Complex Valve Surgery in Elderly Patients: Increasingly Necessary and Surprisingly Feasible

Shekhar Saha; Sam Varghese; Ammar Al Ahmad; Ahmad Fawad Jebran; Narges Waezi; Heidi Niehaus; Hassina Baraki; Ingo Kutschka

doi:10.1055/s-0038-1670663

The Thoracic and Cardiovascular Surgeon, Table of Contents

Thorac Cardiovasc Surg 2020; 68(02): 107-113
DOI: 10.1055/s-0038-1670663

Original Cardiovascular

Georg Thieme Verlag KG Stuttgart · New York

Complex Valve Surgery in Elderly Patients: Increasingly Necessary and Surprisingly Feasible

Shekhar Saha

¹Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-Universitat, Magdeburg, Magdeburg, Germany

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Sam Varghese

¹Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-Universitat, Magdeburg, Magdeburg, Germany

,

Ammar Al Ahmad

¹Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-Universitat, Magdeburg, Magdeburg, Germany

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Ahmad Fawad Jebran

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Narges Waezi

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Heidi Niehaus

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Hassina Baraki

¹Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-Universitat, Magdeburg, Magdeburg, Germany

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

,

Ingo Kutschka

¹Department of Cardiothoracic Surgery, University Hospital, Otto-von-Guericke-Universitat, Magdeburg, Magdeburg, Germany

²Department of Thoracic and Cardiovascular Surgery, University Hospital, Georg-August-Universitat, Göttingen, Germany

› Author Affiliations

Abstract

All articles of this category

Abstract

Objectives The increasing proportion of elderly patients in cardiac surgery poses additional challenges for the clinical management and leads to a higher operative risk due to multiple comorbidities of these patients. We reviewed the outcome of patients who were 75 years and older and underwent complex multiple valve surgery at our institution.

Methods A retrospective review was performed to identify patients who were 75 years and older and underwent multiple valve surgery between January 2011 and May 2016 at our institution. Patients were assigned to one out of four subgroups: combined aortic and mitral valve surgery (group AM), aortic and tricuspid valve surgery (group AT), mitral and tricuspid valve surgery (group MT), and aortic, mitral, and tricuspid valve surgery (group AMT).

Results A total of 311 patients underwent multiple valve surgery, of whom 119 (38.3%) were 75 years and older (median: 78 [25th–75th quartile: 76–80]). The estimated operative mortality (EuroSCORE II) in the overall cohort was 10.7%. The observed 30-day mortality was 4.2% (7% in group AM, 0% in group AT, 2.2% in group MT, 3.8% in group AMT; p = 0.685). Main complications were reexplorative surgery in 16%, adverse cerebrovascular events in 6.7%, prolonged mechanical ventilation in 10.1%, renal replacement therapy in 15.1%, nosocomial pneumonia in 15.1%, and pacemaker implantation in 18.5%.

Conclusions This study demonstrates the feasibility of complex multiple valve surgery in elderly patients. The observed perioperative mortality was lower than predicted. However, we observed a substantial rate of adverse events; therefore, careful patient selection is required in this high-risk patient population.

