Conventional aortic valve replacement in 2005 elderly patients: a 32-year experience

Conventional aortic valve replacement in 2005 elderly patients: a 32-year experience Abstract OBJECTIVES: Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS: A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS: Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS: AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients. Aortic stenosis, Elderly, Aortic valve replacement, Transcatheter aortic valve implantation, Long-term survival, Ageing INTRODUCTION Aortic stenosis is the most frequent valvulopathy in industrialized countries. Nowadays, its incidence increases with age and represents a major health concern in populations where life expectancy has increased regularly throughout the 20th century [1, 2]. Aortic valve replacement (AVR) provides excellent long-term survival with functional improvement at a reasonable operative risk in the vast majority of patients [1, 3–5]. Consequently, increasing numbers of elderly patients are referred for aortic valve surgery. Transcatheter aortic valve implantation (TAVI) has been developed in the last decade and offers an alternative to open-heart surgery with good immediate results in non-operable or high-risk patients [6, 7]. This recent and rapid development raises new concerns about the management of aortic stenosis in the elderly. Should everyone benefit from an aggressive therapy? How one should decide between both strategies in fragile patients: conventional surgical replacement or a transcatheter approach? In order to answer these questions, we reviewed our experience of AVR in octogenarians since our first replacement in 1978. PATIENTS AND METHODS From 8th December 1978 to 30th June 2011, 2005 patients aged ≥80 years underwent an AVR in our institution. These octogenarians represented 14.8% of the 13 559 AVRs that we performed during this 32-year period. We considered all consecutive octogenarians who underwent an AVR, whether it was the sole procedure or whether it was associated with coronary bypass or another cardiac procedure (such as mitral or tricuspid valve procedures or ascending aorta replacement). No octogenarians who underwent an AVR during this period were excluded from the study. In order to achieve sufficient follow-up, even for the most recently operated patients, we decided to close enrolment in June 2011. Last follow-up inquiries for all living patients were performed during spring 2015. Preoperative characteristics Clinical data are detailed in Table 1. The mean age was 82.9 ± 2.2 years (range 80–96.3 years), and the median age was 82.5 years; 317 (15.8%) patients were ≥85 years. Another group of 76 (3.8%) patients were operated on as non-elective surgery. Table 1: Preoperative clinical data   Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4    Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4  NYHA: New York Heart Association; PTCA: percutaneous transluminal coronary angioplasty. Table 1: Preoperative clinical data   Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4    Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4  NYHA: New York Heart Association; PTCA: percutaneous transluminal coronary angioplasty. Fifty patients had a history of cardiac surgery [26 AVR, 4 mitral valve replacement, 19 coronary artery bypass grafting (CABG) and 1 ascending aorta]. Half of the patients (1009 of 2005) had at least 1 associated extracardiac comorbidity, including carotid stenosis (n = 281), cerebrovascular accident (n = 79), residual neurological deficit (n = 27), peripheral arteriopathy (n = 176), pulmonary disease (n = 231), chronic renal failure (defined by creatinine clearance <40 ml/min, n = 113) that required haemodialysis in 2 cases or previous cancer considered to be cured (n = 150). Among the entire cohort, 1310 (65%) patients had at least 1 risk factor for atherosclerosis, 290 (14.5%) patients were overweight and 140 (7%) patients had diabetes (which is a normal prevalence in France in this age group). Coronary arteriography showed significant lesions in 646 (32%) patients. Nineteen patients had a history of CABG and 83 patients had previous percutaneous coronary angioplasty. Preoperative echocardiography identified 130 (6.4%) patients with an impaired left ventricular function defined by an ejection fraction <40% (Table 2). Aortic stenosis was the predominant lesion, either pure or associated with a significant regurgitation, in 146 (7.3%) patients. Only 32 (1.6%) patients had pure aortic insufficiency, and 263 (13.7%) patients chronic atrial fibrillation (Table 2). Table 2: Preoperative investigations   Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6    Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6  AF: atrial fibrillation; ECG: electrocardiography; LVEF: left ventricular ejection fraction; SD: standard deviation. Table 2: Preoperative investigations   Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6    Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6  AF: atrial fibrillation; ECG: electrocardiography; LVEF: left ventricular ejection fraction; SD: standard deviation. Surgical data AVR was performed according to our standard surgical procedures through median sternotomy. Cardiopulmonary bypass was achieved using moderate hypothermia (nasopharyngeal temperature of 28°C until 1996 then 32°C). Myocardial protection relied on antegrade cold crystalloid cardioplegia (Bretschneider or St Thomas) added to topical cooling or antegrade warm blood perfusion (for the last 12 years) according to the surgeon’s preference. Immediate haemodynamic recovery was excellent in 1659 (85%) cases, moderate or poor in 287 (15%) cases (Table 3) requiring pharmacological support during weaning from cardiopulmonary bypass or in the early postoperative course. Table 3: Surgical data Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  AVR: aortic valve replacement; CABG: coronary artery bypass grafting; SD: standard deviation. Table 3: Surgical data Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  AVR: aortic valve replacement; CABG: coronary artery bypass grafting; SD: standard deviation. AVR was the only procedure in 1515 (76%) patients, while in 396 (19%) cases, it was performed with coronary revascularization. A group of 94 (5%) patients had another associated cardiac procedure (Table 3). All except 17 (0.8%) patients received a bioprosthesis. All major models have been implanted, according to the time frame and technical evolutions. Among those, 21- and 23-mm diameters account for two-thirds of the implantations (n = 676, 34% and n = 694, 35%), while 19-mm valves (n = 285) and 25-mm valves (n = 295) represent 14% each of the implanted bioprostheses respectively. Among the 396 patients who underwent concomitant CABG, 290 received 1 graft, 92 patients received 2 grafts, 13 patients received 3 grafts and 1 patient had 4 grafts. Thirty-one patients had an ascending aorta replacement associated with the AVR, 26 patients had a mitral valve procedure (13 replacements and 13 repairs) and 8 patients had a tricuspid valvuloplasty. Degenerative aortic stenosis was the most prominent lesion (92%). Data analysis This is a retrospective study performed from our Cardiovascular Surgery Department database. All clinical data and investigative reports were collected at the time of surgery and entered in our database, which is regularly updated. Patients surviving the AVR were subjected to a periodic follow-up, updated by a written questionnaire sent