Valvular disease in the elderly: Influence on surgical results

Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function. In contrast, mitral valve disease in the elderly often is ischemic in nature with damage occurring to both valve and myocardium. The present study was undertaken to compare results of aortic (AVR) and mitral valve replacement (MVR) in the elderly and to ascertain predictors of poor outcome. Because patients who had concomitant coronary artery bypass grafting (CABG) are included (51% for AVR, 55% for MVR), patients who had isolated CABG were used as a comparison group. Between January 1, 1984, and June 30, 1991, 1,386 patients aged 70 years and older underwent CABG (n = 1,043), AVR (n = 245), or MVR (n = 98). The operative mortality rates were 5.3% for AVR, 20.4% for MVR, and 5.8% for CABG. Late follow-up of patients undergoing operation in 1984 and 1985 was available for 98% (231/237). Overall survival was comparable for all three groups through the first 5 years of follow-up (AVR, 68% ± 8%; MVR, 73% ± 8%; CABG, 78% ± 3%). After 5 years, survival for patients having AVR and MVR was less than that for those having CABG. Patient age, sex, New York Heart Association functional class, concomitant CABG, prosthetic valve type, native valve pathology, and preoperative catheterization data were examined as possible predictors of outcome by multivariate logistic regression. Among MVR patients, New York Heart Association functional class, ischemic valvular pathology, and higher pulmonary capillary wedge pressure were predictive of operative mortality; poor left ventricular function was a predictor of poor long-term survival (17% versus 100% at 7 years; p < 0.0005). Among AVR patients, only advanced functional class was associated with a poor outcome. Compared with MYR patients, AVR patients were older (76.5 ± 4.6 versus 74.5 ± 3 years; p = 0.0002), were more often male (55% versus 39%; p = 0.006), had a lower pulmonary capillary wedge pressure (18 ± 11 versus 24 ± 10 mm Hg; p = 0.0001), and had fewer critically diseased vessels (p = 0.001). These results suggest that AVR in the elderly has an operative mortality similar to that of isolated CABG. In contrast, MVR is less well tolerated, especially in patients with ischemic mitral disease. Survival 5 years postoperatively is similar among AVR, MYR, and CABG patients but becomes significantly worse thereafter for AVR and MVR patients.