- Email: [email protected]
Aortic Valve Surgery in Octogenarians: The Simpler, the Better?
746
CORRESPONDENCE
aortoesophageal fistula after extra-anatomic bypass of aortic coarctation [1]. We agree with their approach, in that endovascular exclusion is a temporary solution which stabilizes a patient with a lethal aortic complication, and to proceed to elective full repair of the lesion under optimal conditions. It should not be forgotten that reoperation, even in an optimally stabilized patient, carries a very significant risk of complication or death. It is very difficult to recommend to a now healthy patient that he or she should undergo a complex and ultimately dangerous reoperation when he or she feels back to normal [2]. The unavoidability of reinfection or rebleeding must be discussed after initial stabilization, as when these events occur it usually becomes too late to safely remove an endovascular device and perform a complete repair. The optimal timing of elective full repair remains to be determined. Kakkos and colleagues [3] showed that all patients who were bridged with endovascular exclusion of aortoesophageal fistulas died at their eventually reoperation. On the other hand, very early repair risks recurrent infection unless homograft or biodegradable materials are used [4]. Our patient was managed with temporization through endovascular exclusion of the aortoesophageal fistula and discharged on suppressive antibiotics [5]. Temporarily under our care during a vacation as he was from a foreign country, and given his stabilization, it was decided that further management would be provided back in his unit. As a fit 52-year-old patient he was maintained on chronic suppressive antibiotics. Eighteen months after this initial repair he presented with recurrent fevers of unknown origin, and recurrent graft infection was suspected. He underwent full repair with removal of all infected graft, and has been doing well for the following 3 months since this repair. Patrick O. Myers, MD Nicolas Murith, MD Division of Cardiovascular Surgery Geneva University Hospitals & Faculty of Medicine 4, rue Gabrielle-Perret-Gentil 1211 Geneva 14, Switzerland e-mail: [email protected]
MISCELLANEOUS
References 1. Hermsen JL, Sweet MP, Mulligan MS. Finish the job! (letter). Ann Thorac Surg 2015;99:745. 2. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41: 635–6. 3. Kakkos SK, Antoniadis PN, Klonaris CN, et al. Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 2011;41:625–34. 4. Myers PO, Cikirikcioglu M, Kalangos A. Biodegradable materials for surgical management of infective endocarditis: new solution or a dead end street? BMC Surg 2014;14:48. 5. Myers PO, Gemayel G, Mugnai D, Murith N, Kalangos A. Endovascular exclusion of aortoesophageal fistula after coarctation extraanatomical bypass. Ann Thorac Surg 2014;98: 314–6.
Ann Thorac Surg 2015;99:744–8
we read with great interest the article by Penaranda and colleagues [1] who, in their retrospective analysis, evaluated the clinical and hemodynamic outcome of octogenarian patients with a small aortic root who underwent aortic valve replacement (AVR) with or without aortic root enlargement. Although patients who received aortic root enlargement derived an echocardiographic benefit in terms of less patientprosthesis mismatch (PPM), no differences in functional status and survival were observed at follow-up between patients with or without PPM. We agree with the authors that PPM occurrence should be prevented also in octogenarians even if, in this setting, short-term results and postoperative quality of life are of greater importance than long-term survival. Therefore, we disagree on the need to expose patients to longer procedural times to reduce the risk of PPM. In patients who underwent AVR with aortic root enlargement, aortic cross-clamp (ACC) and cardiopulmonary bypass times were 67 and 102 minutes, respectively. Despite similar outcomes in both groups, operative mortality was 10% in the aortic root enlargement group with complications occurring in almost three quarters of patients. In a recent retrospective analysis of AVR patients, Ranucci and colleagues [2] found that ACC time was an independent predictor of morbidity, with an increased risk of 1.4% per minute. Use of a sutureless aortic bioprosthesis (eg, Perceval can combine both advantages of a shorter ischemic time, with reported ACC times of less than 20 minutes [3], and avoidance of PPM (due to the stentless profile that allows to maximize the effective orifice area), besides resulting in an easier implantation procedure. Although Penaranda and colleagues did not find any significant difference in shorter ACC times, it is likely that differences in clinical outcome would become apparent if ACC time could be 40 minutes shorter, as it emerges by comparing ACC times of patients undergoing AVR with aortic root enlargement versus patients undergoing sutureless AVR (67 vs 20 minutes). Our considerations are aimed at keeping the debate open on this issue as the most appropriate approach remains controversial. Giuseppe Santarpino, MD Francesco Pollari, MD Theodor Fischlein, MD Department of Cardiac Surgery Klinikum N€ urnberg – Paracelsus Medical University Breslauerstraße 201-90471 Nuremberg, Germany e-mail: [email protected]
References 1. Penaranda JG, Greason KL, Pislaru SV, et al. Aortic root enlargement in octogenarian patients results in less patient prosthesis mismatch. Ann Thorac Surg 2014;97:1533–8. 2. Ranucci M, Frigiola A, Menicanti L, Castelvecchio S, de Vincentiis C, Pistuddi V. Aortic cross-clamp time, new prostheses, and outcome in aortic valve replacement. J Heart Valve Dis 2012;21:732–9. 3. Flameng W, Herregods MC, Hermans H, et al. Effect of sutureless implantation of the Perceval S aortic valve bioprosthesis on intraoperative and early postoperative outcomes. J Thorac Cardiovasc Surg 2011;142:1453–7.
