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

Eugene A. Grossi, Charles F. Schwartz, Pey Jen Yu, Ulrich P. Jorde, Gregory A. Crooke, Juan B. Grau, Greg H. Ribakove, F. Gregory Baumann, Patricia Ursumanno, Alfred T. Culliford, Stephen B. Colvin, Aubrey C. Galloway

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189 Scopus citations

Abstract

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.

Original languageEnglish (US)
Pages (from-to)102-107
Number of pages6
JournalAnnals of Thoracic Surgery
Volume85
Issue number1
DOIs
StatePublished - Jan 1 2008
Externally publishedYes

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

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    Grossi, E. A., Schwartz, C. F., Yu, P. J., Jorde, U. P., Crooke, G. A., Grau, J. B., Ribakove, G. H., Baumann, F. G., Ursumanno, P., Culliford, A. T., Colvin, S. B., & Galloway, A. C. (2008). High-Risk Aortic Valve Replacement: Are the Outcomes as Bad as Predicted? Annals of Thoracic Surgery, 85(1), 102-107. https://doi.org/10.1016/j.athoracsur.2007.05.010