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Tissue Versus Mechanical Prostheses: Quality of Life in Octogenarians
Mariano Vicchio, MD, Alessandro Della Corte, MD, Luca Salvatore De Santo, MD, Marisa De Feo, MD, PhD, Giuseppe Caianiello, MD, Michelangelo Scardone, MD, and Maurizio Cotrufo, MD Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, and Department of Cardiovascular Surgery and Transplants, V. Monaldi Hospital, Naples, Italy
Presenter:R1 朱律敏Date: 2008/07/09
Background Improvements in surgical standards and
postoperative care increase people aged > 80 years
Very low incidence of anticoagulation-related complications in patients >70 y/o
Prolonged life expectancy of elderly AVR patients
Hospital mortality of 13~ 25% for degenerated biologic prostheses in advanced age
Aim Whether prognosis and quality of life (QOL)
after aortic valve replacement (AVR) in octogenarians differ depending on the choice of mechanical (MP) or tissue (BP) valves.
Material and Methods July 1992~Sept. 2006 160 octogenarians underwent AVR for
aortic valve stenosis, 68 with BP, 92 with MP. Concomitant CABG also enrolled.
Material and Methods Valve type Guided by patient’s biologic age
rather than birth age Group BP: Contraindication to anticoagulationMultiple noncardiac comorbidities : life
expectancy<10 years. Group MP: Life expectancy of more than 10 years.Already receiving anticoagulation for chronic Af
p.s. Need for concomitant CABG: no difference in choice of the valve substitute
In-Hospital Management Anticoagulant therapyOral sodium warfarin in all patientsTarget INR of 2.2 (range, 1.8 to 2.5) for bileatlet
prostheses 3 months postoperatively in BP group
Quality of Life Assessment Italian version of the Medical Outcome
Study Short-Form 36 Health Survey (SF-36) QOL questionnaire.
36 items grouped into eight domains 0 to 100 points, higher scores indicating
better-perceived QOL.
SF-36 Physical Functioning (10 items) Role-physical (4 items) Bodily Pain (2 items) General Health (6 items) Vitality (4 items) Social Functioning (2 items) Role-emotional (3 items) Mental Health (5 items)
Results Global hospital mortality was 8.8% (14
patients) 7 patients died in group BP (10.3%) 7 in group MP (7.6%; p 0.75).
Predictors of hospital death: Duration of cardiopulmonary bypass Emergency operation
Survival Mean follow-up of 3.4 ±
2.8 years 21 late deaths:
Noncardiac in 61.9% 8 late deaths: sudden
death, MI, stroke, re-open
Significant difference in survival for two group: Reflect the criteria for
choosing a bioprosthesisimplant
46.558.176.986.4BP
7081.688.691.3MP
8531
(p=0.025)
Freedom From Valve-Related Events
No statistical difference in the 8-year freedom from valve-related complications: One anticoagulant-related hemorrhage in group
MP One ischemic stroke in group BP
All survivors experienced significant improvements in New York Heart Association functional class
Freedom From Valve-Related Events
87%BP82.6%MP
(p=0.55)
Results Coronary Artery Bypass Grafting: Prevalence, long-term survival are similar between two
groups Hospital mortality with CABG was 10% vs 8.5%
without non-significant Quality of Life: 122 patients (97.6% of survivors) completed the SF-36
questionnaire. Satisfactory and comparable in the two groups. 7/8 domains significantly higher than Italian population,
except vitality
Quality of Life(SF-6) Comment Results after AVR in very old patients focus on
three questions: 1. Do surgical procedures have an acceptable rate of
hospital mortality in the 80th decade of life? 2. Are there improvements in survival and QOL after
intervention in patients aged 80 years and older? 3. Is there a prosthesis of choice for implantation in
octogenarians?
Mortality Survival Quality Type
Q1 Hospital mortality rate ranging between
4.2% and 14.7% [1997.2003]
An acceptable rate of hospital mortality, although higher than in younger patients.
Q2 Selective criteria excluded: Patients lacked a self-sufficient life style Severe physical disabilities Diseases such as cancer or cerebrovascular accidents
Excellent late survival reported: Taylor and colleagues: the UK Heart Valve Registry
data of 1100 patients >80 years [1997]
No differences between BP and MP Similar result as this study
Q2 Health-related QOL: Physical functioning,psychologic status and
social dimensions. Standardized questionnaires: Self-completed, efficacious, and inexpensive SF-36 questionnaire: comprehensive, concise,
can be administered in person, by phone, or by mail, even in elderly patients
Q2 Sundt and colleagues: [2000]
Postoperative comparable SF-36 scores in AVR patients > 80 with general elderly population
7/8 domain with higher score in this study
Interpreting this result: >70% patients in NYHA class III to IV increase the
perception of health status. Healthy elderly: compare with their youth
Similar impact on QOL for BP and MP patients in the eighth decade of life.
Q3 Ideal valve prosthesis for octogenarians
still being debated. Increase in long-term survival of the population
older than 80 years Very low risk of anticoagulation-related
complications
Conclusion Similar rates of early mortality, very low
rates of valve-related complications Similar perceived QOL Both BP and MP can be the choice of the
valve substitute for Octogenarian.
The End