% and 77% in the biologic group (p = 0.76). Postoperative NYHA functional class was I or II in 96% of patients. Quality-of-life scores were excellent considering the age of the patients. No differences were found between the two groups. Surgical treatment for symptomatic aortic stenosis in octogenarians has an acceptable operative risk with excellent long-term results and good quality of life. In this cohort, survival rate is slightly but significantly higher with mechanical prostheses.

Impact of Surgeon Training on Outcomes After Resective Hepatic Surgery

Higher hospital and surgeon volumes have been associated with improved outcomes after hepatic resection. Subspecialty training has not previously been associated with improved outcomes after hepatic resection. The objective of this study was to determine what effects, if any, surgeon's volume and training had on the outcomes after hepatic resection. Administrative procedure codes were used to identify all adult patients from the fiscal year 1991-1992 to 2003-2004 who underwent a hepatic resection in two large urban health regions in Canada (Calgary and Capital health regions). The primary outcomes were operative mortality and postoperative complications. There were 1107 hepatic resections in the stated time period performed by a total of 72 surgeons. There were 66 deaths, resulting in an in-hospital mortality rate of 6.0%, and an overall complication rate of 46%. Statistically significant predictors of operative mortality were: urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing burden of comorbid medical illness. Surgeon training along with patient's sex, the urgency of admission, diagnosis of primary hepatic malignancy, extent of resection, and increasing comorbidity were predictive of postoperative complications. This study found surgeon training to be highly predictive of postoperative complications after hepatic resection.

Relationship Between Race and Mortality and Morbidity After Valve Replacement Surgery

Previous studies have shown that black race is an independent predictor of increased operative mortality after coronary artery bypass surgery. Given the higher incidence of hypertension and hypertension-associated left ventricular hypertrophy in blacks, we hypothesized that black race might be associated with increased risk of mortality and morbidity after aortic valve replacement (AVR) or mitral valve replacement (MVR). We could not identify a previous study that used a multivariable model to evaluate the association between race and operative mortality after AVR or MVR. The Society of Thoracic Surgeons National Cardiac Database was used for a retrospective review of 3137 black and 46,249 white patients who underwent MVR alone or AVR alone from 1999 through 2002. Multivariate logistic regression was used to assess the association between race and mortality and 6 other adverse outcomes (stroke, renal failure, prolonged ventilation, prolonged postoperative stay, sternal infection, and bleeding) after adjustment for covariates. Unadjusted operative mortality for MVR only was 5.60% for blacks versus 6.18% for whites (OR 0.90 [95% CI 0.71 to 1.14]) and 4.60% for blacks versus 3.62% for whites for AVR only (OR 1.28 [95% CI 1.02 to 1.62]). After adjustment for other risk factors, black race was not a significant predictor of operative mortality after AVR or MVR; however, black race was associated with an increased risk of several complications: prolonged ventilation after AVR or MVR, postoperative stay >14 days after AVR or MVR, reoperation for bleeding after AVR, and postoperative renal failure after MVR. There was no significant association between race and the risk of stroke or deep sternal wound infection for either AVR or MVR. In contrast to previously published results that defined race as an independent risk factor for operative mortality after coronary artery bypass surgery, race does not appear to be a significant predictor of operative mortality after isolated AVR or MVR; however, there is evidence of an association between race and certain complications.

Risk of repeat mitral valve replacement for failed mitral valve prostheses

BackgroundAdvances in tissue prosthetic valve design and manufacturing have stimulated renewed interest in the use of biological valves in younger patients. This approach, however, risks reoperation. We therefore reviewed our recent experience with repeat mitral valve replacement to better define its contemporary risks. MethodsUsing a computerized database, we identified and compared 106 patients undergoing repeat mitral valve replacement with 562 control patients undergoing primary mitral valve replacement between January 1993 and December 2000 at our institution. ResultsThere were no significant differences between repeat and primary surgery groups with respect to age (mean 66 ± 12 vs 64 ± 13 years), gender distribution (women 65% vs 64%), preoperative functional class, ejection fraction, or active endocarditis (6.6% vs 3.4%). The indication for reoperation in the repeat group was structural dysfunction in 49 patients (46%), paravalvular leak in 21 patients (20%), nonstructural dysfunction in 11 patients (10%), and progression of other native valve disease in 8 patients (8%). Prior prostheses were mechanical in 46 patients (43%). Mean time to reoperation was 11.5 ± 7.1 years. There were 5 deaths out of 106 patients in the repeat group (4.7%) and there were 23 deaths out of 562 patients in the control group (4.1%) (p = NS). Multivariate analysis identified prior myocardial infarction (p = 0.014, odds ratio 2.9) and nonelective surgical status (p = 0.004, odds ratio 2.3) as significant predictors of operative mortality. ConclusionsThe risk of repeat mitral valve replacement was low suggesting that there should be less reluctance to recommend patients choose a bioprosthesis over a mechanical prosthesis. Given the expected durability of current designs, bioprosthetic use may be explored in younger patients without subjecting those individuals to excessive risk.

