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AVR viable for select nonagenarians with aortic valve stenosis
Aortic valve replacement appears to be a viable method of treating select nonagenarian patients with symptomatic, severe aortic valve stenosis, according to recent findings.
However, transcatheter aortic valve replacement with the SAPIEN valve (Edwards Lifesciences) is associated with an elevated risk for vascular injury in this population, the researchers wrote.
In a retrospective study, researchers reviewed the records of 59 patients collected from the database of the division of cardiovascular surgery at the Mayo Clinic. All patients were aged 90 years or older, with severe aortic stenosis that had been treated through isolated AVR between January 1993 and August 2013. The cohort was 64.4% female and had a median age of 91 years.
Patients were stratified according to procedure type: Surgical AVR was performed in 33 patients and 26 patients underwent TAVR. The researchers extracted patient characteristics, operative data and surgical techniques from the database and patient medical records, recorded incidences of complications and assessed mortality risk according to the Society of Thoracic Surgeons prediction method.
Twenty-two patients experienced operative complications, including acute renal failure in seven patients and stroke in one patient. Surgical AVR recipients were more likely to experience pulmonary complications (21% of patients vs. zero TAVR recipients; P=.013), whereas vascular injury occurred only among patients who underwent TAVR with the SAPIEN transcatheter heart valve (42.9%). Researchers noted a numerically lower risk for operative complication in the surgical AVR group, but this did not achieve statistical significance (OR=0.681; 95% CI, 0.233-1.978).
Among patients with evaluable discharge information, 21.7% of the surgical AVR group and 48% of the TAVR group were discharged to their homes (P=.072). All other patients were discharged to nursing facilities, with a mean length of stay of 5 days in the TAVR group and 8 days in the surgical AVR group (P=.0004).
There were two cases of operative mortality in the surgical AVR group and one operative death in the TAVR group (P=1). Researchers calculated a Kaplan-Meier survival estimate of 81.3% at 1 year, with no significant difference between the groups (P=.636) or between the entire population and age- and gender-matched controls (P=.415). They noted a numerically lower but nonsignificant risk for late death among TAVR recipients (HR=0.776; 95% CI, 0.244-2.114).
“[AVR] can be done with acceptable operative morbidity and mortality in select nonagenarian patients,” the researchers concluded. “TAVR is our first choice in this group of patients as it seems a less invasive option, but transfemoral SAPIEN transcatheter heart valve TAVR carries a high risk of vascular complication, and there are less risky options. … After successful operation, the majority of patients require discharge to a skilled nursing facility, and this finding should be shared with patients being counseled in a preoperative setting.”
Disclosure: The researchers report no relevant financial disclosures.