Quality of Life After Aortic Valve Replacement at
the Age of >80 Years
Thoralf M. Sundt, MD; Marci S. Bailey, RN; Marc R. Moon, MD; Eric N. Mendeloff, MD;
Charles B. Huddleston, MD; Michael K. Pasque, MD;
Hendrick B. Barner, MD; William A. Gay, Jr, MD
Downloaded from http://circ.ahajournals.org/ by guest on June 14, 2017
Background—The optimal management of aortic valve disease in patients ⬎80 years old depends on functional outcome
as well as operative risks and late survival.
Methods and Results—We retrospectively identified 133 patients (62 men, 71 women) aged 80 to 91 years (mean 84⫾3
years) who underwent aortic valve replacement alone or in combination with another procedure between January 1,
1993, and April 31, 1998. Demographics included hypertension 68%, diabetes mellitus 17%, and history of stroke 11%.
Operative (30 day) mortality rate was 11%. Urgent or emergent surgery, aortic insufficiency, and perioperative stroke
or renal dysfunction were risk factors for operative death by multivariable analysis. Intensive care unit and total hospital
length of stay were prolonged at 6.2 and 14.7 days, respectively. Late follow-up between July 1, 1998, and November
1, 1999, was 98% complete. Actuarial survival at 1 and 5 years was 80% and 55%, respectively. Predictors of late
mortality were preoperative or perioperative stroke, chronic obstructive pulmonary disease, aortic stenosis, and
postoperative renal dysfunction. The mean New York Heart Association functional class for 65 long-term survivors
improved from 3.1 to 1.7. Quality of life assessed with the Medical Outcomes Study Short Form-36 was comparable
to that predicted for the general population ⬎75 years old.
Conclusions—Functional outcome after aortic valve replacement in patients ⬎80 years old is excellent, the operative risk
is acceptable, and the late survival rate is good. Surgery should not be withheld from the elderly on the basis of age
alone. (Circulation. 2000;102[suppl III]:III-70-III-74.)
Key Words: valves 䡲 surgery 䡲 aging 䡲 cost-benefit analysis
T
he decision between continued medical management and
surgical intervention for aortic valve disease in patients
⬎80 years old may be difficult for both the physician and the
patient. Despite a number of recent studies that demonstrate
acceptable operative risk as well as satisfactory long-term
survival rates,1– 6 there remains significant reluctance to
recommend aortic valve replacement (AVR) in this age
group. This likely relates in part to uncertainty over the
long-term functional results that can be expected. In some
settings, the potential for increased resource utilization may
enter into decision making as well. The advancing age of the
general population makes this an increasingly frequently
encountered dilemma. With these issues in mind, we sought
to examine our results with AVR in patients ⬎80 years old.
Perioperative mortality and morbidity rates, as well as late
survival and functional outcome, including measures of the
quality of life, were assessed.
perioperative events were retrieved from our computerized database.
Late follow-up information was obtained through postal questionnaire or telephone interview between July 1, 1998, and November 1,
1999. Follow-up was 98% complete. Functional status was determined in 65 late survivors. New York Heart Association (NYHA)
functional class was assessed, as was quality of life with the Medical
Outcomes Study (MOS) Short Form-36 (SF-36) tool.7 Eight dimensions of health were investigated: physical functioning, physical
health related to age- and role-specific activities (“Role-Physical”),
bodily pain, general health, vitality, social functioning, personal
feelings of performance in age- and role-specific activities (“RoleEmotional”), and mental health. Scores were compared with those
expected for the general population of a similar age.
