VALVULAR SURGERY IN THE ELDERLY

Background: Previous work from our group demonstrated age to be an ind ependent predictor of operative mortality in valvular heart surgery; 5 .6% of patients under 70 years of age ('young') die compared with 10% of those over 70 years ('old'). These results are largely based on pat ients who underwent heart surgery before the introduction of oxygenate d blood cardioplegia and before the development of retrograde delivery systems. The goal of this study was to determine if age remains a pre dictor of operative outcome in the current era. Methods: Between Novem ber 1989 and December 1993 we performed 423 valvular heart procedures; 300 (71%) in young and 123 (29%) in old patients. Patients were asses sed according to age, sex, preoperative symptoms [New York Heart Assoc iation (NYHA) class ill and IV versus I and II], timing of surgery [el ective versus urgent funder 72 h)], associated coronary artery disease , associated left main stenosis, concomitant bypass surgery, left vent ricular function (ejection fraction <40% versus >40%) and surgical pro cedure (mitral versus aortic valve surgery). Univariate (Fisher's exac t test) and multivariate analyses (logistic regression) were used to a ssess the effects of the above on the outcome of surgery. Results: The mortality was 8.1% in old compared with 2.7% in young patients (P<0.0 2), and the cumulative morbidity and mortality was 34.2% in old compar ed with 17.7% in young patients (P<0.001). Univariate analysis identif ied age and the timing of surgery as the only predictors of survival. Identical results were obtained after multivariate analysis using the stepwise logistic regression model (P-age=0.01; P-timing=0.016). No ad ditional independent predictors of outcome could be identified. Relati ve odds ratio determination demonstrated that the combination of urgen t surgery and advanced age increased the risk of surgery tenfold. Conc lusions: Improvements in myocardial protection and perioperative care may account for the slightly better results of valvular surgery (parti cularly in young patients) in the current study when compared with our previous work. However, age continues to be an important predictor of mortality. In the elderly, therefore, careful patient selection and e arly intervention to avoid-the increased risk associated with urgent s urgery remains the most important factor influencing operative outcome .