Risk factors associated with morbidity and operative mortality of pneumonectomy

Objective: Identifying and evaluation of the predictors of outcome of pneumonectomy for lung cancer. Methods: 123 patients undergoing pneumonectomy from June 1984 to June 2000 were reviewed retrospectively. Results: The operative mortality was 7.3% (9/123). The most significant predictors of operative mortality were presence of coexisting medical conditions, respiratory tract infection, bronchopleural fistula, arrhythmias, myocardial infarction, pulmonary edema and renal failure. There were 76 postoperative complications presenting in 123 patients. The most significant predictors of postoperative morbidity were continued cigarette smoking up to the time of operation and fluid infusion of more than 3L in the first 24-hours. Conclusion: This study has identified preoperative and perioperative factors associated with operative mortality and morbidity after pneumonectomy.

Active Native Valve Endocarditis: Determinants of Operative Death and Late Mortality

Background. In this report, we reviewed 247 patients who underwent operation by our team for active native valve endocarditis between January 1979 and December 1993.Methods. There were 201 male and 46 female patients (mean age, 45.4 ± 6 years). The aortic valve was involved in 163 cases, the mitral valve in 36 cases, both mitral and aortic valves in 44 cases, and the tricuspid valve alone in 4 cases. The most common microorganisms were streptococci. Univariate Pearson (χ2 test) and multivariate (stepwise logistic regression [BMDPLR]) analyses were used to identify significant predictors of operative mortality, reoperation, and recurrent endocarditis. Cox proportional hazards regression model was used to study late survival.Results. Operative mortality was 7.6% (n = 19). Increased age, cardiogenic shock at the time of operation, insidious illness, and greater thoracic ratio (>0.5) were the predominant risk factors; the length of antibiotic therapy appeared to have no influence. Two hundred thirteen patients were followed up. Median follow-up time was 6 years (range, 2 to 19 years). Overall survival rate (operative mortality excluded) was 71.3% ± 3.8% at 9 years. Increased age, preoperative neurologic complications, cardiogenic shock at the time of operation, shorter duration of the illness, insidious illness before the operation, and mitral valve endocarditis were the predominant risk factors for late mortality. The probability of freedom from reoperation (operative mortality included) was 73.3% ± 4.2% at 8 years; risk factors were younger age and aortic valve endocarditis. The rate of prosthetic valve endocarditis was 7%. No significant risk factor was found.Conclusions. Increased age, insidious illness, and hemodynamic failure are the main risk factors for operative mortality. Long-term survival is good except for patients with preoperative neurologic complications and mitral valve endocarditis.(Ann Thorac Surg 1997;63:1737–41)

Aortic valve replacement after previous coronary artery bypass grafting

As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years. In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time. Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.

Hypothermic circulatory arrest in operations on the thoracic aorta: Determinants of operative mortality and neurologic outcome

This study was undertaken to determine the factors that influence the final outcome after hypothermic circulatory arrest. Between 1985 and 1992 a uniform method of hypothermic circulatory arrest was used in 200 patients as the primary method of cerebral protection during operations on aneurysms of the thoracic aorta. There were 30 hospital deaths (15%). Age greater than 60 years (relative risk 3.7, p < 0.02), emergency operation and hemodynamic compromise (relative risk 22.2, p < 0.000), concomitant procedures (relative risk 2.7, p < 0.04), presentation with new neurologic symptoms (relative risk 5.2, p < 0.04), and postoperative permanent neurologic deficits (relative risk 9.4, p < 0.000) were found to be significant predictors of operative mortality. A total of 183 patients were available for evaluation of neurologic function and outcome. Multivariate analysis of this cohort of patients by multiple logistic regression showed that temporary neurologic dysfunction occurred in 36 cases (19%). Temporary neurologic dysfunction correlated with the duration of hypothermic circulatory arrest (47 ± 16 minutes; odds ratio 1.06/minute; p < 0.001) and age (66 ± 14 years; odds ratio 1.07/year; p < 0.001). Embolic strokes occurred in 22 patients (11%) and were associated with permanent deficits in 13 (7%). Strokes correlated significantly with age (older than 60, 21% versus younger than 60, 1%; p < 0.001) and operations on the arch and descending aortic aneurysms containing clot or atheroma ( p < 0.001). This experience shows that the operative mortality is not affected by any parameters related to the use of hypothermic circulatory arrest. The incidence of temporary neurologic dysfunction rises linearly in relation to the age of the patient and the duration of hypothermic circulatory arrest. However, permanent neurologic injury is a result of thromboembolic events and is not related to the method of cerebral protection used. Additional methods to prevent perioperative embolic strokes are needed. Hypothermic circulatory arrest affords adequate cerebral protection if the arrest period is kept less than 60 minutes. We will continue to use this modality until the safety and utility of the alternate methods of cerebral protection are shown to be superior. (J T HORAC C ARDIOVASC S URG 1994;107:788-99)