Members of the Division of Cardiothoracic Surgery carried out
surgical procedures at Barnes and Jewish Hospitals. Although
approaches varied somewhat among surgeons, all procedures were
carried out with cardiopulmonary bypass and at least mild systemic
hypothermia. Cardiac arrest was achieved with cold crystalloid or
blood cardioplegia. All procedures were performed via the standard
median sternotomy approach. The selection of prosthesis type was at
the discretion of the operating surgeon. There is a strong institutional
preference for biologic valves in this age group regardless of the
preoperative presence of atrial fibrillation. Coronary bypass was
performed whenever occlusive disease involved major epicardial
vessels. All continuous data were expressed as mean⫾SD or as a
percentage as indicated. The survival analysis was made with the
Methods
Between January 1, 1993, and April 31, 1998, 133 patients ⬎80
years old underwent AVR with or without concomitant procedures at
Washington University. Preoperative demographic information and
From the Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
Reprint requests to Thoralf M. Sundt, MD, Suite 3106, Queeny Tower, One Barnes Hospital Plaza, St Louis, MO 63110. E-mail
[email protected]
© 2000 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
III-70
Sundt et al
TABLE 1. Demographic Characteristics of the
Study Population
Characteristic
Quality of Life After AVR at >80 Years
TABLE 2.
III-71
Operative Characteristics
Characteristic
Operative priority
Age, mean (range)
83.5⫾2.6 (80.1–90.6)
Elective
112 (84.2)
Female sex, n (%)
71 (53.4)
Urgent
14 (10.5)
Hypertension, n (%)
90 (67.7)
Diabetes mellitus, n (%)
23 (17.3)
Tobacco abuse, n (%)
Active
3 (2.3)
Inactive
47 (35.3)
COPD, n (%)
16 (12)
Emergent
CABG
89 (66.9)
Mitral valve replacement
12 (9.0)
Mitral valve repair
3 (2.3)
CPB time, min (range)
158.6⫾57.91 (55–326)
Cross-clamp time, min (range)
109.7⫾42.1 (32–234)
Chronic renal insufficiency, n (%)*
7 (5.3)
Peripheral vascular disease, n (%)
17 (12.8)
Valve prosthesis
Previous stroke, n (%)
15 (11.3)
Biological
Valve pathology, n (%)
Mechanical
Stenosis
7 (5.3)
Associated procedures
126 (94.7)
7 (5.3)
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104 (78.2)
19 mm
17 (12.8)
Regurgitation
10 (7.5)
21 mm
49 (36.8)
Mixed
19 (14.3)
⬎21 mm
67 (50.4)
Peak gradient, mm Hg†
54⫾22
Aortic valve area, cm2†
0.6⫾0.2
Preoperative atrial fibrillation, n (%)
28 (21.1)
Previous myocardial infarction, n (%)
23 (17.3)
Angina pectoris, n (%)
79 (59.4)
Previous cardiac surgery, n (%)
AVR
5 (3.8)
CABG
8 (6.0)
Pacemaker
7 (5.3)
Other
11 (8.3)
Ejection fraction ⬍0.35, n (%)
19 (14.3)
Preoperative NYHA class, n (%)
I
5 (3.8)
II
20 (15.0)
III
69 (51.9)
IV
39 (29.3)
COPD indicates chronic obstructive pulmonary disease.
*Chronic renal insufficiency is defined as serum creatinine ⬎2.0 g/dL.
†For patients with predominant functional stenosis.
Kaplan-Meier estimator. Univariable analysis of risk factors for early
and late death was performed, and factors found to trend toward
significance (P⬍0.15) were entered into multivariable analysis. A
stepwise multivariable Cox regression model was then constructed
with those factors to determine independent predictors of early and
late death (P⬍0.05). The Friedman nonparametric t test was used to
compare the preoperative and postoperative NYHA functional class.
A value of P⬍0.05 was considered significant for all statistical
calculations. The SYSTAT system for statistics was used for all data
analyses (Version 6.0 for Windows; SPSS).
Results
Demographics of the Study Population
As shown in Table 1, men and women were approximately
equally represented. Two thirds of patients had a history of
hypertension but less than one fifth had diabetes mellitus.
Chronic obstructive pulmonary disease, peripheral vascular
disease, and cerebrovascular disease were less common. The
Values are n (%) or mean⫾SD (range). CPB indicates cardiopulmonary
bypass. n⫽133.
majority of patients had predominant functional stenosis, with
a mean peak gradient of 54⫾22 mm Hg and a calculated
valve area of 0.6⫾0.2 cm2 in this subgroup. Atrial fibrillation
was present preoperatively in one fifth of patients. Angina
pectoris was a presenting complaint in the majority of
patients, and ⬎80% had NYHA functional class III or IV
symptoms of heart failure. Few had undergone previous
cardiac surgery or had a history of myocardial infarction.
