Valve Replacement in Octogenarians: Arguments for an Earlier Surgical Intervention

Background and aim of the study: In octogenarians with symptomatic aortic valve stenosis (AS), aortic valve replacement (AVR) is frequently not performed in due time, because the prognostic benefit is underestimated, while perioperative morbidity and mortality are overestimated. The severely impaired prognosis and quality of life after myocardial decompensation then urges AVR with a significantly increased perioperative risk. Methods: Between 2003 and 2006, all octogenarians with isolated symptomatic AS (indexed aortic valve opening area < 0.5 cm(2)/m(2)) referred to the authors' unit were prospectively included in the survey. Among the 83 patients enrolled (51 women, 32 men; mean age 84 +/- 5.1 years), 38 patients (26 women, 12 men; mean age 84 +/- 2.3 years) had signs of chronic myocardial decompensation (dilated left ventricle and/or reduced left ventricular function; left ventricular ejection fraction (LVEF) 43 +/- 18% (range: 25-53%). These patients comprised group A. All other patients (group B) had normal left ventricular dimensions, a normal LVEF (>55%), and no clinical episodes of myocardial decompensation. All patients underwent AVR, while 23 (28%) underwent simultaneous coronary revascularization. Results: In group A, the 30-day mortality rate was 5.3% (n = 2). Octogenarians without chronic myocardial decompensation had a lower 30-day mortality (1/45; 2.2%). The incidences of major postoperative complications (reversible acute renal failure, stroke, mechanical circulatory support) were significantly higher in group A (26.3% versus 8.9%, p < 0.05). During late follow up (mean 24.2 +/- 12.8 months), another four patients in group A (11.1%) and five in group B (11.4%) died. Octogenarians in group B had a significantly (p < 0.01) more favorable cumulative survival rate (87% versus 78% after 24 months; 81% versus 68% after 46 months). Conclusion: AVR can be performed in octogenarians with a low mortality and morbidity, but should not be postponed. The decision to perform for AVR may take into consideration any life-limiting comorbidities, but should be made independent of the patient's age.