to cardiologists, physicians and patients. Phone inquiries were used to clarify some answers. When death data were missing, the vital records office of the mansion house of the patient’s birth town was contacted to obtain the death certificate. Mortality and morbidity were reported in accordance with the criteria by Akins et al. [8]. Statistical analysis Statistical analyses were performed by the Epidemiology Department within our Institution, using software package, release 9.1 (SAS Institute Inc., Cary, NC, USA). Continuous variables are expressed as their means (±1 SD) and were compared using the Student’s t-test. Qualitative variables are expressed as percentage and compared using either the χ2 test or Fisher’s exact test depending on the size of each population. All variables were first tested individually by univariable analysis and were considered statistically significant when the P-value was <0.05. To evaluate independent factors predictive for mortality, all variables with a P-value <0.2 in univariable analyses were submitted to multivariable analysis and entered in a step-by-step ascending and descending logistic regression analysis (Wald’s test). Results are expressed as P-values and odds ratios (ORs). Analysis of the actuarial survival factors was done by the Kaplan–Meier method and a Cox regression has been utilized for the multivariable analysis. The survival of the current series was compared with that of the French population matched for age and gender. The mortality quotients used were annual quotients. The comparison was done by the Maentel–Haenszel adjustment method. The Ethics Committee of the French Society of Thoracic and Cardiovascular Surgery has certified that this research project has been assessed according to the current regulations framing clinical research in France. The Committee’s decision is referenced as CERC-SFCTCV62012-3-12-11-23-38-LATh. RESULTS Early mortality and morbidity Early mortality (within 30 days) in the entire cohort was 8.6%, and 173 patients died during the postoperative course (10.5  ± 11.9 days). Cardiac aetiologies were the leading cause of death (n = 94, 56%). Among those, 7 deaths were valve related: 3 cerebral embolisms and 4 haemorrhages secondary to aortic annulus or ventricular rupture, the repair of which was beyond surgical possibility. Respiratory failure (n = 20) and mesenteric infarction (n = 18) were responsible for 22% of hospital mortality. Operative mortality has decreased over the years from 6.2% in 1990 to 4.4% in 2010 for isolated AVR. Thirty-nine percent of patients (n = 787) required perioperative blood transfusion. A transient worsening of renal function complicated the early postoperative course in 182 (9.1%) cases requiring haemodialysis in 19 patients. Sixteen patients experienced a coma, with full recovery in 11 cases. Forty-two patients had a neurological deficit that resolved before discharge. Ninety-nine patients needed prolonged respiratory assistance (>48 h) and 111 had respiratory fragility that benefited at least from physiotherapy and oxygen therapy. Fifteen patients were reoperated under cardiopulmonary bypass during the same hospitalization. Forty-four percent of patients (n = 819) experienced at least 1 transient episode of atrial fibrillation, most frequently medically cured, and only 19% were not in sinus rhythm at hospital discharge. The mean hospital stay was 20.2 ± 11 days in the early years of our experience and has progressively been reduced to 12.9 ± 7.2 days in 2010. Multivariable analysis identified 5 independent operative risk factors: older age [P < 0.015; odds ratio (OR) 1.1176], aortic regurgitation (P < 0.001; OR 58.17), New York Heart Association (NYHA) Class IV (P < 0.0007; OR 4.55), atrial fibrillation (P < 0.04; OR 2.38) and single AVR (P < 0.02; OR 0.435). In addition, univariable analysis identified several other operative risk factors such as respiratory failure (P < 0.03), emergency surgery (P < 0.0029), right heart failure (P < 0.03), impaired ejection fraction (P < 0.001), coronary disease (P < 0.01), redo surgery (P < 0.02) and associated CABG (P < 0.008). Late mortality and survival Only 9 of the 1832 patients who initially survived surgery lost to follow-up during the survey. Total follow-up was 8849 patient-years (mean 4.9  ± 3.6 years, range 1 month to 19.9 years) and was 99.5% complete. Late deaths were observed in 901 patients, occurring within 1 month to 19.9 years after surgery with a median survival of 7.1 years (Fig. 1). Actuarial survival (operative mortality included) is 83 ± 0.8%, 62.4 ± 1.2% and 25 ± 1.5% at 2, 5 and 10 years, respectively. Seven patients became centenarians. Predominant causes of death (Table 4) were myocardial complications (20.4%, 184 cases), cancer, cerebrovascular accident and senility at exactly the same rate as surprising as it appears (10.2%, 92 cases). Unfortunately, it was not possible to precisely determine the cause of death for a third of patients but because of the advanced age of this population, one could assume that senility was probably a frequent cause. Table 4: Causes of late death Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Table 4: Causes of late death Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Figure 1: View largeDownload slide Actuarial survival of operated patients (green line) compared with a normal matched French population (blue line). AVR: aortic valve replacement. Figure 1: View largeDownload slide Actuarial survival of operated patients (green line) compared with a normal matched French population (blue line). AVR: aortic valve replacement. Univariable analysis identified male gender, preoperative renal failure, preoperative chronic obstructive pulmonary disease and advanced myocardial disease (NYHA Class IV, atrial fibrillation and impaired left or right ejection fraction on echocardiography) to have a negative impact. On the contrary, concomitant coronary revascularization or an associated cardiac surgery, which are operative risk factors, did not impact long-term survival. Analysis of actuarial survival as a function of prosthesis diameter found no significant difference, even for 19-mm diameter valves (Table 5). Table 5: Risk factors of late death   %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)    %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)  CABG: coronary artery bypass grafting; CI: confidence interval; COPD: chronic obstructive pulmonary disease; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; OR: odds ratio. Table 5: Risk factors of late death   %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)    %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)  CABG: coronary artery bypass grafting; CI: confidence interval; COPD: chronic obstructive pulmonary disease; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; OR: odds ratio. Infective endocarditis of the prosthesis occurred in 19 (0.2%) cases, structural valve deterioration in 13 (0.14%) cases within a delay of 4.9 ± 3.0 years, significant periprosthetic leak in 13 (0.14%) cases requiring reoperation for 3 patients, 30 haemorrhages (0.33%) and 89 thromboembolic accidents (1%). Actuarial freedom from late valve-related complications is 97% ± 0.4% at 2 years, 91.5 ± 0.8% at 5 years and 83.9 ± 1.6% at 10 years. Seven patients have been reoperated due to prosthesis-related complications: 3 periprosthetic leaks, 3 infections and 1 valve thrombosis. Actuarial freedom from reoperation was 99.7 ± 0.1% at 2 years, 99.6 ± 0.1% at 5 years, 