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 Surgerydoctors 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.”


2 Responses to “Aortic Valve Surgery for Nonagenarians”

  1. Ramachandra Barik, DM says:

    The octogenarians with signicant aortic valve stenosis usually have some eccentric clinical features and perioperative response
    Preoperatively they present with more heart failure symptoms, more calcific aortic valve, less aortic valve gradient and lower ejection fraction with or without coronary artery disease.
    Postoperatively these patient are more ventilator dependent irrespective of pulmonary function test result, prolonged hospital stay.
    To be surprised ,discharged patients do very well with bio prosthetic aortic valve.

  2. It is too bad that there was no assessment of patient frailty, disability, and patient reported health status both at baseline and at followup. This would have characterized the patients better than the typical metrics and provided greater insight into the benefit of both forms of valve replacement. These are no longer research metrics but “standard-of-care” especially in this target population. To me this is a limitation of study as great as the small sample size. In addition the results are of historical interest and less importance going forward assuming we have the next generation of TAVR technology available in the US in a timely fashion. This will change the outcomes related to paravalvular leak, vascular complications, use of general anesthesia, need for non-femoral access, and the overall “burden of treatment” on these patients. The hospital LOS metric can not be reported separately from both eh discharge destination but also the LOS of the next facility. These “extremely elderly” patients do not have long to live, even with AVR, as represented by the 46% two year survival rate. Therefore, LOS in all medical-nursing facilities may represent 10% plus of the time “on earth” and this gives priority to whatever technique will get the able to recover, i.e. have sufficiently reduced disability post-procedure, to be home. Therefore the new metric of success such be alive-home-improved functional status (not NYHClass!)-freedom from hospital readmission-and self assessed health status-QOL. Therefore, while this report is of “interest”, it represents too much the inadequate approach to risk/benefit that reflects the past not the future of patient care.