Less than 15% of patients had ejection fractions of ⬍0.35.
Operative Characteristics
Details of the operative procedures are presented in Table 2.
A significant percentage of procedures were performed urgently or emergently. Concomitant CABG was performed
frequently. Biological prostheses predominated, and ⬇50%
of valves used were ⱕ21 mm. Of the 52 patients who
received small valves, 40 (77%) were women.
Perioperative Events
The operative (30-day) mortality rate was 11.1% (Table 3).
Stepwise logistic regression analysis yielded urgent or emergent surgical status (P⫽0.005) as a strong predictor of
operative death. The mortality rate for urgently operated
patients was 21.4%, whereas that for emergently operated
patients was 43%. Aortic insufficiency also was a predictor of
operative risk (P⬍0.05). Among perioperative complications,
perioperative renal dysfunction (P⬍0.05) and stroke
(P⬍0.05) were risk factors for death within 30 days of
surgery. Concomitant CABG was not a risk factor. As shown
in Table 4, the operative mortality rate was actually higher in
those who underwent isolated AVR than in those who
underwent concomitant CABG, although this difference did
not reach statistical significance. Operative risk was not
related to preoperative NYHA functional class, with similar
III-72
Circulation
TABLE 3.
November 7, 2000
30-Day Mortality and Morbidity Incidence
Event
Death
15 (11.1)
Myocardial infarction*
1 (0.75)
Intraoperative/postoperative use of IABP
6 (4.5)
Low-output syndrome†
22 (16.5)
Renal dysfunction‡
15 (11.3)
Renal dialysis
5 (3.8)
Stroke permanent
5 (3.8)
Respiratory failure§
35 (26.3)
Ventricular arrhythmia
18 (13.5)
Atrial arrhythmia
53 (39.8)
Figure 1. Actuarial survival of study group with Kaplan-Meier
method. Mean follow-up is 2.6 years.
Although cost data are notoriously inaccurate, length of
stay may be considered a surrogate for resource use. The
postoperative length of stay in the intensive care unit was
prolonged at a mean of 6.2 days (range 1 to 41 days).
Forty-seven percent of patients spent ⬎4 days in the intensive
care unit. The overall postoperative hospital stay ranged from
4 to 92 days (mean of 14.7 days).
Sternal infection
Deep
0 (0)
Superficial
2 (1.5)
Reoperation for bleeding
14 (10.5)
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Values are n (%). IABP indicates intra-aortic balloon pump.
*Myocardial infarction defined as a new Q wave.
†Low output defined as cardiac index ⬍2.0 or intra-aortic balloon support.
‡Renal dysfunction defined as serum creatine ⬎2.0 g/dL.
§Respiratory failure defined as intubation ⬎24 hours or reintubation.
n⫽133.
Late Results
The actuarial survival rate was ⬇80% at 1 year and ⬇55% at
5 years (Figure 1). Stepwise logistic regression analysis
revealed preoperative history of stroke (P⫽0.01), chronic
obstructive pulmonary disease (P⬍0.001), and aortic stenosis
(P⬍0.001) as preoperative predictors of late death. Perioperative renal dysfunction (P⫽0.001) and perioperative stroke
(P⬍0.001) were also predictive of late death. Late survival
was not worse for those in an advanced NYHA functional
class before surgery. Those in NYHA functional class I or II
who underwent isolated AVR actually had a worse late
survival rate than those in class III or IV (Table 4), which
reached statistical significance, likely due to the small number of individuals in this group.
Sixty-five long-term survivors responded to postal questionnaires or telephone interviews regarding their functional
operative mortality rates observed for individuals in NYHA
functional class I or II as for those in class III or IV (Table 4).