99.5 ± 0.2% at 10 years and 99.5 ± 0.2% at 15 years. At the last follow-up, 922 patients are still alive, 96% indicated that their quality of life had been improved or very much improved by the valve replacement (90% of patients were in NYHA Class I or II at late follow-up) (Fig. 2). Sinus rhythm was documented in 70% of patients and atrial fibrillation in 20%. Figure 2: View largeDownload slide Evolution of NYHA status before and after AVR. AVR: aortic valve replacement; NYHA: New York Heart Association. Figure 2: View largeDownload slide Evolution of NYHA status before and after AVR. AVR: aortic valve replacement; NYHA: New York Heart Association. DISCUSSION Cardiovascular diseases are the leading cause of mortality in the elderly, far outpacing cancer and other illnesses. As a consequence of increasing life expectancy, octogenarians represent 5.9% of the French population (3 964 205 of 66 990 826 people) and number about 27 million in the European Union [9]. Aortic valve stenosis is the most frequently identified lesion. Its incidence increases with age, exceeding 5% >80 years [1, 2]. Our team and others have previously reported that AVR is possible even in advanced age patients with an acceptable mortality, good long-term survival and patent functional improvement, provided that the stenosis is tight and symptomatic [10–18]. Since our first AVR in an octogenarian on the 8th December 1978, surgical indications have progressively been extended. During the early years of our experience, only patients with good ventricular function and without associated comorbidities or coronary disease were considered for surgery. The patient profile has progressively evolved, as we have already published [16], such that in the most recent years of this series, a third of the patients had associated CABG with the AVR and >50% of them had at least 1 extracardiac comorbidity. Ageing of the population and indications have led more and more elderly people to undergo this surgery such that, today, octogenarians represent 20% of the AVRs performed annually in our institution (Fig. 3). The reported early mortality of 8.8% of this series may seem too high when compared with the recent publications, but it does not reflect the contemporary mortality of AVR in octogenarians. It is an historical series, which spans over 30 years. In parallel to the development of cardiac surgery in the elderly, improvements in the field of surgery, anaesthesiology, myocardial protection and intensive care have led to a marked decrease of early mortality, as we reported in 2011 with a 5.5% mortality in cases of isolated AVR despite increasing numbers of high-risk patients [11, 16, 18]. New approaches such as minimal access or sutureless valve have been reported to reduce postoperative pain, intensive care unit and hospital stays and shorter ventilation time [19]. Therefore, these techniques may be beneficial in terms of morbidity and mortality and improve the early postoperative course even more in future. Figure 3: View largeDownload slide Evolution of proportion of AVR in the elderly (red column) compared with AVR in younger patients (blue column). AVR: aortic valve replacement. Figure 3: View largeDownload slide Evolution of proportion of AVR in the elderly (red column) compared with AVR in younger patients (blue column). AVR: aortic valve replacement. Analysis of the actuarial survival (Fig. 1) displays a significant drop of the curve during the 1st year. This may be due to both early mortality and poor survival of patients with an advanced cardiomyopathy who obviously had been operated on too late. As we reported, the early mortality of the entire cohort decreased with time due to medical progress, from 6.2% in 1990 to 4.2% in 2010. One can indeed assume that early mortality is mainly observed in high-risk patients that have been characterized in a previous study [11] Moreover, the proportion of high-risk octogenarians in our surgical population will probably decrease in future, taking into account the development of percutaneous procedures. Comparison with the survival of a French-matched population showed that the 2 curves were initially parallel and then tended to draw closer before crossing at 10 years postoperatively, demonstrating that conventional AVR restores life expectancy similar to that of a French-matched population as we have previously reported for younger populations [5, 12]. Above all, 96% of operative survivors reported significant improvement. With the greying of Western countries, the burden on states’ coffers will become heavier and heavier. The enormous cost of social protection in Western countries is a noose that is slowly strangling the economies of these countries. So, one may question whether it is worth or reasonable, economically speaking, to propose such expensive techniques to elderly people. When calculating the subsequent survival freedom from serious valve-related events, the group of survivors fared reasonably well, emphasizing the highly satisfactory results of contemporary AVR. Besides the symptomatic relief and the prevention of sudden death, it will also prevent recurrent episodes of heart failure, leading to repeat hospitalizations, generating increasing costs for the society and the loss of autonomy for the patient. Relief of symptoms and improvement in quality of life should assume greater importance than the issue of increased life expectancy. Frailty characterizes the increased vulnerability of elderly people to acute stressors as a consequence of decline in overall function and physiological reserves. An estimated 30% of octogenarians are frail. Frailty predicts death and heralds the transition to disability in general population. It also predicts the expected benefit of AVR and the postoperative recovery. It appears that simple ‘eyeballing’ is no longer enough to appreciate the preoperative status of our patients, though it remains useful despite several risk scores. A heart team approach including surgeons, cardiologists, anaesthesiologists, geriatricians and physiotherapists can be helpful to assess these elderly candidates and choose the best approach to treat aortic stenosis. Age itself has already been identified as a risk factor [12, 18]. The increased mortality rate reflects the lack of functional reserve for stressful events in this older population. We previously identified and reported operative risk factors in this elderly population belonging to the following 3 categories: the patients themselves and their general clinical status, their cardiological condition and the surgical procedure itself. Determining the expected quality of life after surgery must be part of the selection process [11]. Percutaneous aortic valve implantation has been developed during the last 10 years. Recent publications [7, 20, 21] indicate that TAVI is not only a safe and effective treatment for high-risk patients with severe aortic stenosis but also might be the preferred treatment alternative in intermediate-risk patients [22]. These data are sufficient to support the use for high-risk patients because they have a higher operative mortality rate with conventional AVR and probably a lower life expectancy. But there are still many unanswered questions about the long-term complications and durability of TAVI valves [23]. Very few robust data are available after 3 or 4 years. In the light of this series, conventional AVR is safe and has excellent long-term outcome with 30% of octogenarian patients still alive at 10 years with