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Background: Aortic valve replacement has some major adverse outcomes. For these, the predictors need identification., Methods: This was a retrospective file study of 1000 consecutive patients who underwent AVR for degenerative aortic valve disease. Twenty-five preoperative and 5 peroperative factors were screened by a univariate Fisher-exact analysis. The predictors were identified in a second step by logistic regression multivariate analysis., Results: Five hundred thirty patients were male. The mean age was 75 (71-77) years and 610 also underwent CABG. For hospital mortality, need for urgent aortic valve replacement (p < 0.001) was the dominant predictor. Need for digitalis (p = 0.002) and age > 80 (p = 0.005) followed. For postoperative congestive heart failure, need for urgent aortic valve replacement was also dominant (p <0.001). Atrial fibrillation (p = 0.001,) and ejection fraction < 50% (p = 0.055) were less important. For ventricular arrhythmia, previous infarction (p = 0.025) and ejection fraction < 50% (p = 0.032) were identified. For bleeding, concomitant CABG (p = 0.046) and chronic obstructive pulmonary disease were identified. For thromboembolic events only an ejection fraction < 50% (p = 0.027) was identified., Conclusions: Need for urgent aortic valve replacement is the dominant predictor for postoperative mortality and congestive heart failure. Once a degenerative aortic valve disease becomes symptomatic, prompt referral could prevent the development for need for urgent surgery, with all its adverse postoperative consequences.

Aim: Postoperative renal dysfunction after aortic valve replacement is a serious complication. To minimize its occurrence, risk factors have to be identified, and if possible eliminated., Methods: Of 1000 consecutive patients, who underwent AVR, a file study was performed chi(2)nd logistic regression analysis were performed to study the effect of 24 preoperative, 7 peroperative and 7 postoperative factors on the occurrence of 30-day postoperative worsening of renal function., Results: Fifty-three patients had a 30-day postoperative decrease of renal function. Nine of these patients died, which is significantly more than the mortality without this complication (P<0.0001). In those nine patients, another complication (postoperative heart failure, thromboembolism or respiratory failure) was present. Thirteen factors were significant in an univariate analysis: preoperative renal dysfunction (P<0.001), age>80 (P<0.001), atrial fibrillation (P<0.001) , preoperative pulmonary edema (P=0.001), conduction defect (P=0.002), diabetes (P=0.006), myocardial infarction (P=0.006), postoperative heart failure (P=0.007), cross clamp time >75 min (P=0.015), previous coronary artery bypass grafting (CABG) (P=0.018), concomitant CABG (P=0.031), ejection fraction <50% (P=0.033) and CVA (P=0.035). Four factors were identified as independent predictors in a multivariate analysis: renal dysfunction (P<0.001, Odds ratio [OR] 5.5; 95% confidence interval [CI] 2.9-10.4), preoperative atrial fibrillation (P=0.010, OR=2.3, 95% CI=1.2-4.2), age>80 (P=0.014, OR=2.2, 95% CI=1.2-4.1) and myocardial infarction (P=0.022, OR=2.2, 95% CI=1.1-4.4)., Conclusions: Few factors are liable for therapeutic intervention, especially in elderly and patients with comorbidity. In patients with risk factors, shortening of cross clamping time or installation of minimal extracorporeal circulation might be beneficial.

Degenerative aortic valve disease is the most frequent acquired valve disease. Especially in the elderly, its prevalence is increasing. Once the disease becomes symptomatic, it is rapidly fatal. The disease cannot be considered a result of aging alone. The condition is an active process, which occurs with rapid progression, especially when calcification can be documented. This calcification can be the end result of cellular mechanisms involving cell death pathways (such as autophagy) and cellular matrix remodeling. These processes are beginning to be unraveled in the initiation and propagation of the disease. Autophagy could be the common step through which these mechanisms lead to this pathway of cell death in this disease. Autophagy can be detected by procedures described hereafter.

Background and Aim of the Study: Over the past 20 years, both the typical age and co-morbidity of patients referred for aortic valve replacement (AVR) have increased. In order to assess the effect of these changes on hospital complications, an evaluation was conducted of patient characteristics within this time period., Methods: This retrospective study included 1,000 consecutive patients who underwent AVR with a pericardial valve. Concomitant coronary artery bypass grafting (CABG) was performed in 610 cases. Among 25 preoperative and five perioperative factors, and eight hospital complications, the changes in incidence that occurred during the periods 1986-1991, 1992-1996, 1997-2001, and 2002-2006, were investigated. Predictive factors for non-cardiac hospital complications required further exploration, as these were the only complications to increase significantly with time; however, this type of complication is less lethal., Results: Significant increases were identified in age, and in the incidence of non-cardiac co-morbidity, previous CABG and preoperative congestive heart failure (p mostly <0.0001). Among hospital complications, only non-cardiac problems showed a significant increase. The independent predictors included previous CABG (p = 0.004), concomitant CABG (p = 0.006), renal impairment (p = 0.008), conduction defects (p = 0.010), previous pacemaker implantation (p = 0.014), chronic obstructive lung disease (p = 0.015), and concomitant carotid artery surgery (p = 0.032)., Conclusion: During the past 20 years, patients referred for AVR have become older and have more co-morbidity. However, the incidence only of non-cardiac hospital complications was increased. Previous and concomitant surgery, as well as non-cardiac co-morbidity, are important predictors that must be taken into account at referral, but should not contraindicate AVR.

