High-Risk Aortic Valve Replacement: Are the Outcomes as Bad as Predicted?

• Published in: The Annals of thoracic surgery Vol. 85; no. 1; pp. 102 - 107
• Main Authors: Grossi, Eugene A., MD, Schwartz, Charles F., MD, Yu, Pey-Jen, MD, Jorde, Ulrich P., MD, Crooke, Gregory A., MD, Grau, Juan B., MD, Ribakove, Greg H., MD, Baumann, F. Gregory, PhD, Ursumanno, Patricia, PhD, Culliford, Alfred T., MD, Colvin, Stephen B., MD, Galloway, Aubrey C., MD
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 2008
• Subjects: Aged; Aged, 80 and over; Aortic Valve - physiopathology; Aortic Valve - surgery; Aortic Valve Insufficiency - mortality; Aortic Valve Insufficiency - surgery; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - surgery; Cardiothoracic Surgery; Cause of Death; Female; Follow-Up Studies; Geriatric Assessment; Heart Valve Prosthesis Implantation - methods; Heart Valve Prosthesis Implantation - mortality; Hospital Mortality - trends; Humans; Male; Odds Ratio; Postoperative Complications - mortality; Predictive Value of Tests; Probability; Prospective Studies; Risk Assessment; Severity of Illness Index; Surgery; Survival Analysis; Time Factors; Treatment Outcome; 35
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2007.05.010

Background Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution’s surgical results in this target population. Methods From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index. Results The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 ( p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease ( p = 0.019; OR, 2.14), and peripheral vascular disease ( p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age ( p < 0.001), previous cardiac operations ( p < 0.014; OR, 1.51), renal failure ( p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease ( p < 0.007; OR, 1.30) were predictors of worse survival. Conclusions Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points.