Octogenarians have better survival rates following heart valve surgery

Octogenarians need not shy away from heart valve surgery because of their age; however, those sent home following surgery do better than those discharged to care facilities, according to an observational study published in the September 2012 issue of The Annals of Thoracic Surgery.

Key Points
‧ Heart valve surgery is safe for people older than 80 years.
‧ Elderly people who go directly home from the hospital fare well partly because of social support.
‧ Patients discharged to specialized facilities do equally as well.

To analyze long-term survival rates of octogenarian patients discharged to home versus to a facility, the researchers from the Inova Heart and Vascular Institute in Falls Church, Va., used local data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database on 307 patients aged 80 years or older who had valve surgery from 2002 to 2010. They found that octogenarians have excellent survival, but may do better when discharge to a care facility can be avoided.

"Based on our study results, I strongly recommend that these patients recover at home and not in a facility which may have very limited professional resources such as staff nutritionists, physical and occupational therapists. If home is not an option, then a good alternative is a facility staffed with medical professionals who are trained to assist complex patients in quickly regaining their strength so they can go home," explained lead investigator Linda Henry, PhD, RN.

Although octogenarians routinely undergo valve surgery with excellent results, many of these patients are very sick and unable to return home following surgery because they require extra services, according to the study.

Dr. Henry said that the biggest advantage of being discharged to home is the social support of family and friends. Plus, being in familiar surroundings physiologically reinforces the understanding that they are getting better.

Patients are often transferred to care facilities because they lack social support at home, so often there is no choice in their disposition. Also, many patients not able to go home immediately have more complications prior to discharge, so transferred patients may be at higher risk for subsequent events. However, patients discharged to more specialized facilities, as opposed to less specialized facilities, had equivalent survival to those who went home, according to the study.

"Some of the octogenarians require focused services on a more regimented basis than what can be given to them in less specialized facility," commented Dr. Henry. "Psychologically, patients in specialized facilities may feel that they are actively working to get stronger so they can return home."

New minimally invasive technology may further increase heart surgery safety

Diseased heart valves may cause shortness of breath, weakness, dizziness, fainting, swelling, palpitations, and chest tightness. Cardiothoracic surgeons can replace or repair heart valves to relieve symptoms and prolong life.

Senior author Niv Ad, MD said it has become more and more common to perform heart surgery on octogenarians, something he is doing multiple times a week.

"I am very optimistic about the outlook for people older than 80 with heart disease," stated Dr. Ad, Chief of Cardiac Surgery at Inova Heart and Vascular Institute.
Dr. Ad said that for the first time in 50 years, heart surgeons have new tools and devices on the horizon that will significantly improve the outcome of any patient, especially elderly patients, "These new approaches, including the ability to place new heart valves without sutures, will further enhance our ability to minimize the size of the incision and shorten the time on the heart-lung machine, further reducing the risk of strokes and renal failure."

Recent breakthroughs in valve technology include the minimally invasive transcatheter aortic valve replacement (TAVR), a procedure that has shown great promise during its early use in both Europe and selected US centers. Other techniques on the horizon include minimally invasive procedures that allow for the surgical removal of diseased valves, replacing them with valves that require no sutures and thus may be inserted more quickly.

"TAVR is a complex procedure that has different implications and challenges than traditional heart surgery," Dr. Ad explained. "By considering the pros and cons of traditional surgery and the outcomes, we hope to identify the best patients to undergo TAVR, including elderly ones."

Dr. Ad concluded that more research is needed to understand surgical risk and recovery: "To gain perspective on elderly patients, we need to understand frailty, social support, stamina, and the motivation to be well. If we can blend these factors together with the medical aspect, we will be able to better determine who to treat, how to treat, and when to treat."

Source: The Annals of Thoracic Surgery