good functional status. In addition, the switch from conventional AVR to TAVI for many high-risk patients during recent years has led to a significant decrease of early mortality for AVR to 1.3% in 2016. Recently, new recommendations have been published, proposing the expansion of TAVI indications [24]. In view of our results, we consider that for the moment TAVI should be proposed only to patients contraindicated for surgery or selected patients at high risk of mortality and morbidity. Where this line is drawn is a moving target and remains controversial [25]. Manuel Antunes [26] wrote in 2012 that AVR in the elderly has a low operative mortality and provides reliable durability. To our knowledge, this series is one of the largest monocentric reported experiences of AVR in the elderly with a follow-up over 30 years. As Manuel Antunes proposed in his editorial, we consider that these kinds of results should constitute the benchmark for TAVI. Limitations The first limitation of the present study is the retrospective analysis of a single-centre experience. However, very few randomized studies in the field have been published. Furthermore, during a 32-year period, the results may have been affected by variations in perioperative medical and surgical management. However, despite the long period of our study, very few data are missing (follow-up is 99% complete). Moreover, despite this exhaustive follow-up, the exact cause of deaths remains uncertain for 37%. CONCLUSION Considering the very poor outcome of non-surgical options, AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides excellent quality of life and improves life expectancy. Percutaneous valve implantation is to be considered in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis in the vast majority of patients. ACKNOWLEDGEMENTS The authors acknowledge Anne Ingels, Sylvie Marie and Brigitte Héluard for their contribution to this study. Conflict of interest: none declared. REFERENCES 1 Carabello BA, Paulus WJ. Aortic stenosis. Lancet  2009; 373: 956– 66. Google Scholar CrossRef Search ADS PubMed  2 Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nat Rev Cardiol  2011; 8: 162– 72. Google Scholar CrossRef Search ADS PubMed  3 Craver JM, Puskas JD, Weintraub WW, Shen Y, Guyton RA, Gott JP et al.   601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg  1999; 67: 1104– 10. Google Scholar CrossRef Search ADS PubMed  4 Sundt TM, Bailey MS, Moon MR, Mendeloff EN, Huddleston CB, Pasque MK et al.   Quality of life after aortic valve replacement at the age of >80 years. Circulation  2000; 102: III70– 4. Google Scholar CrossRef Search ADS PubMed  5 Logeais Y, Roussin R, Langanay T, Sevray B, Chaperon J, Leguerrier A et al.   Aortic valve replacement for aortic stenosis in 200 consecutive octogenarians. J Heart Valve Dis  1995; 4(Suppl 1): S64– 71. Google Scholar PubMed  6 Holmes DRJr, Brennan JM, Rumsfeld JS, Dai D, O’Brien SM, Vemulapalli S et al.   Clinical outcomes at 1 year following transcatheter aortic valve replacement. JAMA  2015; 313: 1019– 28. Google Scholar CrossRef Search ADS PubMed  7 Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK et al.   Transcatheter or surgical aortic-valve replacement in intermediate-risk patients. N Engl J Med  2016; 374: 1609– 20. Google Scholar CrossRef Search ADS PubMed  8 Akins CW, Miller DC, Turina MI, Kouchoukos NT, Blackstone EH, Grunkemeier GL et al.   Guidelines for reporting mortality and morbidity after cardiac valve interventions. Eur J Cardiothoracic Surg  2008; 33: 523– 8. Google Scholar CrossRef Search ADS   9 INSEE. French Demographic Data. https://wwwinseefr/fr/statistiques/2017 (1 September 2018, date last accessed). 10 Pellikka PA, Sarano ME, Nishimura RA, Malouf JF, Bailey KR, Scott CG et al.   Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation  2005; 111: 3290– 5. Google Scholar CrossRef Search ADS PubMed  11 Langanay T, Flécher E, Fouquet O, Ruggieri VG, De La Tour B, Félix C et al.   Aortic valve replacement in the elderly: the real life. Ann Thorac Surg  2012; 93: 70– 7. Google Scholar CrossRef Search ADS PubMed  12 Logeais Y, Langanay T, Roussin R, Leguerrier A, Rioux C, Chaperon J et al.   Surgery for aortic stenosis in elderly patients. A study of surgical risk and predictive factors. Circulation  1994; 90: 2891– 8. Google Scholar CrossRef Search ADS PubMed  13 Ashikhmina EA, Schaff HV, Dearani JA, Sundt TM3rd, Suri RM, Park SJ et al.   Aortic valve replacement in the elderly: determinants of late outcome. Circulation  2011; 124: 1070– 8. Google Scholar CrossRef Search ADS PubMed  14 Likosky DS, Sorensen MJ, Dacey LJ, Baribeau YR, Leavitt BJ, DiScipio AW et al.   Long-term survival of the very elderly undergoing aortic valve surgery. Circulation  2009; 120: S127– 33. Google Scholar CrossRef Search ADS PubMed  15 Akins CW, Daggett WM, Vlahakes GJ, Hilgenberg AD, Torchiana DF, Madsen JC et al.   Cardiac operations in patients 80 years old and older. Ann Thorac Surg  1997; 64: 606– 14. Google Scholar CrossRef Search ADS PubMed  16 Langanay T, De Latour B, Ligier K, Derieux T, Agnino A, Verhoye JP et al.   Surgery for aortic stenosis in octogenarians: influence of coronary disease and other comorbidities on hospital mortality. J Heart Valve Dis  2004; 13: 545– 52. Google Scholar PubMed  17 Gehlot A, Mullany CJ, Ilstrup D, Schaff HV, Orzulak TA, Morris JJ et al.   Aortic valve replacement in patients aged eighty years and older: early and long-term results. J Thorac Cardiovasc Surg  1996; 111: 1026– 36. Google Scholar CrossRef Search ADS PubMed  18 Langanay T, Verhoye JP, Ocampo G, Vola M, Tauran A, De La Tour B et al.   Current hospital mortality of aortic valve replacement in octogenarians. J Heart Valve Dis  2006; 15: 630– 7. Google Scholar PubMed  19 Alassar Y, Yildirim Y, Pecha S, Detter C, Deuse T, Reichenspurner H. Minimal access median sternotomy for aortic valve replacement in elderly patients. J Cardiothorac Surg  2013; 8: 103. Google Scholar CrossRef Search ADS PubMed  20 Brennan JM, Thomas L, Cohen DJ, Shahian D, Wang A, Mack MJ et al.   Transcatheter versus surgical aortic valve replacement: propensity-matched comparison. J Am Coll Cardiol  2017; 70: 439– 50. Google Scholar CrossRef Search ADS PubMed  21 Auffret V, Lefevre T, Van Belle E, Eltchaninoff H, Iung B, Koning R et al.   Temporal trends in transcatheter aortic valve replacement in France: FRANCE 2 to FRANCE TAVI. J Am Coll Cardiol  2017; 70: 42– 55. Google Scholar CrossRef Search ADS PubMed  22 Thourani VH, Kodali S, Makkar RR, Herrmann HC, Williams M, Babaliaros V et al.   Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet  2016; 387: 2218– 25. Google Scholar CrossRef Search ADS PubMed  23 Siontis GC, Praz F, Pilgrim T, Mavridis D, Verma S, Salanti G et al.   Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of severe aortic stenosis: a meta-analysis of randomized trials. Eur Heart J  2016; 37: 3503– 12. Google Scholar CrossRef Search ADS PubMed  24 Falk V, Baumgartner H, Bax JJ, De Bonis M, Hamm C, Holm PJ, Iung B et al.   2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg  2017; 52: 616– 64. Google Scholar CrossRef Search ADS PubMed  25 Muneretto C, Bisleri G, Moggi A, Di Bacco L, Tespili M, Repossini A et al.   Treating the patients in the ‘grey-zone’ with aortic valve disease: a comparison among conventional surgery, sutureless valves and transcatheter aortic valve replacement. Interact CardioVasc Thorac Surg  2015; 20: 90– 5. Google Scholar CrossRef Search ADS PubMed  26 Antunes MJ. Aortic stenosis in octogenarians and other high-risk groups: what can surgical valve replacement offer? Eur J Cardiothorac Surg  2012; 42: 940– 1. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. 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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

