Aortic valve replacement in patients 70 years and older.

BACKGROUND: Aortic valvular disease is the most common valvular lesion among elderly patients. Because of changing demographics, it has become increasingly frequent. Aortic valve replacement (AVR) is the only effective treatment for aortic valvular disease. HYPOTHESIS: This study was undertaken to evaluate the results of AVR in an elderly population. METHODS: Data were retrospectively analyzed in 117 consecutive patients (mean age 73.8 years) who underwent AVR between 1991 and 2002. RESULTS: Pure or predominant severe aortic stenosis was present in 108 patients. Nine patients had severe aortic regurgitation. Before valve replacement, 62.4% of the patients were in New York Heart Association (NYHA) functional class III-IV. A bioprosthesis was implanted in 62.4% of the patients, and 37.6% received a mechanical valve. Concomitant cardiac surgical procedures were performed in 25 patients (coronary artery bypass graft in 22, mitral valve replacement in 3). There were 17 deaths, giving a perioperative mortality rate of 14.5%. Multivariate logistic regression showed that repeat surgery for bleeding, prolonged cardiopulmonary bypass time, postoperative respiratory failure, and postoperative acute renal insufficiency were significant independent predictors of operative mortality. Of the 100 hospital survivors, 78 were followed for a mean of 42.9 months. There were six deaths during follow-up; only two of these were cardiac related. Five-year actuarial survival for all patients and for hospital survivors were 70 and 91.1%, respectively. One year post surgery, all patients were in NYHA functional class I-II. CONCLUSION: In a selected patient population, AVR in the elderly is associated with acceptable mortality and morbidity. The outlook for hospital operative survivors is excellent with improved quality of life and an expected survival normal for this particular age.

Acute right ventricular infarction: clinical spectrum, results of reperfusion therapy and short-term prognosis.

BACKGROUND: The role of thrombolytic therapy (TT) and percutaneous coronary interventions (PCIs) in subgroups of patients with right ventricular infarction (RVI) has not been evaluated. METHODS AND RESULTS: We risk-stratified 302 patients with RVI into three subsets upon admission. Class A (n=197) comprised patients without right ventricular (RV) failure, Class B (n=69) with RV failure and Class C (n=36) with cardiogenic shock. All eligible patients in Class A or B received either PCI or TT. Patients in Class C eligible for reperfusion were treated with PCI. All patients were evaluated for in-hospital major adverse cardiac events and short-term mortality. There was a statistically significant difference in in-hospital mortality among the classes. Classes B and C were the strongest indicators of in-hospital mortality. By multivariate analysis TT or PCI did not reduce mortality in Classes A and B, but a clinically favorable trend in mortality reduction was documented: both methods decreased RV dysfunction in Class B (from 97% to 61% with TT and to 28% with PCI; P < 0.001) and PCI reduced the risk of mortality in Class C (89.5% compared with 58%; P < 0.05). CONCLUSIONS: Classification into types A, B or C allows the prediction of mortality. The use of TT or PCI suggests a clinical favorable trend in the reduction of mortality in Class A, either is beneficial in Class B for decreasing morbidity and PCI appears to be the most appropriate procedure for Class C since it reduced mortality.