Dennis F. Pupello

Surgical Management of Aortic Valve Disease in the Elderly: A Longitudinal Analysis

From November, 1972, through December, 1986, 219 consecutive patients 70 years of age and older with aortic stenosis (AS) underwent aortic valve replacement. One hundred seven of them had isolated pure AS, and 112 had AS and coronary artery disease (AS + CAD). The mean age of the AS group was 75.4 years (range, 70 to 88 years) and of the AS + CAD group, 74.8 years (range, 70 to 86 years). The mean aortic valve gradient in the AS group was 87.7 +/- 30.6 mm Hg and in the AS + CAD group, 68.0 +/- 51.3 mm Hg (p less than 0.001). Hospital mortality for the AS group was 12.1% (13 patients) and for the AS + CAD group, 8.9% (10 patients). The long-term survival at seven years was 77.2 +/- 5.5% (+/- the standard error of the mean) for the AS group and 57.0 +/- 6.9% for the AS + CAD group (p less than 0.006). Postoperative assessment reveals substantial functional improvement. These early and long-term favorable results provide a much needed reference point when valvuloplasty is being considered. Aortic valve replacement is the treatment of choice in elderly patients with symptomatic AS.

Bioprosthetic valve longevity in the elderly: An 18-year longitudinal study

The issue of bioprosthetic valve durability has become of critical importance as the number of elderly patients requiring valve operation has continued to increase. Our previous study showed bioprosthetic valve durability to be in excess of 83% at 13 years for patients 70 years of age and older at the time of implantation. There is limited follow-up data in the literature beyond this time point, however. Accordingly a retrospective analysis was conducted of all patients with bioprosthetic valves who were 70 years of age and over at the time of implantation. From September 1974 to April 1994, 1007 patients 70 years of age and over underwent valve replacement using a porcine bioprosthesis. The patients ranged in age from 70 to 104 years (mean, 75.6 +/- 4.3 years). There were 549 men (54.5%) and 458 women (45.5%). Preoperatively 98.8% of the patients were in New York Heart Association functional class III or IV. Operation was performed as an emergency in 66 patients (6.6%). The hospital mortality was 10.9% (110 patients), with 897 hospital survivors. There were 961 valves at risk. Follow-up extended from 1 month to 18.8 years (mean, 56.6 months). The cumulative follow-up is 4232.3 patient-years. A total of 31 valves failed, 12 in the aortic position and 19 in the mitral position (p < 0.0024). The causes of valve failure have included structural deterioration (16 valves), prosthetic endocarditis (7 valves), nonstructural dysfunction (5 valves), prosthetic thrombosis (1 valve), and other (2 valves).(ABSTRACT TRUNCATED AT 250 WORDS)

Long-Term Results of the Bioprosthesis in Elderly Patients: Impact on Quality of Life

BACKGROUND A wealth of data exists on acceptable mortality and morbidity for valve operations in older patients, yet information documenting quality of life is lacking. METHODS From October 1974 to May 1998, 2,075 patients aged 65 years and older underwent valve replacement using a porcine bioprosthesis. There were 1,126 men (54.3%) and 949 women (45.7%) with a mean age of 73.9 years (range 65 to 104 years). RESULTS The elective hospital mortality was 8.5% (158 patients), and urgent/emergent/salvage mortality was 25.8% (54 patients). Follow-up was completed for 1,863 patients (98.2%) and extended from 1 month to 23.0 years (mean 60.8 months) with a cumulative follow-up of 9,442.1 patient-years. At follow-up, surviving patients (n = 849) completed the Short Form-36 Quality of Life Survey. Results showed patients had a more favorable quality of life compared with control subjects matched for age and sex. Functional improvement was significant with 96.3% in New York Heart Association functional class I or II at follow-up. There were 74 valves that failed from all causes (33 aortic and 41 mitral valves). Actuarial freedom from valve failure at 9 years was 94.4%+/-1.1% and at 18 years was 83.7%+/-2.4%. CONCLUSIONS Valve replacement in older patients provides excellent functional improvement, reduces late cardiac events, and enhances quality of life.