Background and Aim of the Study: The study aim was to determine if aortic valve replacement in octogenarians is still rewarding., Methods: Between 1986 and 2000, 500 patients received a Carpentier-Edwards pericardial valve in the aortic position. Of these patients, 348 also underwent coronary artery bypass grafting (CABG). Sixty patients were aged > or =80 years. A retrospective follow up totaled 2,022 patient-years. A Cox multivariate regression analysis included 17 preoperative potential risk factors: age >80 years; gender; carcinoma; chronic obstructive pulmonary disease; renal failure; stroke; arterial hypertension; carotid artery disease; myocardial infarction; coronary artery disease; conduction defects; atrial fibrillation; medically treated endocarditis; severity of symptoms; urgent operation; left ventricular function; and need for digitalis., Results: For hospital mortality, independent predictors were urgent surgery (Risk Ratio 10.2, 95% CI 2.5-42.0, p = 0.001); age over 80 (RR 4.5, CI 1.3-14.9; p = 0.015); need for digitalis (RR 3.8, CI 1.3-10.6, p = 0.010); male gender (RR 3.7, CI 1.1-12.4; p = 0.035); and myocardial infarction (RR 3.1, CI 1.0-9.4, p = 0.051). For long-term mortality, independent predictors. were urgent surgery (RR 4.5, CI 1.6-12.6; p = 0.004), age >80 (RR 2.5, CI 1.4-4.5, p = 0.002); myocardial infarction (RR 2.1, CI 1.3-3.4; p = 0.003); carcinoma (RR 2.0; CI 1.1-3.7; p = 0.021); and digitalis use (RR 1.8; CI 1.2-2.7; p = 0.004). Univariate analysis revealed that age >80 years (38.6% versus 77.0%), need for urgent operation (0% versus 75.1%), need for digitalis (69.4% versus 76.3%) and myocardial infarction (57.1% versus 76.4%) had a significant effect on five-year survival., Conclusion: For hospital mortality and long-term mortality, a need for urgent surgery was the most determining factor. Age >80 years was the second most important factor, but previous myocardial infarction and need for digitalis were almost equally important. Aortic valve replacement in octogenarians is still rewarding, as five-year survival is 38.6%. Thus, surgery in these patients should not be postponed.

Background and Aim of the Study: The effect of concurrent disease and cardiac comorbidity on survival after bioprosthetic valve replacement in elderly patients was assessed retrospectively. Risk factors were categorized as general, non-cardiac (age, diabetes, previously treated carcinoma) and cardiac (LVEF, three-vessel disease, previous CABG or valve replacement, and endocarditis)., Methods: A total of 400 elderly patients (median age 73 years; range: 71-76 years) was studied. Medical history included diabetes, previous CABG or aortic valve replacement (AVR), endocarditis and treatment of previous carcinoma. A left ventricular ejection fraction (LVEF) of <0.66 and presence of three-vessel disease were also investigated. Hospital deaths (and cause) were recorded; survival or date and cause of death after discharge were obtained by questionnaire. Kaplan-Meier univariate and Cox proportional hazards multivariate regression analyses were carried out., Results: Mortality during follow up was 28.3%; hospital mortality was 3.8%. Univariate analysis showed five factors significantly to affect survival: LVEF, history of endocarditis, carcinoma, age and three-vessel disease. Fifteen of 38 patients with history of carcinoma died, 10 due to a malignancy. Of 76 patients with three-vessel disease, 26 died. A history of diabetes and previous CABG did not influence survival significantly. Four of eight patients with preoperative endocarditis died, all in hospital. Six of 11 patients died after redo-AVR, none before 36 months follow up. By Cox regression analysis, LVEF and histories of carcinoma and endocarditis remained significant., Conclusion: AVR should be performed before ventricular deterioration occurs. Previous CABG is not a contraindication for AVR. Endocarditis impaired survival. Long-term mortality after redo-AVR in this population was relatively high, but acceptable. AVR should also be performed in elderly patients with aortic valve disease. Since prognosis of symptomatic aortic valve disease is poor in the short term, AVR is indicated in patients treated for carcinoma.