Abstract OBJECTIVES: Considering the good immediate results reported for transcatheter aortic valve implantation in high-risk patients, the role of conventional aortic valve replacement (AVR) is being questioned, especially in elderly patients. The aim of this study was to evaluate our long-term results of conventional AVR in octogenarians. METHODS: A total of 2005 patients aged ≥80 years underwent AVR for aortic stenosis in our institution between 1978 and 2011. Of these, 1009 (50%) patients had an associated extracardiac comorbidity and 650 (32%) patients had coronary lesions. Valve replacement was the sole procedure in 1515 (76%) patients, and 396 (19%) patients had concomitant coronary artery bypass grafting. Data were collected at the time of surgery in our database, and regularly updated by mailed questionnaires and telephone contact. RESULTS: Early mortality of isolated AVR was 5.5% for the last 10 years of the series. Significant risk factors were chronic obstructive pulmonary disease, chronic renal failure, advanced cardiac disease [left or right ventricular failure, New York Heart Association (NYHA) Class IV and atrial fibrillation] and coronary disease. Long-term follow-up was 99.5% complete (9 patients lost to follow-up), totalling 8849 patient-years. Nine hundred and one patients died at late follow-up with a median survival of 7.1 years, with 7 patients becoming centenarian. Apart from older age, main late causes of death were cardiovascular (20.5%), neurological deficit (10.2%) and cancer (10.2%). Actuarial survival was 83%, 62.5% and 25% at 2, 5 and 10 years, respectively. This survival compares favourably with that of a French-matched population. Above all, 90% of late survivors reported functional improvement. Univariable and multivariable analysis identified risk factors of late death as male gender, associated comorbidity, renal failure, advanced cardiac disease, atrial fibrillation and impaired ventricular function. Coronary lesions, associated cardiac surgery and small diameter prostheses (19 or 21 mm) did not impair long-term survival. CONCLUSIONS: AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides an excellent quality of life and restores life expectancy. Percutaneous valve implantation is to be considered, in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis for the majority of patients. Aortic stenosis, Elderly, Aortic valve replacement, Transcatheter aortic valve implantation, Long-term survival, Ageing INTRODUCTION Aortic stenosis is the most frequent valvulopathy in industrialized countries. Nowadays, its incidence increases with age and represents a major health concern in populations where life expectancy has increased regularly throughout the 20th century [1, 2]. Aortic valve replacement (AVR) provides excellent long-term survival with functional improvement at a reasonable operative risk in the vast majority of patients [1, 3–5]. Consequently, increasing numbers of elderly patients are referred for aortic valve surgery. Transcatheter aortic valve implantation (TAVI) has been developed in the last decade and offers an alternative to open-heart surgery with good immediate results in non-operable or high-risk patients [6, 7]. This recent and rapid development raises new concerns about the management of aortic stenosis in the elderly. Should everyone benefit from an aggressive therapy? How one should decide between both strategies in fragile patients: conventional surgical replacement or a transcatheter approach? In order to answer these questions, we reviewed our experience of AVR in octogenarians since our first replacement in 1978. PATIENTS AND METHODS From 8th December 1978 to 30th June 2011, 2005 patients aged ≥80 years underwent an AVR in our institution. These octogenarians represented 14.8% of the 13 559 AVRs that we performed during this 32-year period. We considered all consecutive octogenarians who underwent an AVR, whether it was the sole procedure or whether it was associated with coronary bypass or another cardiac procedure (such as mitral or tricuspid valve procedures or ascending aorta replacement). No octogenarians who underwent an AVR during this period were excluded from the study. In order to achieve sufficient follow-up, even for the most recently operated patients, we decided to close enrolment in June 2011. Last follow-up inquiries for all living patients were performed during spring 2015. Preoperative characteristics Clinical data are detailed in Table 1. The mean age was 82.9 ± 2.2 years (range 80–96.3 years), and the median age was 82.5 years; 317 (15.8%) patients were ≥85 years. Another group of 76 (3.8%) patients were operated on as non-elective surgery. Table 1: Preoperative clinical data   Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4    Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4  NYHA: New York Heart Association; PTCA: percutaneous transluminal coronary angioplasty. Table 1: Preoperative clinical data   Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4    Number  %  Number of patients  2005    Age (years)  82.9 ± 2.2  Range 80–96  Male patients  918  46  Female patients  1087  54  Aortic stenosis  1827    Aortic insufficiency  32    Aortic stenosis + insufficiency  146    Systemic arterial hypertension  1037  51  Diabetes  140  7  Overweight  290  15  Associated disease(s)  1009  50  Chronic obstructive pulmonary disease  231  12  Chronic renal failure  113  10  Previous myocardial infarction  93    NYHA class   I  37  2   II  875  43   III  951  48   IV  145  7  Angina   On exertion  672  34   At rest  159  8   Unstable  42  2  Syncope  274  14  Left heart failure  646  32  Right heart failure  143  7  Non-elective surgery  76  4  Previous cardiac surgery  50  3  Previous PTCA  83  4  NYHA: New York Heart Association; PTCA: percutaneous transluminal coronary angioplasty. Fifty patients had a history of cardiac surgery [26 AVR, 4 mitral valve replacement, 19 coronary artery bypass grafting (CABG) and 1 ascending aorta]. Half of the patients (1009 of 2005) had at least 1 associated extracardiac comorbidity, including carotid stenosis (n = 281), cerebrovascular accident (n = 79), residual neurological deficit (n = 27), peripheral arteriopathy (n = 176), pulmonary disease (n = 231), chronic renal failure (defined by creatinine clearance <40 ml/min, n = 113) that required haemodialysis in 2 cases or previous cancer considered to be cured (n = 150). Among the entire cohort, 1310 (65%) patients had at least 1 risk factor for atherosclerosis, 290 (14.5%) patients were overweight and 140 (7%) patients had diabetes (which is a normal prevalence in France in this age group). Coronary arteriography showed significant lesions in 646 (32%) patients. Nineteen patients had a history of CABG and 83 patients had previous percutaneous coronary angioplasty. Preoperative echocardiography identified 130 (6.4%) patients with an impaired left ventricular function defined by an ejection fraction <40% (Table 2). Aortic stenosis was the predominant lesion, either pure or associated with a significant regurgitation, in 146 (7.3%) patients. Only 32 (1.6%) patients had pure aortic insufficiency, and 263 (13.7%) patients chronic atrial fibrillation (Table 