Piper Cornelia, Hering Detlev, Kleikamp Georg, Körfer Reiner, Horstkotte Dieter
Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Georgstr. 11, D-32545 Bad Oeynhausen, Germany.
J Heart Valve Dis. 2009 May;18(3):239-44.
In octogenarians with symptomatic aortic valve stenosis (AS), aortic valve replacement (AVR) is frequently not performed in due time, because the prognostic benefit is underestimated, while perioperative morbidity and mortality are overestimated. The severely impaired prognosis and quality of life after myocardial decompensation then urges AVR with a significantly increased perioperative risk.
Between 2003 and 2006, all octogenarians with isolated symptomatic AS (indexed aortic valve opening area <0.5 cm2/m2) referred to the authors' unit were prospectively included in the survey. Among the 83 patients enrolled (51 women, 32 men; mean age 84 +/- 5.1 years), 38 patients (26 women, 12 men; mean age 84 +/- 2.3 years) had signs of chronic myocardial decompensation (dilated left ventricle and/or reduced left ventricular function; left ventricular ejection fraction (LVEF) 43 +/- 18% (range: 25-53%). These patients comprised group A. All other patients (group B) had normal left ventricular dimensions, a normal LVEF (>55%), and no clinical episodes of myocardial decompensation. All patients underwent AVR, while 23 (28%) underwent simultaneous coronary revascularization.
In group A, the 30-day mortality rate was 5.3% (n = 2). Octogenarians without chronic myocardial decompensation had a lower 30-day mortality (1/45; 2.2%). The incidences of major postoperative complications (reversible acute renal failure, stroke, mechanical circulatory support) were significantly higher in group A (26.3% versus 8.9%, p < 0.05). During late follow up (mean 24.2 +/- 12.8 months), another four patients in group A (11.1%) and five in group B (11.4%) died. Octogenarians in group B had a significantly (p < 0.01) more favorable cumulative survival rate (87% versus 78% after 24 months; 81% versus 68% after 46 months).
AVR can be performed in octogenarians with a low mortality and morbidity, but should not be postponed. The decision to perform for AVR may take into consideration any life-limiting comorbidities, but should be made independent of the patient's age.
在患有症状性主动脉瓣狭窄（AS）的八旬老人中，主动脉瓣置换术（AVR）常常未能及时进行，因为其预后益处被低估，而围手术期发病率和死亡率却被高估。心肌失代偿后严重受损的预后和生活质量促使进行AVR，但围手术期风险显著增加。
2003年至2006年期间，所有转诊至作者所在科室的患有孤立性症状性AS（主动脉瓣开口面积指数<0.5 cm2/m2）的八旬老人均被前瞻性纳入该调查。在纳入的83例患者中（51例女性，32例男性；平均年龄84±5.1岁），38例患者（26例女性，12例男性；平均年龄84±2.3岁）有慢性心肌失代偿的体征（左心室扩张和/或左心室功能降低；左心室射血分数（LVEF）43±18%（范围：25 - 53%））。这些患者组成A组。所有其他患者（B组）左心室尺寸正常，LVEF正常（>55%），且无心肌失代偿的临床发作。所有患者均接受了AVR，其中23例（28%）同时进行了冠状动脉血运重建。
A组30天死亡率为5.3%（n = 2）。无慢性心肌失代偿的八旬老人30天死亡率较低（1/45；2.2%）。A组术后主要并发症（可逆性急性肾衰竭、中风、机械循环支持）的发生率显著更高（26.3%对8.9%，p < 0.05）。在后期随访（平均24.2±12.8个月）期间，A组又有4例患者（11.1%）和B组5例患者（11.4%）死亡。B组八旬老人的累积生存率显著更优（p < 0.01）（24个月后为87%对78%；46个月后为81%对68%）。
八旬老人进行AVR的死亡率和发病率较低，但不应推迟。决定是否进行AVR可考虑任何限制生命的合并症，但应独立于患者年龄做出决定。