The morbidity rate was significant. More than 10% of
patients experienced renal dysfunction defined as an increase
in serum creatinine to ⬎2.0 g/dL, and almost 4% of patients
required hemodialysis after surgery. More than one fourth of
patients required mechanical ventilation for ⬎24 hours.
Permanent stroke, however, was observed in only 4% of
patients. Atrial fibrillation was common, and a relatively high
percentage of patients experienced bleeding complications.
TABLE 4.
Mortality Incidence by Subgroup
Operative Procedure
n
Perioperative Deaths
Early Plus Late Deaths
Isolated AVR, n (%)
35
3 (8.6)*
12 (34.3)*
6
1 (16.7)
4 (66.7)
NYHA class I or II
NYHA class III or IV
AVR⫹CABG, n (%)
29
2 (6.9)†
71
10 (14.1)*
8 (27.6)‡
27 (38.0)*
NYHA class I or II
15
2 (13.3)
6 (40)
NYHA class III or IV
56
8 (14.3)
21 (37.5)
AVR⫹MVR, n (%)
4
1 (25)
AVR⫹MVR⫹CABG, n (%)
8
2 (25)
1 (25)
AVR⫹MV repair⫹CABG, n (%)
3
0
AVR⫹CEA, n (%)
5
1 (20)
2 (40)
AVR⫹CABG⫹CEA, n (%)
3
0
1 (33)
AVR⫹ascending aortic replacement, n (%)
4
1 (25)
2 (50)
AVR⫹CABG⫹ascending aortic replacement, n (%)
2
1 (50)
2 (100)
AVR⫹other (tricuspid annuloplasty, ASD, atrial
myxoma, septal myectomy), n (%)
4
0
0
2 (25)
2 (66.7)
ASD indicates atrial septal defect; CEA, carotid endarterectomy; and MVR, mitral valve replacement.
*P⫽NS for isolated AVR vs AVR⫹CABG.
†P⫽NS for class I or II vs class III or IV.
‡P⫽0.001 for class I or II vs class III or IV.
Sundt et al
Figure 2. Improvement in NYHA class among 60 survivors who
respond to postal questionnaire or telephone interview. Median
class improved from 3 to 1, and mean class from 3.1 to 1.7.
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status. For this subgroup, the mean NYHA functional class
improved from 3.1 to 1.7 (Figure 2) with ⬎80% of patients in
class I or II (P⬍0.001). Scores on the SF-36 were comparable
to those for the general population ⱖ75 years old (Figure 3).
Subjects actually scored higher than the control population in
5 areas, including Bodily Pain, General Health, Social Functioning, Role-Emotional, and Mental Health. Unfortunately,
matched preoperative data on subjects are unavailable.
Discussion
The results of the present study demonstrate that gratifying
late results may be achieved with AVR in patients ⬎80 years
old. Survival rates at 1 and 5 years postoperatively were
satisfactory, and there was marked improvement in NYHA
functional class among long-term survivors. Furthermore, the
quality of life as assessed with the MOS SF-36 survey was
comparable to that is expected among the general elderly
population. This can be accomplished at an acceptable
Figure 3. Results of MOS SF-36 for subjects compared with
general population with definitions of 8 health concepts from
Bungay and Ware.7
Quality of Life After AVR at >80 Years
III-73
operative risk even among patients with advanced symptoms
of heart failure.
There are ample data in the literature that support the
excellent late survival rates to be achieved in this age group.
Remarkably, there have been multiple reports1– 6,8,9 of similar
5-year survival rates of 55% to 66%. Less attention has been
paid to functional outcome, however. A clear improvement in
NYHA functional class has been reported,4 as have measures
such as autonomy8 and “satisfaction” with present quality of
life8 or with the decision to proceed with surgery.2,9 In recent
years, interest has increased in more sophisticated and standardized measurement of functional outcome, and several
previous studies have been published.
Khan et al4 evaluated 61 octogenarians (mean age 83.5
years) who underwent cardiac surgery and obtained Karnofski performance scores before and after surgery. Of these
patients, 47 underwent isolated AVR. Functional improvement was significant, with an improvement in the Karnofski
score of 50% by 1 month and a 2-class improvement in
median NYHA status. Levin et al10 and Olsson et al11 also
explored the measurement of quality of life with their own
assessment tools, again with documented improvement.
