Minimally invasive aortic valve replacement in octogenarian, high-risk, transcatheter aortic valve implantation candidates

Abstract

Objective: Risk-stratifying algorithms are currently used to determine which patients may be at prohibitive risk for surgical aortic valve replacement, and thus candidates for transcatheter aortic valve implantation. Minimally invasive surgical approaches have been successful in reducing morbidity and improving survival after aortic valve replacement, especially in octogenarians. We documented outcomes after minimally invasive aortic valve replacement in high-risk octogenarians who may be considered candidates for percutaneous/transapical aortic valve replacement.

Methods: From 1996 to 2009, minimally invasive aortic valve replacement was performed in 249 consecutive octogenarians. We used the modified European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons score to risk-stratify patients and characterize all early and late results.

Results: The mean age at operation was 84±3 (range 80-95) years, and 111 patients (45%) were male. Twenty-one percent (n=52) had previous cardiac surgery. Operative mortality was 3% (n=8/249). The median modified European System for Cardiac Operative Risk Evaluation (11%; interquartile range, 6-14) and Society of Thoracic Surgeons score (10.5%; interquartile range, 7-17) were not predictive of 30-day mortality in this cohort of patients (European System for Cardiac Operative Risk Evaluation c-index=0.527, P=.74, Society of Thoracic Surgeons score c-index=0.67, P=.18). Despite their poor predictive power, the Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation were correlated with each other (r=0.40, P<.0001). Postoperative complications included stroke in 10 patients (4%), pneumonia in 3 patients (1%), renal failure requiring dialysis in 2 patients (1%), cardiac arrest in 2 patients (1%), pulmonary embolism in 1 patient (1%), and sepsis in 1 patient (1%). Follow-up was available for 238 patients (96%) and extended up to 12 years. Overall, long-term survival after minimally invasive aortic valve replacement at 1, 5, and 10 years was 93%, 77%, and 56%, respectively. There was no significant difference in long-term survival compared with that of a US age- and gender-matched population (standardized mortality ratio, 1.01; 95% confidence interval, 0.76-1.37; P=.88). A multivariate Cox-proportional hazards model indicated that increasing age (hazard ratio, 1.10; P=.008) and severe chronic obstructive pulmonary disease (hazard ratio, 2.52; P<.007) were significant predictors of survival. By using these factors, a clinical prediction model (P=.02) was developed and demonstrated that low-risk patients (first quartile prediction score) had 1-, 5-, and 8-year survival of 94%, 84%, and 67%, whereas high-risk patients (third quartile prediction score) had 1-, 5-, and 8-year survival of 89%, 74%, and 49%, respectively.

Conclusions: Patients thought to be high-risk candidates for surgical aortic valve replacement have excellent outcomes after minimally invasive surgery with long-term survival that is no different than that of an age- and gender-matched US population. These data provide a benchmark against which outcomes of transcatheter aortic valve implantation could be compared.