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