These studies share a significant strength in having both
preoperative and postoperative data on subjects. Their use of
nonstandardized instruments, however, may make their methodology of limited applicability.
We have chosen to explore the use of a widely accepted
instrument for the assessment of quality of life, the MOS
SF-36. Many such tools have been developed, and each may
be more applicable to a specific disease state than to another;
however, this instrument was previously used in a similar
study of a somewhat younger patient population who underwent cardiac surgery at the Johns Hopkins School of Medicine. Tseng et al12 studied patients ⬎70 years old who
underwent AVR. The mean age of their study group was 76.2
years. In comparison with the general population, as in the
present study, excellent functional recovery was achieved. A
shortcoming of their study, like ours, was the lack of
preoperative data on the study subjects, an inherent limitation
of retrospective analysis. In addition, for any such study, the
completion of even a “short-form” questionnaire can be a
challenge for elderly individuals whose vision or mental
faculties may be compromised. The result is a likely selection
bias among responders for those with the best functional
outcome. Nonetheless, the present study confirms in this
older population the finding that even in elderly persons, an
excellent quality of life can be anticipated in a significant
proportion of individuals.
This improvement in functional status comes at some cost,
however. In addition to the risk of perioperative death, the
morbidity rate was considerable and the hospital length of
stay was, for the current era, prolonged. This can be expected
to translate into increased overall costs and should be taken
into consideration when projecting health care expenditures.
Among the risk factors for operative death that were identified
in the present study, only surgical status is potentially modifiable. The marked increase in operative risk for urgent and
emergent procedures suggests that surgical intervention should
be considered before hemodynamic decompensation has oc-
III-74
Circulation
November 7, 2000
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curred. We favor an aggressive approach once a patient has been
deemed a surgical candidate. In contrast, patients who present in
a decompensated state may benefit from the optimization of
hemodynamics before surgery.
The present study identified the presence of preoperative
stroke and chronic obstructive pulmonary disease as predictors of late death. This finding also is consistent with previous
studies2,9,12 and suggests that a less aggressive approach may
be warranted in these individuals.
Concomitant CABG was performed in a significant number
of patients in our series. Early studies of AVR in elderly persons
suggested that the mortality rate for the combined procedure was
increased, with mortality rates for the combined procedure
ranging from 12% to 37% compared with rates of 5% to 7% for
AVR alone.2,13–15 Concomitant revascularization was not a
predictor of death in our more contemporary series, possibly due
to the neutralizing effect of improved myocardial protection.
Several other recent series have shown similar results, with no
effect of CABG,8 or an affect only in women who underwent the
combined procedure.16
A significant number of patients in this series received
valves of ⱕ21 mm. Although body surface area data were not
available, the majority of these valves were placed in women.
This also reflects our reluctance to embark on more extensive
procedures, such as root enlargement, in the very old. This
practice is supported in the literature,5 and small valve size
did not fall out as a risk factor for early or late death.
The present study was retrospective, and there are inherent
weaknesses and limitations of any such analysis. Principal
among these is the potential selection bias in favor of more
robust patients imposed by the cardiologists who propose this
intervention and the surgeons who accept the patients as
candidates. This factor cannot be accounted for in any
rigorous way, because there is no database of patients who
were// refused surgery. A large number of surgeons and
cardiologists were involved in the care of these patients, and
there are no codified criteria for acceptance for surgery at our
institution. Still the majority of patients were of advanced
functional class, and many required concomitant bypass
grafting suggesting that this is not a highly selected subgroup.
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Quality of Life After Aortic Valve Replacement at the Age of >80 Years
Thoralf M. Sundt, Marci S. Bailey, Marc R. Moon, Eric N. Mendeloff, Charles B. Huddleston,
Michael K. Pasque, Hendrick B. Barner and William A. Gay, Jr
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Circulation. 2000;102:Iii-70-Iii-74
doi: 10.1161/01.CIR.102.suppl_3.III-70
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