Effect of stent mounting on tissue valves for aortic valve replacement.

Stent mounting of homograft valves was first reported by our group in 1968. Since then, there has been question as to whether or not stent mounting of bioprostheses adversely affects the incidence of structural deterioration in aortic valve replacement. Between November 1967 and July 1988, 571 consecutive patients underwent valve replacement with a stented or unstented homograft. There were 351 men (61.5%) and 220 women (38.5%). The mean age of the group was 49.2 years (range 18 to 79 years). Five hundred thirty‐four patients left the hospital (30‐day overall mortality 6.5%). Follow‐up extends from 6 months to 22 years with a mean of 7.6 years. The cumulative follow‐up for the series was 4,095.9 patient‐years. Hospital mortality, early technical failure, and prosthetic valve endocarditis were considered censoring events and excluded from this study. Actuarial analysis revealed a significant difference (p < 0.02) in the freedom from structural valve deterioration for unstented and stented isoiated aortic valve replacement. Age (50 and under, and over 50) does not appear to be a factor In structural deterioration in unstented homografts but does influence the rate of failure in stented homografts (p < 0.05). These results clearly indicate that stent mounting adversely affects tissue valve durability with aortic valve replacement. Moreover, age correlates with structural deterioration if valves are stented and does not if they are unstented. Based on these results, the use of unstented bioprostheses should be reevalvated, along with the design of porcine valve stents.

The Carpentier-Edwards bioprosthesis: a comparative study analyzing failure rates by age.

Bioprosthetic valve durability and the significance of patient age at implantation have received much attention recently. Indications and/or contraindications for implantation of the bioprosthesis in the very young and in the elderly have been reasonably well defined. Patients in the middle years (sixth and seventh decades) present a special problem In the choice of a prosthesis. To better elucidate the failure rate of the Carpentier‐Edwards bioprosthesis in middle‐aged patients, a comparative study of value failure rates was conducted using the Wilcoxon (Breslow) statistical technique.From September 1978 to December 1986, 502 patients underwent valve replacement with a Carpentier‐Edwards bioprosthesis. All patients were operated on by a single surgical team using precisely the same method of valve implantation and myocardial preservation. The overall 30‐day mortality was 8.4%. PATIENT SURVIVAL: Follow‐up was obtained on all 460 hospital survivors and extends to 109.2 months with a mean of 36.8 months. The cumulative survival is 1,410.6 patient‐years. VALVE SURVIVAL: The 481 patients that left the hospital were divided into two subgroups. Group I included patients aged 55 to 69 years; group II, 70 years and older. There were 8 valve failures in group I. The percent of valves free of failure plotted by the actuarial method is 95.4% at 5 years (SEM 1.7, 81 valves at risk) and 95% at 7 years (SEM 1.7, 23 valves at risk). In group II (age 70 and above), there were only two valve failures. The percent of valves free of failure by the same method is 99.5% at 5 years (SEM 0.05, 43 valves at risk) and 95% at 7 years (SEM 4.3, 14 valves at risk). This comparison generated no statistically significant difference beween the valve failure rate for the two groups (P = .144). This study suggests that the failure rate of the Carpentier‐Edwards bloprosthesis in middle age and elderly patients is low and additional long‐term evaluation appears warranted.

