Massachusetts Chapter of the American College of Surgeons

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Outcomes of Surgical and Transcatheter Aortic Valve Replacement in the Octogenarians –Surgery Still An Option?
Sameer A. Hirji MD1, Fernando Ramirez-Del Val MD MPH1, Ahmed A. Kolkailah MD1, Julius I. Ejiofor MD MPH1, Siobhan McGurk BS1, Ritam Chowdhury MBBS MPH PhD SM2, Jiyae Lee BS1, Pinak B. Shah MD3, Piotr S. Sobieszczyk MD3, Sary F. Aranki MD1, Marc P. Pelletier MD MSc1, Prem S. Shekar MD1, Tsuyoshi Kaneko MD1.
1Division of Cardiac Surgery; 2Center for Surgery and Public Health (CSPH); 3Department of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA.

Background: Contemporary approaches for aortic valve replacement (AVR) include transcatheter and surgical approaches (TAVR and SAVR). Evidence is compiling for TAVR in high and intermediate risk patients, and some believe all patients over 80 should receive TAVR. We compared outcomes of TAVR and SAVR, including minimally-invasive AVR (mAVR) in the elderly.

Methods: Between 2002 to 2015, 1029 octogenarians underwent isolated AVR; 307 TAVR and 722 SAVR, with 21% (378) of which were mAVR. Logistic regression and Cox modeling evaluated operative mortality and mid-term survival, respectively. Median follow-up was 35(14-64) months.

Results: TAVR patients were older (86?3years vs 84?3years) and more likely had chronic kidney disease (CKD)(13% vs. 5%), NYHA III/IV (78.5% , vs 51.1%), and a higher STS-PROM (6.8±4.5% vs. 5.6±3.5%), all p?0.001. Operative mortality was similar in unadjusted TAVR (4%) vs. SAVR (5%), and adjusted analysis (SAVR (OR:0.99), mAVR (OR:0.94), and alternative access TAVR (OR:1.26), compared to transfemoral TAVR, all p>0.05. Adjusted survival analysis only identified age (HR:1.06), hypercholesterolemia (HR:1.60), NYHA III/IV (HR:1.66), CKD (HR:2.07), diabetes (HR:1.52), peripheral vascular disease (HR:1.53), and prior cardiac surgery (HR:1.36), as significant predictors of decreased survival (all p<0.05).

Conclusion: After adjusting for confounders, TAVR, SAVR and mAVR had comparable mortality and mid-term survival. SAVR remains a safe and established treatment for octogenarians, and should be offered in patients without risk factors given valve duration uncertainty in TAVR.

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