Keywords

cardiac surgery - elderly - outcome - mortality - valve replacement

Full Text

References

References
1 Beckmann A, Funkat AK, Lewandowski J. , et al. German Heart Surgery Report 2016: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2017; 65 (07) 505-518
2 Gummert JF, Funkat A, Beckmann A. , et al; German Society for Thoracic and Cardiovascular Surgery. Cardiac surgery in Germany during 2007: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2008; 56 (06) 328-336
3 Huber CH, Goeber V, Berdat P, Carrel T, Eckstein F. Benefits of cardiac surgery in octogenarians--a postoperative quality of life assessment. Eur J Cardiothorac Surg 2007; 31 (06) 1099-1105
4 Deschka H, Erler S, Martens S, Wimmer-Greinecker G. Cardiac reoperations in octogenarians: do patients really benefit?. Interact Cardiovasc Thorac Surg 2014; 19: S93
5 Seco M, Edelman JJ, Forrest P. , et al. Geriatric cardiac surgery: chronology vs. biology. Heart Lung Circ 2014; 23 (09) 794-801
6 Friedrich I, Simm A, Kötting J, Thölen F, Fischer B, Silber R-E. Cardiac surgery in the elderly patient. Dtsch Arztebl Int 2009; 106 (25) 416-422
7 Arrowsmith JE, Grocott HP, Reves JG, Newman MF. Central nervous system complications of cardiac surgery. Br J Anaesth 2000; 84 (03) 378-393
8 Levy B, Bastien O, Karim B. , et al. Experts' recommendations for the management of adult patients with cardiogenic shock. Ann Intensive Care 2015; 5(1): 52
9 Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 2006; 4 (04) 759-765
10 Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368 (9540): 1005-1011
11 Iung B, Baron G, Butchart EG. , et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003; 24 (13) 1231-1243
12 Chaturvedi RK, Blaise M, Verdon J. , et al. Cardiac surgery in octogenarians: long-term survival, functional status, living arrangements, and leisure activities. Ann Thorac Surg 2010; 89 (03) 805-810
13 Sepehri A, Beggs T, Hassan A. , et al. The impact of frailty on outcomes after cardiac surgery: a systematic review. J Thorac Cardiovasc Surg 2014; 148 (06) 3110-3117
14 Sündermann S, Dademasch A, Praetorius J. , et al. Comprehensive assessment of frailty for elderly high-risk patients undergoing cardiac surgery. Eur J Cardiothorac Surg 2011; 39 (01) 33-37
15 Johnson WM, Smith JM, Woods SE, Hendy MP, Hiratzka LF. Cardiac surgery in octogenarians: does age alone influence outcomes?. Arch Surg 2005; 140 (11) 1089-1093
16 Wiedemann D, Bernhard D, Laufer G, Kocher A. The elderly patient and cardiac surgery - a mini-review. Gerontology 2010; 56 (03) 241-249
17 Noack T, Emrich F, Kiefer P. , et al. Preoperative predictors and outcome of triple valve surgery in 487 consecutive patients. Thorac Cardiovasc Surg 2017; 65 (03) 174-181
18 Pagni S, Ganzel BL, Singh R. , et al. Clinical outcome after triple-valve operations in the modern era: are elderly patients at increased surgical risk?. Ann Thorac Surg 2014; 97 (02) 569-576
19 Lio A, Murzi M, Di Stefano G. , et al. Triple valve surgery in the modern era: short- and long-term results from a single centre. Interact Cardiovasc Thorac Surg 2014; 19 (06) 978-984
20 Peterss S, Fortmann C, Pichlmaier M. , et al. Advanced age: a contraindication for triple-valve surgery?. J Heart Valve Dis 2012; 21 (05) 641-649
21 Beckmann A, Funkat A-K, Lewandowski J. , et al. Cardiac surgery in Germany during 2014: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2015; 63 (04) 258-269
22 Lee R, Li S, Rankin JS. , et al; Society of Thoracic Surgeons Adult Cardiac Surgical Database. Fifteen-year outcome trends for valve surgery in North America. Ann Thorac Surg 2011; 91 (03) 677-684 , discussion 684
23 Rowe R, Iqbal J, Murali-Krishnan R. , et al. Role of frailty assessment in patients undergoing cardiac interventions. Open Heart 2014; 1 (01) e000033
24 Lee DH, Buth KJ, Martin B-J, Yip AM, Hirsch GM. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation 2010; 121 (08) 973-978
25 Ad N, Holmes SD, Halpin L, Shuman DJ, Miller CE, Lamont D. The effects of frailty in patients undergoing elective cardiac surgery. J Card Surg 2016; 31 (04) 187-194
26 Uchmanowicz I, Lisiak M, Wontor R. , et al. Frailty Syndrome in cardiovascular disease: clinical significance and research tools. Eur J Cardiovasc Nurs 2015; 14 (04) 303-309
27 Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet 2013; 381 (9868): 752-762
28 Rodriguez-Mañas L, Fried LP. Frailty in the clinical scenario. Lancet 2015; 385 (9968): e7-e9
29 Nicolini F, Agostinelli A, Vezzani A. , et al. The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes. BioMed Res Int 2014; 2014: 736298
30 Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur J Cardiothorac Surg 2011; 39 (03) 295-303
31 Ghoreishi M, Dawood MY, Gammie JS. Mitral valve surgery in elderly patients with mitral regurgitation: repair or replacement with tissue valve?. Curr Opin Cardiol 2013; 28 (02) 164-169
32 Kitai T, Furukawa Y, Murotani K. , et al. Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation. Int J Cardiol 2017; 227: 803-807
33 Gosev I, Yammine M, McGurk S. , et al. Should moderate-to-severe tricuspid regurgitation be repaired during reoperative left-sided valve procedures?. Semin Thorac Cardiovasc Surg 2016; 28 (01) 38-45
34 Badhwar V, Rankin JS, He M. , et al. Performing concomitant tricuspid valve repair at the time of mitral valve operations is not associated with increased operative mortality. Ann Thorac Surg 2017; 103 (02) 587-593
35 Dreyfus GD, Martin RP, Chan KMJ, Dulguerov F, Alexandrescu C. Functional tricuspid regurgitation: a need to revise our understanding. J Am Coll Cardiol 2015; 65 (21) 2331-2336
36 Kaneko T, Cohn LH, Aranki SF. Tissue valve is the preferred option for patients aged 60 and older. Circulation 2013; 128 (12) 1365-1371
37 Holzhey DM, Shi W, Borger MA. , et al. Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. Ann Thorac Surg 2011; 91 (02) 401-405
38 Seeburger J, Raschpichler M, Garbade J. , et al. Minimally invasive mitral valve surgery in octogenarians-a brief report. Ann Cardiothorac Surg 2013; 2 (06) 765-767