Long-term follow-up of elderly patients subjected to aortic valve replacement with mechanical prostheses☆
Goncalo F. Coutinho
0
Rita Pancas
0
Pedro E. Antunes
0
Manuel J. Antunes
0
0
Centre of Cardiothoracic Surgery, University Hospital
, Coimbra,
Portugal
We propose to analyse the long-term follow-up in patients older than 65 years of age who received a mechanical valve in the aortic position, using death and prosthetic-related complications as endpoints. From April 1988 to December 1995, 144 consecutive patients 6575 years of age (mean 67.7"2.5) were enrolled. Total duration of follow-up was 1663 patient-years (median 13.0 years) and was complete for 99% of the patients. Thirty-day mortality was 1.4% (ns2). At the end of the study, 77 patients (53.8%) were alive, with ages ranging from 77 to 91 years (mean 82.1"3.2 years). The overall 5-, 10- and 15-year actuarial survival was 87.4%"3.0, 67.7%"4.3 and 58.5%"4.5, respectively. Freedom from stroke was 93.3"3.1%, 84.6"3.3% and 71.7"4.5%, respectively, after identical periods. Freedom from major bleeding was 97.2"1.1%, 90.4"3.5% and 86.4"4.0%, respectively. Freedom from endocarditis was 95.7"2.3%, 95.0"2.1% and 94.4"2.5%, respectively, and freedom from reoperation was 98.0"1.2%, 97.6"1.3%, 96.9"2.4% and 96.4"2.6%, respectively. Freedom from major valve-related events was 87.7"2.6%, 73.9"3.4% and 61.5"4.6%, respectively. Nearly two-thirds of the patients were alive and free from major adverse valve-related events. Hence, we consider implantation of a mechanical prosthesis in elderly patients safe and appropriate, but the choice must be tailored for each specific patient. 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
1. Introduction
There is no perfect valve substitute. All prostheses,
whether mechanical or biological, involve some
compromise and all introduce a new disease process, the prosthetic
disease. Considerations for choosing between a mechanical
valve and a bioprosthesis concern haemodynamic
performance, long-term durability and the need for chronic
anticoagulation.
Currently in Europe and in the USA, there are trends
towards increasing the use of tissue valves, in progressively
younger patients w13x, probably supported by reports of
very low rates of bioprosthetic failure in elderly patients
w4, 5x, particularly with the newer models w6x.
Although there are several studies addressing the
behaviour of mechanical valves in the elderly patients, only a
few have long follow-up analysis concerning survival and
valve-related events w710x. In the present study, we
analyse early and late survival, adverse valve-related events
and the quality of life in this specific patient population
(6575 years), in a follow-up of up to 20 years.
Presented at the 22nd Annual Meeting of the European Association for
Cardio-thoracic Surgery, Lisbon, Portugal, September 1417, 2008.
*Corresponding author. Centro de Cirurgia Cardiotoracica, Hospitais da
Universidade, 3000-075 Coimbra, Portugal. Tel.: q351-239400418; fax:
q351-239829674.
E-mail address: (M.J. Antunes).
2009 Published by European Association for Cardio-Thoracic Surgery
2. Material and methods
2.1. Patient population
From April 1988 to December 1995, a total of 144
consecutive patients aged 6575 years (mean 67.7"2.5 years),
93 males (64.6%), underwent aortic valve replacement
(AVR) with a mechanical prosthesis. Patients receiving
concomitant coronary artery bypass surgery (CABG) and
other surgical procedures were included. The time interval
for inclusion in this study was determined to permit at
least a 12-year period of follow-up.
During the same time interval, we also implanted 102
bioprostheses in patients of this age group. The initial
design of the work was a comparative study between the
two types of valves, but patients in the biological valve
group were significantly older, with more co-morbidities,
which precluded an accurate comparison.
Preoperatively, 87 patients (60.4%) were in NYHA (New
York Heart Association) class III or IV, 28 (19.4%) had left
ventricular dysfunction (ejection fraction -45%) and 30
(20.8%) were in chronic atrial fibrillation. Table 1
summarizes the baseline demographic and clinical characteristics
of the patients.
Surgical indications for AVR were: stenosis (ns101,
70.1%), insufficiency (ns40, 27.8%) and endocarditis (ns3,
2.1%), including one case of aortic prosthetic endocarditis.
Five cases were re-operative cardiac interventions (3.5%).
DemographicalyClinical
n (%) or mean"S.D.
NYHA, New York Heart Association; EF, ejection fraction; ECC,
extracorporeal circulation; CABG, coronary artery bypass grafting.
The decision to implant a mechanical valve was made
jointly by the cardiac surgeon, cardiologist, nurse and
patient. Performance status, physical condition, ability to
manage anticoagulation (including good family support)
and patients tolerance to the eventual need for repeat
valve replacement were our main determinants of valve
selection.
2.2. Operative technique and data
The operative technique was standardized for all p (...truncated)