Outcome of Patients Aged 80 and Older Undergoing Isolated AVR
The literature search performed on January 2011 yielded 3,364 articles, of which 1,019 were found to be pertinent with this topic. Forty-eight articles were found to report data of interest and fulfilled the inclusion criteria of the present study (Figure 2). These studies included 13,216 patients ≥80 years old who underwent primary or redo isolated AVR. Forty-seven studies including 13,092 patients contributed to analysis of immediate postoperative mortality, whereas 28 studies including 3,863 patients contributed to analysis of late survival.Table I summarizes the main characteristics of these studies.
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Figure 2.
Flowchart of literature search and review.
Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8–7.5, 47 studies, 13,092 patients), with a significant heterogeneity across studies (P = .0001) (Figure 3). Funnel plot did not show any significant publication bias (Figure 4). Studies with a mid-date from 2000 to 2006 had a pooled proportion of immediate postoperative mortality of 5.8 % (95% CI 4.8–6.9), whereas it was 7.5% (95% CI 6.8–8.2) in studies with a mid-date from 1982 to 1999 (P = .009). Mid-date of studies significantly correlated with postoperative mortality (ρ = −0.307, P = .032 (Figure 5), also when adjusted for the number of patients (P = .044)
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Figure 3.
Forest plot of pooled immediate postoperative mortality after isolated AVR in patients ≥80 years old.
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Figure 4.
Funnel plot for immediate postoperative mortality after isolated AVR in patients ≥80 years old.
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Figure 5.
Scatterplot of correlation between immediate postoperative mortality after isolated AVR in patients aged ≥80 years and mid-date of the included studies (cubic fit line along with individual 95% CI is depicted).
Pooled proportion of immediate postoperative mortality was 6.0% (95% CI 4.7–7.4) in audited registries and 7.1% (95% CI 6.3–8.0) in institutional series (P = .176).
Three studies included a variable number of patients operated on through ministernotomy. Their pooled proportion of immediate postoperative mortality was 5.8 % (95% CI 1.6–12.3). Only one study included a series of 249 patients who underwent AVR exclusively through ministernotomy and reported a 30-day mortality rate of 3.2%.
Four studies reported data on primary isolated AVR in 841 patients, and their pooled proportion of immediate postoperative mortality was 4.6% (95% CI 3.3–6.1). Eight studies reported data on 1,981 patients, among whom there were patients with prior cardiac surgery, and the corresponding pooled proportion of immediate postoperative mortality was 6.6% (95% CI 5.0–8.3) (Table I).
Four studies reported on logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the immediate postoperative mortality. The pooled logistic EuroSCORE was 15.0% (95% CI 11.9–18.0), and the pooled proportion of mortality was 6.1% (95% CI 3.5–10.5, predicted-to-observed ratio 2.5).
Pooled proportion of postoperative stroke was 2.4% (95% CI 2.0–2.9, P value for heterogeneity = .215, 21 studies, 8,436 patients) (Figure 6). Eleven studies with a mid-date from 2000 to 2006 had a pooled stroke proportion of 2.3% (95% CI 1.9–2.8), and it was 2.3% (95% CI 1.6–3.2) among 10 studies with a mid-date from 1982 to 1999. Accordingly, mid-date of studies did not correlate with postoperative stroke (ρ = 0.275, P = .228).
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Figure 6.
Forest plot of pooled immediate postoperative stroke after isolated AVR in patients ≥80 years old.
Pooled proportion of postoperative dialysis was 2.6% (95% CI 1.6–3.8, P value for heterogeneity = .030, 10 studies, 1,945 patients). Pooled proportion of implantation of pacemaker was 4.7% (95% CI 3.4–6.1, P value for heterogeneity = .242, 6 studies, 1,470 patients). The mean length of stay in the intensive care unit was 3.5 days (95% CI 2.8–4.3, P value for heterogeneity = .030, 6 studies, 1,172 patients), and the mean length of in-hospital stay was 13.3 days (95% CI 11.1–15.6, P value for heterogeneity = .242, 9 studies, 1,172 patients).
Pooled proportions of late survival are summarized inFigure 7. Data are characterized by significant heterogeneity at all intervals. Pooled survival rates at 1, 3, 5, and 10 years were 87.6%, 78.7%, 65.4%, and 29.7%. Studies with a mid-date after 1999 and those with an earlier mid-date had similar pooled 5-year survival (65.4% [95% CI 58.3–71.8%] vs 65.2% [95% CI 62.3–73.3%]).
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Figure 7.
Pooled proportions of late survival after isolated AVR in patients ≥80 years old.
