At this session five speakers discussed the main problems related to indications for valve surgery in the field of elderly patients.
The first speaker B. E. Keogh, from London, GB, stressed the importance of preoperative risk factors (either cardiac and non cardiac) and how they influence the outcome. Postoperative stroke is one of the most significant problems in this population and the way to lower operative risk is trying to eliminate those factors like emergency surgery, or ameliorate pulmonary, renal or other general diseases. Taking in account risk scores is the way to go.
The next two speakers discussed the indications for a tissue or a mechanical valve:
Dr R Dion from Leiden NL, gave the reasons for the indication of a biological valve, stressing the importance of the higher risk of bleeding when anticoagulation is needed and that in eldely patients the safe margins of RIN are much smaller and precise than in the young. Reoperation can be done safely when elective, with a similar risk to the first operation. Between 63 and 67 years of age the lines of life expectancy with mechanical and tissue valves crossed each other, showing above this age better expectancy at ten years with a biological valve.
Dr. E G Butchart (Cardiff, GB) pointed out that in some elderly patients a mechanical valve should still be an indication because life expectancy is steadily growing and the appearance of chronic atrial fibrillation after valve replacement in the elderly is a fact. Also, in the decision we should take in account risk factors.
Dr. Lung from Paris reviewed the results of the Euro Heart Survey with 408 patients above 75 years of age and 61% incidence of coronary desease. To 33% of patients with aortic stenosis and to 64% with mitral regurgitation the operation was denied. The main reasons were left ventricular ejection fraction, age and other risk factors. In mitrals, also valve biological factors. It should be taken in account that there is no scientific reason to deny an operation to a patient with aortic stenosis because of low ejection fraction.
Dr CM Otto from Seattle, US summarised the previous concepts and stressed the importance of taking in account the expectation of life at the different age points of a patient, for example 9 years at the age of 80 in the USA. |