Original article
Cardiovascular
High-Risk Aortic Valve Replacement: Are the Outcomes as Bad as Predicted?

Presented at the Forty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 29–31, 2007.
https://doi.org/10.1016/j.athoracsur.2007.05.010Get rights and content

Background

Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution’s surgical results in this target population.

Methods

From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index.

Results

The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 (p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease (p = 0.019; OR, 2.14), and peripheral vascular disease (p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age (p < 0.001), previous cardiac operations (p < 0.014; OR, 1.51), renal failure (p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease (p < 0.007; OR, 1.30) were predictors of worse survival.

Conclusions

Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points.

Section snippets

Patient Selection

This study was conducted with the approval of the New York University (NYU) School of Medicine Institutional Review Board with specific waiver of the need for individual patient consent. Between January 1996 and March 2006, 1507 consecutive patients underwent isolated AVR at the NYU Medical Center. Of these, 731 patients (48.5%) had an additive EuroSCORE of 7 or greater and were identified as high-risk patients. Operative techniques included direct aortic clamping, moderate systemic

Results

Of the 1507 patients who underwent isolated AVR between January 1996 and March 2006, 731 had a EuroSCORE of 7 or higher and were identified as high risk; 332 had a EuroSCORE of 10 or higher. The demographics and preoperative characteristics of this cohort are listed in Table 1. Notably, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had previous cardiac surgery, 127 (17.4%) had cerebrovascular disease, 69 (9.4%) had a low ejection fraction (EF),

Comment

The reported major adverse prognostic indicators for patients undergoing AVR include advanced age [21, 22, 23], impaired left ventricular systolic function [24, 25, 26], and the presence of renal disease [23, 27], all of which are factored into the calculation of the EuroSCORE. In fact, the EuroSCORE system has been shown to be one of the most accurate risk-stratification models for cardiac surgery. Geissler and colleagues [28] reported that the EuroSCORE had the highest predictive value among

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