Cirugía de reemplazo valvular aórtico aislado en pacientes octogenarios: evaluación, riesgo operatorio y resultados a mediano plazo

Abstract

Background: Aortic valve replacement benefits and indications have been clearly established, even for elder populations with high comorbidity. Even so, the manipulation of aortic atheromas, the use of extracorporeal circulation and aortic clamp, cardiac arrest, and the decalcification related to this technique and its possible consequences generate doubts about its indication in this group of patients.Objective: To communicate morbidity and mortality of the procedure in octogenarian patients and validate the usefulness of the risk prediction scores most frequently used.Material and Methods: A total of 87 octogenarian patients undergoing isolated aortic valve replacement were studied; preoperative, intraoperative, and postoperative variables were analyzed and EuroSCORE was applied; to make easier the sub-analysis of logistic EuroSCORE, the population was divided into three groups: low, moderate, and high risk. Conventional surgical technique was used. For the follow-up, the patient’s medical history was analyzed and/or a telephone survey was made.Results: Mean age was 83±2.5 years, with a range of 80 to 90 years. About 60% of the population studied was female. Surgical indication was: stenosis 92%, endocarditis 4.6%, and valve disease 3.4%. Medical history: hypertension 71%, smoking 31%, dyslipidemia 39%, diabetes 11.5%, COPD 10%, CKD-dialysis 2.3%, CVA 11.5%, previous AMI 8%, atrial fibrillation 16%, reoperation 15%. Clinical manifestation: asymptomatic 3.45%, chronic stable angina 10.3%, unstable angina 11%, CHF 13.8%, FC III-IV dyspnea 60%. Moderate to severe left ventricular dysfunction 18.3%. Risk through logistic EuroSCORE 12.4%±15%. Mean operative time was 200±61.7 min, extracorporeal circulation 86±32.5 min, and aortic clamp 65±18.2 min. Complications: medical bleeding 17.2%, reoperation due to bleeding 5.7%, low cardiac output 13.8%, inotropic agents >48 hours 32.1%, balloon pump 1.2%, atrial fibrillation 32.2%, temporary pacemaker 20.7%, permanent pacemaker 5.7%, pulmonary complication 3.4%, CVA with sequelae 3.4%, oliguric ARF 27.6%, dialysis 5.7%, sternal infection 1.2%, ICU stay 3±5.2 days, hospital stay 8±9.6 days, total mortality 10.34%, elective mortality 9.5%, non-elective mortality 12.5%. Divided into groups, the reported mortality was 7.14%, 15.38%, and 5% for low, medium, and high risk respectively. Low postoperative cardiac output at 30 days was identified as a mortality predictor (OR 7, p=0.0011). A total of 71 patients were followed (91%), median 1,203 days (51 to 3,927). Regardless of the preoperative score, survival at the first year was 98.6%, at three years 87.65%, at five years 77.3%, and at seven years 48.6%. 72% observed an improvement in quality of life, 21% saw no changes, and 7% noted worsening. No predictors in the follow-up were found.Conclusions: Valve replacement surgery is a safe and durable procedure, with proven functional benefit and long-term survival comparable to the general population. The use of preoperative risk scores should be revised, due to the demonstrated overestimation of operative risk.