Results
Literature Search
The literature search performed on January 2011 yielded 3,364 articles, of which 1,019 were found to be pertinent with this topic. Forty-eight articles were found to report data of interest and fulfilled the inclusion criteria of the present study (Figure 2). These studies included 13,216 patients ≥80 years old who underwent primary or redo isolated AVR. Forty-seven studies including 13,092 patients contributed to analysis of immediate postoperative mortality, whereas 28 studies including 3,863 patients contributed to analysis of late survival.Table I summarizes the main characteristics of these studies.
(Enlarge Image)
Figure 2.
Flowchart of literature search and review.
Immediate Postoperative Mortality
Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8–7.5, 47 studies, 13,092 patients), with a significant heterogeneity across studies (P = .0001) (Figure 3). Funnel plot did not show any significant publication bias (Figure 4). Studies with a mid-date from 2000 to 2006 had a pooled proportion of immediate postoperative mortality of 5.8 % (95% CI 4.8–6.9), whereas it was 7.5% (95% CI 6.8–8.2) in studies with a mid-date from 1982 to 1999 (P = .009). Mid-date of studies significantly correlated with postoperative mortality (ρ = −0.307, P = .032 (Figure 5), also when adjusted for the number of patients (P = .044)
(Enlarge Image)
Figure 3.
Forest plot of pooled immediate postoperative mortality after isolated AVR in patients ≥80 years old.
(Enlarge Image)
Figure 4.
Funnel plot for immediate postoperative mortality after isolated AVR in patients ≥80 years old.
(Enlarge Image)
Figure 5.
Scatterplot of correlation between immediate postoperative mortality after isolated AVR in patients aged ≥80 years and mid-date of the included studies (cubic fit line along with individual 95% CI is depicted).
Pooled proportion of immediate postoperative mortality was 6.0% (95% CI 4.7–7.4) in audited registries and 7.1% (95% CI 6.3–8.0) in institutional series (P = .176).
Three studies included a variable number of patients operated on through ministernotomy. Their pooled proportion of immediate postoperative mortality was 5.8 % (95% CI 1.6–12.3). Only one study included a series of 249 patients who underwent AVR exclusively through ministernotomy and reported a 30-day mortality rate of 3.2%.
Four studies reported data on primary isolated AVR in 841 patients, and their pooled proportion of immediate postoperative mortality was 4.6% (95% CI 3.3–6.1). Eight studies reported data on 1,981 patients, among whom there were patients with prior cardiac surgery, and the corresponding pooled proportion of immediate postoperative mortality was 6.6% (95% CI 5.0–8.3) (Table I).
Four studies reported on logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and the immediate postoperative mortality. The pooled logistic EuroSCORE was 15.0% (95% CI 11.9–18.0), and the pooled proportion of mortality was 6.1% (95% CI 3.5–10.5, predicted-to-observed ratio 2.5).
Other Immediate Postoperative Adverse Events
Pooled proportion of postoperative stroke was 2.4% (95% CI 2.0–2.9, P value for heterogeneity = .215, 21 studies, 8,436 patients) (Figure 6). Eleven studies with a mid-date from 2000 to 2006 had a pooled stroke proportion of 2.3% (95% CI 1.9–2.8), and it was 2.3% (95% CI 1.6–3.2) among 10 studies with a mid-date from 1982 to 1999. Accordingly, mid-date of studies did not correlate with postoperative stroke (ρ = 0.275, P = .228).
(Enlarge Image)
Figure 6.
Forest plot of pooled immediate postoperative stroke after isolated AVR in patients ≥80 years old.
Pooled proportion of postoperative dialysis was 2.6% (95% CI 1.6–3.8, P value for heterogeneity = .030, 10 studies, 1,945 patients). Pooled proportion of implantation of pacemaker was 4.7% (95% CI 3.4–6.1, P value for heterogeneity = .242, 6 studies, 1,470 patients). The mean length of stay in the intensive care unit was 3.5 days (95% CI 2.8–4.3, P value for heterogeneity = .030, 6 studies, 1,172 patients), and the mean length of in-hospital stay was 13.3 days (95% CI 11.1–15.6, P value for heterogeneity = .242, 9 studies, 1,172 patients).
Late Survival
Pooled proportions of late survival are summarized inFigure 7. Data are characterized by significant heterogeneity at all intervals. Pooled survival rates at 1, 3, 5, and 10 years were 87.6%, 78.7%, 65.4%, and 29.7%. Studies with a mid-date after 1999 and those with an earlier mid-date had similar pooled 5-year survival (65.4% [95% CI 58.3–71.8%] vs 65.2% [95% CI 62.3–73.3%]).
(Enlarge Image)
Figure 7.
Pooled proportions of late survival after isolated AVR in patients ≥80 years old.