Bioprosthetic Valve Durability in the Elderly: The Second Decade

With an increasing number of elderly patients requiring cardiac valve surgery, the topic of bioprosthetic durability becomes critically important. Previous reports have shown expected survival of bioprosthetic valves to be in excess of 95% at 9 years. However, primary tissue failure appears to accelerate at the end of the first decade and there is limited data into the second decade. With this in mind, we proceeded to analyze all bioprosthetic valves implanted in patients 70 years of age and older. From September 1974 to December 1990, 781 patients underwent valve replacement using a bioprosthesis. Ages ranged from 70 to 88 years with a mean of 75.1. There were 423 males (54.2%) and 358 females (45.8%). Preoperatively, 99.0% of the patients were in either New York Heart Association functional Class III or IV. Fifty‐nine patients (7.6%) were done as emergencies. Six hundred ninety‐four patients left the hospital (30‐day overall mortality 11.1 %). In this cohort, there were 733 valves at risk. Follow‐up extended from 1 to 186.0 months with a mean of 52.9, which resulted in 3,059.9 patient‐years of cumulative follow‐up. Bioprosthetic Survival: A total of 23 valves failed in the series; 15 primary tissue failures, seven from endocarditis, and one perivalvuiar leak. Actuarial survival at 7 years was 94.5% ± 1.4% standard error of the mean (SEM; 168 valves at risk) and at 13 years, 83.7% ± 4.8% SEM (11 valves at risk). This analysis provides further documentation of the long‐term favorable durability of the bioprosthesis when utilized in patients 70 years of age and over.

Influence of coronary artery disease on structural deterioration of porcine bioprostheses

The number of patients undergoing valve replacement and concomitant coronary artery bypass grafting (CABG) is increasing. To further evaluate the indications for the use of the porcine bioprosthesis, this retrospective comparative analysis of valve structural deterioration was conducted in patients with and without concomitant CABG. From September 1974 to October 1993, 1,567 patients underwent valve replacement using a porcine xenograft. The series was divided into two groups: patients with isolated valve replacement (VR; n = 876) and those with VR and CABG (VR + CABG; n = 691). Aortic valve replacement was performed in 938 patients, mitral valve in 518, tricuspid in 2, and multiple valve replacement in 109 patients. The mean age for the series was 70.7 years (range, 50 to 104 years). The hospital mortality was 8.8% (138 patients). The hospital mortality for the VR group was 7.4% (65 deaths) and the VR + CABG group, 10.6% (73 deaths) p = 0.0365. There were 1,429 patients discharged from the hospital with 1,489 valves at risk. Follow-up extended from 1 month to 17.9 years with a mean of 66.9 months and was 98.3% complete. The cumulative follow-up was 7,927.1 patient-years. Structural deterioration was found to be significantly greater in the VR group for the age category 50 to 59 years (p = 0.0121) and the 60 to 69 years (p = 0.0230). No significant difference in the rate of structural deterioration was found for the two groups for the age category 70 years and older.(ABSTRACT TRUNCATED AT 250 WORDS)

Implantation of the Unstented Bioprosthetic Aortic Root: An Improved Method

Abstract The problem of early onset aortic insufficiency as seen with the scalloped, sub‐coronary homograft aortic valve replacement is reduced with the use of a total root replacement. In addition, the naturally competent aortic root is more durable. From September 1985 to April 1991, 26 consecutive patients underwent aortic root replacement with 10 autografts, 14 homografts, and 2 xenografts using a modified implantation method. Twenty‐five patients were discharged from the hospital. This partial inclusion root technique for implanting unstented valves in the aortic position decreases the probability of early failure secondary to technical malalignment at the time of implantation. In contrast to total root replacement, it avoids the need to destroy the recipient aortic root. A longitudinal aortotomy is performed to the aortic annulus in the mid‐portion of the noncoronary sinus. The proximal suture line is interrupted with the valve oriented in the anatomical position. Circumferential running monofilament side‐to‐side anastomoses approximate the donor coronary ostia to the recipient. A running medial and lateral posterior suture line to the lateral superior portions of the aortotomy completes the integrity of the anterior wall of the implantation. One autograft attempt failed and one homograft patient died postoperatively. Follow‐up ranges from 1 to 6 years in 24 patients. Postoperative aortic insufficiency was significant in one case due to inappropriate sizing of the proximal aortic suture line. There has been no evidence of progressive aortic insufficiency detected by the early onset of diastolic murmurs or echocardiograms as was our previous experience with the scalloped subcoronary method.