2). Table 2: Preoperative investigations   Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6    Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6  AF: atrial fibrillation; ECG: electrocardiography; LVEF: left ventricular ejection fraction; SD: standard deviation. Table 2: Preoperative investigations   Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6    Number  %  Cardiothoracic index, mean ± SD  53.6 ± 5.1    ECG sinus rhythm  1666  84   AF + flutter  263 + 10  14  Pacemaker  116  58  Echocardiography   LVEF, mean ± SD  58.2 ± 12    LVEF <40%  130  6  AF: atrial fibrillation; ECG: electrocardiography; LVEF: left ventricular ejection fraction; SD: standard deviation. Surgical data AVR was performed according to our standard surgical procedures through median sternotomy. Cardiopulmonary bypass was achieved using moderate hypothermia (nasopharyngeal temperature of 28°C until 1996 then 32°C). Myocardial protection relied on antegrade cold crystalloid cardioplegia (Bretschneider or St Thomas) added to topical cooling or antegrade warm blood perfusion (for the last 12 years) according to the surgeon’s preference. Immediate haemodynamic recovery was excellent in 1659 (85%) cases, moderate or poor in 287 (15%) cases (Table 3) requiring pharmacological support during weaning from cardiopulmonary bypass or in the early postoperative course. Table 3: Surgical data Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  AVR: aortic valve replacement; CABG: coronary artery bypass grafting; SD: standard deviation. Table 3: Surgical data Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  Variables  Number  (%)  Cardiopulmonary bypass duration (min), mean ± SD  66 ± 26    Aortic cross-clamping time (min), mean ± SD  50 ± 21    Myocardial protection   Warm blood cardioplegia  541  27   Cold crystalloid cardioplegia  1464  73  Performed surgery   Isolated AVR  1515  76   AVR + CABG  396  19   AVR + associated surgery  94  5   Mitral valve  26  1   Ascending aorta  31  2   Tricuspid valvuloplasty  8  1  AVR: aortic valve replacement; CABG: coronary artery bypass grafting; SD: standard deviation. AVR was the only procedure in 1515 (76%) patients, while in 396 (19%) cases, it was performed with coronary revascularization. A group of 94 (5%) patients had another associated cardiac procedure (Table 3). All except 17 (0.8%) patients received a bioprosthesis. All major models have been implanted, according to the time frame and technical evolutions. Among those, 21- and 23-mm diameters account for two-thirds of the implantations (n = 676, 34% and n = 694, 35%), while 19-mm valves (n = 285) and 25-mm valves (n = 295) represent 14% each of the implanted bioprostheses respectively. Among the 396 patients who underwent concomitant CABG, 290 received 1 graft, 92 patients received 2 grafts, 13 patients received 3 grafts and 1 patient had 4 grafts. Thirty-one patients had an ascending aorta replacement associated with the AVR, 26 patients had a mitral valve procedure (13 replacements and 13 repairs) and 8 patients had a tricuspid valvuloplasty. Degenerative aortic stenosis was the most prominent lesion (92%). Data analysis This is a retrospective study performed from our Cardiovascular Surgery Department database. All clinical data and investigative reports were collected at the time of surgery and entered in our database, which is regularly updated. Patients surviving the AVR were subjected to a periodic follow-up, updated by a written questionnaire sent to cardiologists, physicians and patients. Phone inquiries were used to clarify some answers. When death data were missing, the vital records office of the mansion house of the patient’s birth town was contacted to obtain the death certificate. Mortality and morbidity were reported in accordance with the criteria by Akins et al. [8]. Statistical analysis Statistical analyses were performed by the Epidemiology Department within our Institution, using software package, release 9.1 (SAS Institute Inc., Cary, NC, USA). Continuous variables are expressed as their means (±1 SD) and were compared using the Student’s t-test. Qualitative variables are expressed as percentage and compared using either the χ2 test or Fisher’s exact test depending on the size of each population. All variables were first tested individually by univariable analysis and were considered statistically significant when the P-value was <0.05. To evaluate independent factors predictive for mortality, all variables with a P-value <0.2 in univariable analyses were submitted to multivariable analysis and entered in a step-by-step ascending and descending logistic regression analysis (Wald’s test). Results are expressed as P-values and odds ratios (ORs). Analysis of the actuarial survival factors was done by the Kaplan–Meier method and a Cox regression has been utilized for the multivariable analysis. The survival of the current series was compared with that of the French population matched for age and gender. The mortality quotients used were annual quotients. The comparison was done by the Maentel–Haenszel adjustment method. The Ethics Committee of the French Society of Thoracic and Cardiovascular Surgery has certified that this research project has been assessed according to the current regulations framing clinical research in France. The Committee’s decision is referenced as CERC-SFCTCV62012-3-12-11-23-38-LATh. RESULTS Early mortality and morbidity Early mortality (within 30 days) in the entire cohort was 8.6%, and 173 patients died during the postoperative course (10.5  ± 11.9 days). Cardiac aetiologies were the leading cause of death (n = 94, 56%). Among those, 7 deaths were valve related: 3 cerebral embolisms and 4 haemorrhages secondary to aortic annulus or ventricular rupture, the repair of which was beyond surgical possibility. Respiratory failure (n = 20) and mesenteric infarction (n = 18) were responsible for 22% of hospital mortality. Operative mortality has decreased over the years from 6.2% in 1990 to 4.4% in 2010 for isolated AVR. Thirty-nine percent of patients (n = 787) required perioperative blood transfusion. A transient worsening of renal function complicated the early postoperative course in 182 (9.1%) cases requiring haemodialysis in 19 patients. Sixteen patients experienced a coma, with full recovery in 11 cases. Forty-two patients had a neurological deficit that resolved before discharge. Ninety-nine patients needed prolonged respiratory assistance (>48 h) and 111 had respiratory fragility that benefited at least from physiotherapy and oxygen therapy. Fifteen patients were reoperated under cardiopulmonary bypass during the same hospitalization. Forty-four percent of patients (n = 819) experienced at least 1 transient episode of atrial fibrillation, most frequently medically cured, and only 19% were not in sinus rhythm at hospital discharge. The mean hospital stay was 20.2 ± 11 days in the early years of our experience and has progressively been reduced to 12.9 ± 7.2 days in 2010. Multivariable analysis identified 5 independent operative risk factors: older age [P < 0.015; odds ratio (OR) 1.1176], aortic regurgitation (P < 0.001; OR 58.17), New York Heart Association (NYHA) Class IV (P < 0.0007; OR 4.55), atrial fibrillation (P < 0.04; OR 2.38) and single AVR (P < 0.02; OR 0.435). In addition, univariable analysis identified several other operative risk factors such as respiratory failure (P < 0.03), emergency surgery (P < 0.0029), right heart failure (P < 0.03), impaired ejection fraction (P < 