J. Sathananthan

Aortic valve replacement in over 70- and over 80-year olds: 5-year cohort study.

Background Demand for aortic valve intervention remains high, and together with the recent introduction of transcatheter aortic valve implantation, this motivates a review of surgical aortic valve replacement in elderly recipients. Methods Consecutive patients over 70 years of age having isolated aortic valve replacement during 2007–11 were retrospectively identified and divided into 70–79 and ≥ 80 years age groups for analyses. Results 62 octogenarians and 121 septuagenarians were eligible. Among octogenarians, a lower proportion were in Canadian Cardiovascular Society angina class 3–4 (3.2% vs. 14.0%, p = 0.022) and fewer had diabetes (11.3% vs. 24.8%, p = 0.034), but a higher proportion had infective endocarditis (6.5% vs. 0%, p = 0.012), and EuroSCORE II was higher (4.9% vs. 3.7%, p < 0.001). Despite this, operative mortality was lower in octogenarians (0% vs. 7.4%, p = 0.029), although hospital stay (11.7 vs. 8.9 days, p = 0.026) was longer. One-, 3-, and 5-year survival rates were 95.2%, 90.1%, and 75.3% for octogenarians and 89.2%, 81.7%, and 70.2% for septuagenarians (p = 0.398). Canadian Cardiovascular Society angina class 3–4 and the presence of other valvular stenosis or regurgitation were independent predictors of mortality. Conclusion Octogenarians had lower operative mortality despite a higher predicted risk preoperatively. Other factors beyond age and EuroSCORE, such as frailty, may be important in deciding whether elderly patients should undergo aortic valve replacement.

Isolated Aortic Valve Replacement in Octogenarians Before and After the Introduction of Trans-catheter Aortic Valve Implantation

BACKGROUND Trans-catheter aortic valve implantation (TAVI) became available at Auckland City Hospital in 2011 for patients with severe aortic stenosis in whom surgical aortic valve replacement (AVR) was deemed at high risk. We assessed whether introduction of TAVI affected the characteristics and outcomes of octogenarians undergoing AVR. METHODS Isolated AVR performed in patients ≥80 years of age during 2008-2012 were divided into two groups, pre- and post-TAVI introduction, for analyses. RESULTS Isolated AVR was undertaken in 35 and 33 octogenarians pre- and post-TAVI introduction. The post-TAVI group were older (84.2 vs 82.3 years, P=0.003), had lower ejection fraction (P=0.026), more had inpatient surgery (76% vs 29%, P<0.001), with higher EuroSCORE II (5.4 vs 3.9%, P=0.033). Operative mortality was 0.0% in both groups. One-year survival was similar (97.6% vs 94.3%, P=0.613), but composite morbidity was lower in the post-TAVI group (9.1% vs 31.4%, P=0.035). Chronic respiratory disease (P=0.043) independently predicted mortality during follow-up, while number of coronary vessel>50% stenosis (P=0.050), creatinine clearance (P=0.016) and being in the pre-TAVI era group (P=0.022) predicted composite morbidity. CONCLUSIONS Since TAVI was introduced, mean age and risk scores significantly increased in octogenarians undergoing AVR, while mortality rates remained similar and composite morbidity decreased.

Management of Intracoronary Thrombus

Partial or complete occlusion of the infarct-related artery (IRA) with intracoronary thrombus (ICT) is the pathognomonic hallmark of patients presenting with ST-elevation myocardial infarction (STEMI). Thrombus burden can be highly variable, but its presence is associated with worse outcomes, including lower procedural success, increased abrupt vessel closure and an increased frequency of major in-hospital complications including death and recurrent myocardial infarction (MI). ICT poses a unique series of challenges, but appropriate management is an essential prerequisite for successful primary percutaneous coronary intervention (PPCI). This can largely be achieved using a combination of pharmacological and mechanical approaches prior to coronary stent insertion.

Assessing Surgical Risk for Aortic Valve Surgery in Octogenarians: A Comparison of Three Risk Calculators

(p 35 were 0.3, 0 and −0.05 respectively. Variation in measurements was greater for WC (IQR −3% to 4%) than BMI (IQR −2% to 3%). Conclusion: There is no change in BMI or waist circumference at follow-up following admission with acute coronary syndrome. The increased variation in waist circumferencemeasurement compared to BMI likely reflects differences in measurement technique than true weight change. Patients following ACS need improved education strategies stressing the importance of weight loss. http://dx.doi.org/10.1016/j.hlc.2013.04.068