Long-Term Survival After Aortic Valve Replacement Among High-Risk Elderly Patients in the United States: Insights From the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 1991 to 2007

Study Questions:

What is the long-term survival for high-risk elderly patients who undergo surgical aortic valve replacement (AVR) in the United States?

Methods:

Long-term survival was examined for 145,911 patients ≥65 years of age undergoing AVR at 1,026 centers participating in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 1991 to 2007. In-hospital complications and long-term survival were stratified by age, STS perioperative risk of mortality, and comorbidities.

Results:

Median patient age was 76 years; 16% had chronic lung disease, 6% had preoperative renal failure, 38% had heart failure, and 12% had prior cardiac surgery. Median survival in patients 65-69, 70-79, and ≥80 years of age undergoing isolated AVR was 13, 9, and 6 years, respectively. For AVR plus coronary artery bypass grafting (CABG) procedures, median survival was 10, 8, and 6 years, respectively. Only 5% of isolated AVR patients had a high STS perioperative risk of mortality ≥10%; among this cohort, median survival was 2.5-2.7 years. Severe lung disease and renal failure each were associated with a ≥50% reduction in median survival among all age groups compared with those who did not have these comorbidities, whereas left ventricular dysfunction and prior cardiac operation were associated with a 25% reduction in median survival.

Conclusions:

Long-term survival after surgical AVR in the elderly is excellent, although patients with a high STS perioperative risk of mortality and those with certain comorbidities carry a particularly poor long-term prognosis.

Perspective:

Surgical AVR remains the standard of care for the treatment of symptomatic aortic valve disease. Data from this study are important in several regards. First, they confirm that most elderly patients fare well after isolated AVR or after AVR with concomitant CABG. Second, they confirm that factors predicted to be associated with high risk (including STS-predicted risk of mortality score ≥10%, renal failure, and severe lung disease) are in fact associated with worse outcomes. Third, among high-risk patients, the greatest mortality risk is in the first few months after surgery (see manuscript, Figure 3). These data provide further reassurance that perioperative and subsequent risk typically can be predicted using established models, and that most elderly patients with severe symptomatic aortic valve disease can be expected to do well after surgical AVR.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD & Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD & Pediatrics and Arrhythmias, CHD & Pediatrics and Interventions, CHD & Pediatrics and Quality Improvement, Acute Heart Failure, Interventions and Structural Heart Disease

Keywords: Risk, Heart Defects, Congenital, Heart Valve Prosthesis Implantation, Thoracic Surgery, Survivors, Prognosis, Renal Insufficiency, Heart Failure, Heart Valve Diseases, Cardiovascular Diseases, Cardiac Surgical Procedures, Coronary Artery Bypass, Ventricular Dysfunction, Left, United States


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