Editorial comment
Surgery for symptomatic aortic stenosis in the elderly: Still an excellent option
Cirurgia na estenose aórtica sintomática em idosos: ainda uma excelente opção
Manuel J. Antunes
Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Antunes" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Manuel J." "apellidos" => "Antunes" "email" => array:1 [ 0 => "mjantunes48@sapo.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Faculty of Medicine, University of Coimbra, Coimbra, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Cirurgia na estenose aórtica sintomática em idosos: ainda uma excelente opção" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">As a result of the aging of populations, aortic stenosis (AS) is rapidly turning into the cardiac epidemic of the 21st century, with an estimated incidence of about 10% in patients over 80 years of age.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> This potentially lethal condition is still mainly treated by surgery, and patients’ general condition, both physical and mental, after the operation is perceived as being at least as important as survival, especially in elderly patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In a paper published in this issue of the <span class="elsevierStyleItalic">Journal</span>,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> Bento et al. of the surgical group at Santa Marta Hospital in Lisbon set out to determine the impact of surgical aortic valve replacement (SAVR) on quality of life in octogenarians. In a retrospective analysis of 163 octogenarians (mean age 83 years) who underwent isolated SAVR for symptomatic severe AS between 2011 and 2015, quality of life was assessed by applying the Medical Outcomes Study Short Form (SF-36) questionnaire repeatedly up to 12 months after surgery. The authors came to the conclusion that SAVR improved the physical and mental health status of octogenarians with severe AS, and that this improvement was evident at three months and consistent at six and 12 months. Furthermore, it was observed in all eight domains of the questionnaire (physical function and performance, body pain, general and mental health, social functioning, emotional performance and vitality). The SF-36 survey had previously been validated for the Portuguese population.</p><p id="par0015" class="elsevierStylePara elsevierViewall">As could intuitively have been expected, the main hypothesis of the study was thus confirmed. Few studies had previously been conducted in this age group, and none in the Portuguese population, but the results of the Santa Marta study confirm the findings of others. This is important, as some surveys have shown that the Portuguese have different perceptions of their health status from those of most other European peoples. In a recent survey, only 43% of Portuguese people aged 16 years and over perceived their health status as good or very good, well below the 65% average of the 28 European Union member states, and lower still than the 75% of people in Iceland, Norway and Switzerland, for example.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hence, the results of the current study are highly encouraging. However, it should be borne in mind that the population involved was relatively small. Only 81 of the 163 patients (49.7%) were eligible for the analysis. Nineteen patients (12% of surgical survivors) had died one year after surgery and 58 failed to complete the questionnaire at one or more of the time points, a consequence of the retrospective nature of the study. Naturally, this considerably weakens its conclusions.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a much larger cohort of 2005 patients in Rennes, France, Langanay et al.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> reported functional improvement in 90% of cases and a median survival of 7.1 years. Furthermore, Salsano et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> reported that expectation and quality of life after aortic valve replacement, even in patients over 85 years of age, match those of the contemporary general population. However, quality of life may be impaired after SAVR with stented bioprostheses in the presence of patient-prosthesis mismatch (PPM), although only if it is severe.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">6,7</span></a> Unfortunately, there is no information on this point in the paper by Bento et al.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Nevertheless, their study revealed other important findings, which were pointed out by the authors. Perioperative mortality (3.1%) and morbidity, including stroke (1.2%) and pacemaker implantation (1.2%), were low, which is even more remarkable considering that the mean logistic EuroSCORE in the sample was 10.7±5.1% (although these days the use of this score is questionable). Even lower mortality has been reported,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> and the authors acknowledge that it has decreased in recent times, in their experience as in others’.