0.001), coronary disease (P < 0.01), redo surgery (P < 0.02) and associated CABG (P < 0.008). Late mortality and survival Only 9 of the 1832 patients who initially survived surgery lost to follow-up during the survey. Total follow-up was 8849 patient-years (mean 4.9  ± 3.6 years, range 1 month to 19.9 years) and was 99.5% complete. Late deaths were observed in 901 patients, occurring within 1 month to 19.9 years after surgery with a median survival of 7.1 years (Fig. 1). Actuarial survival (operative mortality included) is 83 ± 0.8%, 62.4 ± 1.2% and 25 ± 1.5% at 2, 5 and 10 years, respectively. Seven patients became centenarians. Predominant causes of death (Table 4) were myocardial complications (20.4%, 184 cases), cancer, cerebrovascular accident and senility at exactly the same rate as surprising as it appears (10.2%, 92 cases). Unfortunately, it was not possible to precisely determine the cause of death for a third of patients but because of the advanced age of this population, one could assume that senility was probably a frequent cause. Table 4: Causes of late death Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Table 4: Causes of late death Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Causes  Number  %  Myocardial  184  21  Cancer  92  10  Stroke  92  10  Advanced age senility  92  10  Pulmonary failure  51  6  Miscellaneous  62  7  Unknown  328  37  Figure 1: View largeDownload slide Actuarial survival of operated patients (green line) compared with a normal matched French population (blue line). AVR: aortic valve replacement. Figure 1: View largeDownload slide Actuarial survival of operated patients (green line) compared with a normal matched French population (blue line). AVR: aortic valve replacement. Univariable analysis identified male gender, preoperative renal failure, preoperative chronic obstructive pulmonary disease and advanced myocardial disease (NYHA Class IV, atrial fibrillation and impaired left or right ejection fraction on echocardiography) to have a negative impact. On the contrary, concomitant coronary revascularization or an associated cardiac surgery, which are operative risk factors, did not impact long-term survival. Analysis of actuarial survival as a function of prosthesis diameter found no significant difference, even for 19-mm diameter valves (Table 5). Table 5: Risk factors of late death   %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)    %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)  CABG: coronary artery bypass grafting; CI: confidence interval; COPD: chronic obstructive pulmonary disease; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; OR: odds ratio. Table 5: Risk factors of late death   %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)    %  P-value  OR (95% CI)  Male gender  8.0  0.04  1.15 (1.01–1.31)  NYHA class   I–II  7.6  <10−4  1.48 (1.29–1.71)   III–IV  12.3  Sinus rhythm   Yes  9.7  <10−4  1.71 (1.44–2.05)   No  13.6  Cardiothoracic index    <10−3  1.02 (1.01–1.03)  Non-elective surgery  17.2  <10−3  1.66 (1.24–2.22)  Left heart insufficiency  14.2  <10−4  1.76 (1.44–2.01)  Right heart insufficiency  13.8  <10−3  1.48 (1.17–1.88)  Coronary lesions   0  10.0  0.17     1  10.6    1.17 (0.98–1.39)   2  10.6    1.24 (0.95–1.62)   3  10.6    1.12 (0.84–1.49)  Associated CABG  10.2  0.30  1.11 (0.93–1.32)  LVEF <40%  12.7  0.07  1.26 (0.98–1.63)  Associated cardiac surgery  10.9  0.40  1.11 (0.93–1.33)  Chronic renal failure  12.4  0.008  1.49 (1.10–2.00)  COPD  12.4  0.40  1.09 (0.89–1.34)  Associated extracardiac comorbidity  10.4  0.02  1.17 (1.02–1.33)  19-mm valve diameter  10.6  0.50  1.06 (0.88–1.28)  19- or 21-mm valve diameter  10.4  0.80  1.01 (0.89–1.15)  CABG: coronary artery bypass grafting; CI: confidence interval; COPD: chronic obstructive pulmonary disease; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association; OR: odds ratio. Infective endocarditis of the prosthesis occurred in 19 (0.2%) cases, structural valve deterioration in 13 (0.14%) cases within a delay of 4.9 ± 3.0 years, significant periprosthetic leak in 13 (0.14%) cases requiring reoperation for 3 patients, 30 haemorrhages (0.33%) and 89 thromboembolic accidents (1%). Actuarial freedom from late valve-related complications is 97% ± 0.4% at 2 years, 91.5 ± 0.8% at 5 years and 83.9 ± 1.6% at 10 years. Seven patients have been reoperated due to prosthesis-related complications: 3 periprosthetic leaks, 3 infections and 1 valve thrombosis. Actuarial freedom from reoperation was 99.7 ± 0.1% at 2 years, 99.6 ± 0.1% at 5 years, 99.5 ± 0.2% at 10 years and 99.5 ± 0.2% at 15 years. At the last follow-up, 922 patients are still alive, 96% indicated that their quality of life had been improved or very much improved by the valve replacement (90% of patients were in NYHA Class I or II at late follow-up) (Fig. 2). Sinus rhythm was documented in 70% of patients and atrial fibrillation in 20%. Figure 2: View largeDownload slide Evolution of NYHA status before and after AVR. AVR: aortic valve replacement; NYHA: New York Heart Association. Figure 2: View largeDownload slide Evolution of NYHA status before and after AVR. AVR: aortic valve replacement; NYHA: New York Heart Association. DISCUSSION Cardiovascular diseases are the leading cause of mortality in the elderly, far outpacing cancer and other illnesses. As a consequence of increasing life expectancy, octogenarians represent 5.9% of the French population (3 964 205 of 66 990 826 people) and number about 27 million in the European Union [9]. Aortic valve stenosis is the most frequently identified lesion. Its incidence increases with age, exceeding 5% >80 years [1, 2]. Our team and others have previously reported that AVR is possible even in advanced age patients with an acceptable mortality, good long-term survival and patent functional improvement, provided that the stenosis is tight and symptomatic [10–18]. Since our first AVR in an octogenarian on the 8th December 1978, surgical indications have progressively been extended. During the early years of our experience, only patients with good ventricular function and without associated comorbidities or coronary disease were considered for surgery. The patient profile has progressively evolved, as we have already published [16], such that in the most recent years of this series, a third of the patients had associated CABG with the AVR and >50% of them had at least 1 extracardiac comorbidity. Ageing of the population and indications have led more and more elderly people to undergo this surgery such that, today, octogenarians represent 20% of the AVRs performed annually in our institution (Fig. 3). The reported early mortality of 8.8% of this series may seem too high when compared with the recent publications, but it does not reflect the contemporary mortality of AVR in octogenarians. It is an historical series, which spans over 30 years. In parallel to the development of cardiac surgery in the elderly, improvements in the field of surgery, anaesthesiology, myocardial protection and intensive care have led to a marked decrease of early mortality, as we reported in 2011 with a 5.5% mortality in cases of isolated AVR despite increasing numbers of high-risk patients [11, 16, 18]. New approaches such as minimal access or sutureless valve have been reported to reduce postoperative pain, intensive care unit and hospital stays and shorter ventilation time [19]. Therefore, these techniques may be beneficial in terms of morbidity and mortality and improve the early postoperative