Aortic Valve Surgery in Octogenarians: The Simpler, the Better? To the Editor:
Reply To the Editor:
Extension of life’s expectance in the last 2 decades has led to an increase in elderly patients referred for surgery. In this regard,
We appreciate the response to our article [1] by Santarpino and colleagues [2], who point out the high operative risk
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00
CORRESPONDENCE
aortoesophageal fistula after extra-anatomic bypass of aortic coarctation [1]. We agree with their approach, in that endovascular exclusion is a temporary solution which stabilizes a patient with a lethal aortic complication, and to proceed to elective full repair of the lesion under optimal conditions. It should not be forgotten that reoperation, even in an optimally stabilized patient, carries a very significant risk of complication or death. It is very difficult to recommend to a now healthy patient that he or she should undergo a complex and ultimately dangerous reoperation when he or she feels back to normal [2]. The unavoidability of reinfection or rebleeding must be discussed after initial stabilization, as when these events occur it usually becomes too late to safely remove an endovascular device and perform a complete repair. The optimal timing of elective full repair remains to be determined. Kakkos and colleagues [3] showed that all patients who were bridged with endovascular exclusion of aortoesophageal fistulas died at their eventually reoperation. On the other hand, very early repair risks recurrent infection unless homograft or biodegradable materials are used [4]. Our patient was managed with temporization through endovascular exclusion of the aortoesophageal fistula and discharged on suppressive antibiotics [5]. Temporarily under our care during a vacation as he was from a foreign country, and given his stabilization, it was decided that further management would be provided back in his unit. As a fit 52-year-old patient he was maintained on chronic suppressive antibiotics. Eighteen months after this initial repair he presented with recurrent fevers of unknown origin, and recurrent graft infection was suspected. He underwent full repair with removal of all infected graft, and has been doing well for the following 3 months since this repair. Patrick O. Myers, MD Nicolas Murith, MD Division of Cardiovascular Surgery Geneva University Hospitals & Faculty of Medicine 4, rue Gabrielle-Perret-Gentil 1211 Geneva 14, Switzerland e-mail: [email protected]
MISCELLANEOUS
References 1. Hermsen JL, Sweet MP, Mulligan MS. Finish the job! (letter). Ann Thorac Surg 2015;99:745. 2. McCarthy MJ. Open or endovascular repair of secondary aortoenteric fistulae? Eur J Vasc Endovasc Surg 2011;41: 635–6. 3. Kakkos SK, Antoniadis PN, Klonaris CN, et al. Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study. Eur J Vasc Endovasc Surg 2011;41:625–34. 4. Myers PO, Cikirikcioglu M, Kalangos A. Biodegradable materials for surgical management of infective endocarditis: new solution or a dead end street? BMC Surg 2014;14:48. 5. Myers PO, Gemayel G, Mugnai D, Murith N, Kalangos A. Endovascular exclusion of aortoesophageal fistula after coarctation extraanatomical bypass. Ann Thorac Surg 2014;98: 314–6.
Ann Thorac Surg 2015;99:744–8
we read with great interest the article by Penaranda and colleagues [1] who, in their retrospective analysis, evaluated the clinical and hemodynamic outcome of octogenarian patients with a small aortic root who underwent aortic valve replacement (AVR) with or without aortic root enlargement. Although patients who received aortic root enlargement derived an echocardiographic benefit in terms of less patientprosthesis mismatch (PPM), no differences in functional status and survival were observed at follow-up between patients with or without PPM. We agree with the authors that PPM occurrence should be prevented also in octogenarians even if, in this setting, short-term results and postoperative quality of life are of greater importance than long-term survival. Therefore, we disagree on the need to expose patients to longer procedural times to reduce the risk of PPM. In patients who underwent AVR with aortic root enlargement, aortic cross-clamp (ACC) and cardiopulmonary bypass times were 67 and 102 minutes, respectively. Despite similar outcomes in both groups, operative mortality was 10% in the aortic root enlargement group with complications occurring in almost three quarters of patients. In a recent retrospective analysis of AVR patients, Ranucci and colleagues [2] found that ACC time was an independent predictor of morbidity, with an increased risk of 1.4% per minute. Use of a sutureless aortic bioprosthesis (eg, Perceval can combine both advantages of a shorter ischemic time, with reported ACC times of less than 20 minutes [3], and avoidance of PPM (due to the stentless profile that allows to maximize the effective orifice area), besides resulting in an easier implantation procedure. Although Penaranda and colleagues did not find any significant difference in shorter ACC times, it is likely that differences in clinical outcome would become apparent if ACC time could be 40 minutes shorter, as it emerges by comparing ACC times of patients undergoing AVR with aortic root enlargement versus patients undergoing sutureless AVR (67 vs 20 minutes). Our considerations are aimed at keeping the debate open on this issue as the most appropriate approach remains controversial. Giuseppe Santarpino, MD Francesco Pollari, MD Theodor Fischlein, MD Department of Cardiac Surgery Klinikum N€ urnberg – Paracelsus Medical University Breslauerstraße 201-90471 Nuremberg, Germany e-mail: [email protected]
References 1. Penaranda JG, Greason KL, Pislaru SV, et al. Aortic root enlargement in octogenarian patients results in less patient prosthesis mismatch. Ann Thorac Surg 2014;97:1533–8. 2. Ranucci M, Frigiola A, Menicanti L, Castelvecchio S, de Vincentiis C, Pistuddi V. Aortic cross-clamp time, new prostheses, and outcome in aortic valve replacement. J Heart Valve Dis 2012;21:732–9. 3. Flameng W, Herregods MC, Hermans H, et al. Effect of sutureless implantation of the Perceval S aortic valve bioprosthesis on intraoperative and early postoperative outcomes. J Thorac Cardiovasc Surg 2011;142:1453–7.
Aortic Valve Surgery in Octogenarians: The Simpler, the Better? To the Editor:
Reply To the Editor:
Extension of life’s expectance in the last 2 decades has led to an increase in elderly patients referred for surgery. In this regard,
We appreciate the response to our article [1] by Santarpino and colleagues [2], who point out the high operative risk
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
0003-4975/$36.00