October 30th, 2014
Aortic Valve Surgery for Nonagenarians
As people continue to live longer physicians are increasingly confronted with very elderly patients who have serious conditions that might benefit from surgery but who are at high risk for surgical complications. In a paper published in the Annals of Thoracic Surgery, doctors at the Mayo Clinic reviewed their experience with 59 patients age 90 or older who had severe aortic stenosis and underwent surgical (SAVR) or transcatheter aortic valve replacement (TAVR).
A growing number of elderly patients “are mentally sharp, are enjoying a good quality of life with a low level of concomitant disability, and are willing to undertake the risks of valve replacement to improve both their quality and quantity of life,” write the authors.
Thirty-three patients underwent SAVR, 26 underwent TAVR (one patient had SAVR after a TAVR complication). There were 3 operative deaths; 2 in the SAVR group and 1 in the TAVR group. Operative mortality was lower than predicted. The overall survival rate was 81.3% at one year and 46.2% at two years.
More than a third of the patients had operative complications. Pulmonary complications occurred more often in the surgical group while vascular complications occurred more often in the TAVR group. One TIA occurred in the SAVR group and one stroke in the TAVR group.
Five patients in the SAVR group and 12 patients in the TAVR group were discharged home. The 31 remaining patients went to a skilled nursing facility. Most patients were in NYHA class I or II after the procedure.
Until recently most very elderly patients who underwent surgery were “relatively healthy,” the authors wrote. With the introduction of TAVR, however, more patients with major comorbidities are also now choosing TAVR. Although the experience in this small group suggests they can do well, the authors report that the TAVR patients had a higher incidence of paravalvular regurgitation than did the SAVR patients (48% versus 0%).
The authors concluded that aortic valve replacement “is a reasonable option in select nonagenarian patients.”
In a press release, one author, Kevin Greason, said that AVR “should not be denied” in appropriate patients. “Nearly 80% of our patients had significant heart failure symptoms prior to surgery and most experienced marked improvement following the operation.”
The increasing popularity of AVR in elderly patients highlights the need for further study, said Harlan Krumholz, commenting on the paper. “We need comparative effectiveness studies that focus squarely on the very elderly, an increasingly common population with cardiovascular issues. That small, single center case studies can be published shows you the dearth of information that we currently face.”