Ten-year experience with aortic valve replacement in 482 patients 70 years of age or older: Operative risk and long-term results

A retrospective analysis of an institutional experience with aortic valve replacement (AVR) in patients 70 years of age or older during 1976 to 1987 was performed. The study was prompted in part by the current interest in palliative aortic valvoplasty, an interest based to a certain extent on the impression that AVR in the elderly has a high mortality. The mean age of the patients was 75.0 ± 4.0 years (± the standard deviation) (range, 70 to 89 years). Eighty-three percent of patients received porcine valves and 17%, mechanical valves. Preoperatively 32% were in New York Heart Association class III, and 59% were in class IV. Operative mortality was 5.6% for elective isolated AVR for aortic stenosis (19% of all patients), 8.2% for all isolated AVR (38%), and 12.4% overall. Concomitant operative procedures were done in 62.0%; AVR with coronary artery bypass grafting (42%) had an operative mortality of 14.3%. Multivariate analysis showed significant predictors of operative mortality to be emergency operation ( p < 0.01), isolated aortic regurgitation ( p = 0.01), and previous cardiac operation ( p = 0.02). Follow-up (34 ± 27 months) was 94% complete. Five-year survival from late cardiac-related death was 81.0%. The constant yearly hazard rate for late death for patients 70 year of age or older who underwent AVR was 5.42% per year, which is similar to the 5.77% per year rate calculated for age-matched and sex-matched controls. Five-year freedom from reoperation was 99%; from late thromboembolic complications, 91%; and from late anticoagulant-related complications, 94%. Freedom from all valve-related morbidity and mortality was 61% at 5 years. At follow-up, 80% of patients reported symptomatic improvement, and 76% were in New York Heart Association class I or II. These results show that AVR in the elderly is safe and effective, with late survival rates similar to those of the general population. Thus AVR remains the procedure of choice in patients 70 years of age or older with substantial aortic valve disease.

Surgical results for mitral regurgitation from coronary artery disease

Results of coronary artery bypass grafting with and without mitral valve replacement were analyzed retrospectively in 101 patients with preoperative ischemic mitral regurgitation to determine the effects of severity and surgical treatment of mitral regurgitation on survival. Between 1980 and 1984, a total of 1,475 patients (mean age 59, 77% male) underwent coronary bypass. These patients were divided into three groups: (1) patients without ischemic mitral regurgitation who underwent isolated coronary bypass (1,374; 93%), (2) patients with ischemic mitral regurgitation who underwent isolated coronary bypass without valve replacement (85; 6%), and (3) patients with ischemic mitral regurgitation who underwent combined mitral valve replacement and coronary bypass (16; 1%). Preoperatively, patients with ischemic mitral regurgitation compared to those without regurgitation were significantly older (+6 years, p less than 0.001), had more severe coronary artery disease (p less than 0.001), a higher incidence of congestive heart failure (24% versus 5%, p less than 0.001) and recent myocardial infarction (16% versus 8%, p less than 0.01), and a lower mean ejection fraction (45% versus 61%, p less than 0.001). Operative mortality was significantly increased in patients with ischemic mitral regurgitation who underwent coronary bypass alone (p less than 0.01) and in those who underwent coronary bypass and mitral valve replacement (p less than 0.01)--11% and 19%, respectively--than in the coronary bypass patients without ischemic mitral regurgitation (3.7%). The severity of mitral regurgitation (0 to 4+) proved to be the most significant predictor of operative mortality. The actuarial survival rate at 5 years for the coronary bypass patients without ischemic mitral regurgitation was 85% compared to 91% (p less than 0.05) for the coronary bypass patients without ischemic mitral regurgitation. These results indicate that patients with ischemic mitral regurgitation have a higher prevalence of cardiac risk factors and are at an increased risk of operative mortality. Although the severity of the ischemic mitral regurgitation was strongly predictive of early survival, it proved to have an unexpectedly modest effect on long-term survival after surgical treatment.