course even more in future. Figure 3: View largeDownload slide Evolution of proportion of AVR in the elderly (red column) compared with AVR in younger patients (blue column). AVR: aortic valve replacement. Figure 3: View largeDownload slide Evolution of proportion of AVR in the elderly (red column) compared with AVR in younger patients (blue column). AVR: aortic valve replacement. Analysis of the actuarial survival (Fig. 1) displays a significant drop of the curve during the 1st year. This may be due to both early mortality and poor survival of patients with an advanced cardiomyopathy who obviously had been operated on too late. As we reported, the early mortality of the entire cohort decreased with time due to medical progress, from 6.2% in 1990 to 4.2% in 2010. One can indeed assume that early mortality is mainly observed in high-risk patients that have been characterized in a previous study [11] Moreover, the proportion of high-risk octogenarians in our surgical population will probably decrease in future, taking into account the development of percutaneous procedures. Comparison with the survival of a French-matched population showed that the 2 curves were initially parallel and then tended to draw closer before crossing at 10 years postoperatively, demonstrating that conventional AVR restores life expectancy similar to that of a French-matched population as we have previously reported for younger populations [5, 12]. Above all, 96% of operative survivors reported significant improvement. With the greying of Western countries, the burden on states’ coffers will become heavier and heavier. The enormous cost of social protection in Western countries is a noose that is slowly strangling the economies of these countries. So, one may question whether it is worth or reasonable, economically speaking, to propose such expensive techniques to elderly people. When calculating the subsequent survival freedom from serious valve-related events, the group of survivors fared reasonably well, emphasizing the highly satisfactory results of contemporary AVR. Besides the symptomatic relief and the prevention of sudden death, it will also prevent recurrent episodes of heart failure, leading to repeat hospitalizations, generating increasing costs for the society and the loss of autonomy for the patient. Relief of symptoms and improvement in quality of life should assume greater importance than the issue of increased life expectancy. Frailty characterizes the increased vulnerability of elderly people to acute stressors as a consequence of decline in overall function and physiological reserves. An estimated 30% of octogenarians are frail. Frailty predicts death and heralds the transition to disability in general population. It also predicts the expected benefit of AVR and the postoperative recovery. It appears that simple ‘eyeballing’ is no longer enough to appreciate the preoperative status of our patients, though it remains useful despite several risk scores. A heart team approach including surgeons, cardiologists, anaesthesiologists, geriatricians and physiotherapists can be helpful to assess these elderly candidates and choose the best approach to treat aortic stenosis. Age itself has already been identified as a risk factor [12, 18]. The increased mortality rate reflects the lack of functional reserve for stressful events in this older population. We previously identified and reported operative risk factors in this elderly population belonging to the following 3 categories: the patients themselves and their general clinical status, their cardiological condition and the surgical procedure itself. Determining the expected quality of life after surgery must be part of the selection process [11]. Percutaneous aortic valve implantation has been developed during the last 10 years. Recent publications [7, 20, 21] indicate that TAVI is not only a safe and effective treatment for high-risk patients with severe aortic stenosis but also might be the preferred treatment alternative in intermediate-risk patients [22]. These data are sufficient to support the use for high-risk patients because they have a higher operative mortality rate with conventional AVR and probably a lower life expectancy. But there are still many unanswered questions about the long-term complications and durability of TAVI valves [23]. Very few robust data are available after 3 or 4 years. In the light of this series, conventional AVR is safe and has excellent long-term outcome with 30% of octogenarian patients still alive at 10 years with good functional status. In addition, the switch from conventional AVR to TAVI for many high-risk patients during recent years has led to a significant decrease of early mortality for AVR to 1.3% in 2016. Recently, new recommendations have been published, proposing the expansion of TAVI indications [24]. In view of our results, we consider that for the moment TAVI should be proposed only to patients contraindicated for surgery or selected patients at high risk of mortality and morbidity. Where this line is drawn is a moving target and remains controversial [25]. Manuel Antunes [26] wrote in 2012 that AVR in the elderly has a low operative mortality and provides reliable durability. To our knowledge, this series is one of the largest monocentric reported experiences of AVR in the elderly with a follow-up over 30 years. As Manuel Antunes proposed in his editorial, we consider that these kinds of results should constitute the benchmark for TAVI. Limitations The first limitation of the present study is the retrospective analysis of a single-centre experience. However, very few randomized studies in the field have been published. Furthermore, during a 32-year period, the results may have been affected by variations in perioperative medical and surgical management. However, despite the long period of our study, very few data are missing (follow-up is 99% complete). Moreover, despite this exhaustive follow-up, the exact cause of deaths remains uncertain for 37%. CONCLUSION Considering the very poor outcome of non-surgical options, AVR is effective for all age groups to treat aortic stenosis. Elderly people should not be denied surgery only because of their old age as conventional AVR provides excellent quality of life and improves life expectancy. Percutaneous valve implantation is to be considered in cases of non-operable or high-risk patients. However, to date, open-heart surgery remains the treatment of choice for aortic stenosis in the vast majority of patients. ACKNOWLEDGEMENTS The authors acknowledge Anne Ingels, Sylvie Marie and Brigitte Héluard for their contribution to this study. Conflict of interest: none declared. REFERENCES 1 Carabello BA, Paulus WJ. Aortic stenosis. Lancet  2009; 373: 956– 66. Google Scholar CrossRef Search ADS PubMed  2 Iung B, Vahanian A. Epidemiology of valvular heart disease in the adult. Nat Rev Cardiol  2011; 8: 162– 72. Google Scholar CrossRef Search ADS PubMed  3 Craver JM, Puskas JD, Weintraub WW, Shen Y, Guyton RA, Gott JP et al.   601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg  1999; 67: 1104– 10. Google Scholar CrossRef Search ADS PubMed  4 Sundt TM, Bailey MS, Moon MR, Mendeloff EN, Huddleston CB, Pasque MK et al.   Quality of life after aortic valve replacement at the age of >80 years. Circulation  2000; 102: III70– 4. 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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Mar 16, 2018

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