</p><p id="par0035" class="elsevierStylePara elsevierViewall">It is thus clear that in-hospital mortality and morbidity associated with SAVR in the elderly patient with AS are nowadays low. Hence, age alone is not an acceptable reason to deny these patients conventional surgery, which remains the gold standard treatment for AS, and only a relatively small proportion of patients are in fact inoperable or too high risk. To further improve outcomes (for which there is certainly scope), surgeons should strive to identify modifiable predictors of perioperative mortality in SAVR.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This is another important point to add to the ongoing discussion, in Portugal as elsewhere, about extending the indication for transcatheter aortic valve implantation (TAVI) to all elderly patients, and to more younger individuals. Such indications have often been justified by less good results of surgery in the elderly reported in non-contemporaneous series, and have been partially included in the most recent guidelines, in my view in a premature and unjustified manner, and applied to the extreme in some parts of the world. For example, we are told that in Germany, patients over 70 years of age are now rarely referred or accepted for surgery, but instead go directly to TAVI. <span class="elsevierStyleSmallCaps">I</span> am unaware of any study that has demonstrated the long-term superiority (even non-inferiority) of TAVI over surgery in such patients, especially concerning bioprosthetic valve durability. Reports of early failure of these valves are not uncommon.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">10,11</span></a> It is, however, important to recognize that similar improvement of quality of life has been demonstrated after TAVI.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Naturally, in less economically-developed countries such as Portugal, cost constraints have helped to dampen the enthusiasm for TAVI.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSmallCaps">I</span> do not question that a percutaneous approach has some advantages, including the better hemodynamic properties of the smaller valves, and even accept that, in the future, it may become the procedure of choice for a wider range of patients. Nonetheless, until then, the medical fraternity, patients, and society in general can rest assured that SAVR remains an excellent option in the treatment of patients with severe symptomatic AS, with the added advantage of the proven long-term durability of the bioprosthetic valves used in surgery, especially in the elderly.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Still, there are other alternatives. Recently, Shrestha et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> in Hanover reported the use of rapid-deployment sutureless valves in octogenarians, with 0% hospital mortality or stroke. These valves were developed partly as a surgical response to TAVI, with comparable hemodynamic properties to percutaneous valves (significant PPM is extremely rare with sutureless valves) and an expected durability similar to that of conventional valves. They may thus be particularly useful in these patients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Evidently, the future is not yet here!</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The prevalence of aortic stenosis in the elderly in Iceland and predictions for the coming decades: the AGES-Reykjavík study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 7 | 14 |
| 2024 October | 33 | 32 | 65 |
| 2024 September | 37 | 26 | 63 |
| 2024 August | 31 | 26 | 57 |
| 2024 July | 28 | 26 | 54 |
| 2024 June | 21 | 28 | 49 |
| 2024 May | 24 | 17 | 41 |
| 2024 April | 27 | 24 | 51 |
| 2024 March | 29 | 20 | 49 |
| 2024 February | 24 | 18 | 42 |
| 2024 January | 27 | 24 | 51 |
| 2023 December | 29 | 25 | 54 |
| 2023 November | 46 | 32 | 78 |
| 2023 October | 37 | 12 | 49 |
| 2023 September | 48 | 18 | 66 |
| 2023 August | 28 | 24 | 52 |
| 2023 July | 26 | 17 | 43 |
| 2023 June | 23 | 13 | 36 |
| 2023 May | 34 | 27 | 61 |
| 2023 April | 19 | 8 | 27 |
| 2023 March | 56 | 26 | 82 |
| 2023 February | 39 | 17 | 56 |
| 2023 January | 21 | 17 | 38 |
| 2022 December | 33 | 26 | 59 |
| 2022 November | 41 | 33 | 74 |
| 2022 October | 26 | 20 | 46 |
| 2022 September | 25 | 43 | 68 |
| 2022 August | 25 | 24 | 49 |
| 2022 July | 26 | 41 | 67 |
| 2022 June | 21 | 25 | 46 |
| 2022 May | 22 | 32 | 54 |
| 2022 April | 26 | 32 | 58 |
| 2022 March | 29 | 48 | 77 |
| 2022 February | 29 | 41 | 70 |
| 2022 January | 30 | 28 | 58 |
| 2021 December | 24 | 26 | 50 |
| 2021 November | 23 | 32 | 55 |
| 2021 October | 34 | 40 | 74 |
| 2021 September | 14 | 23 | 37 |
| 2021 August | 17 | 29 | 46 |
| 2021 July | 19 | 21 | 40 |
| 2021 June | 18 | 22 | 40 |
| 2021 May | 23 | 34 | 57 |
| 2021 April | 45 | 93 | 138 |
| 2021 March | 31 | 20 | 51 |
| 2021 February | 43 | 21 | 64 |
| 2021 January | 39 | 15 | 54 |
| 2020 December | 22 | 18 | 40 |
| 2020 November | 23 | 15 | 38 |
| 2020 October | 27 | 12 | 39 |
| 2020 September | 32 | 11 | 43 |
| 2020 August | 10 | 5 | 15 |
| 2020 July | 17 | 13 | 30 |
| 2020 June | 15 | 19 | 34 |
| 2020 May | 18 | 8 | 26 |
| 2020 April | 13 | 5 | 18 |
| 2020 March | 17 | 14 | 31 |
| 2020 February | 27 | 22 | 49 |
| 2020 January | 18 | 9 | 27 |
| 2019 December | 20 | 3 | 23 |
| 2019 November | 7 | 7 | 14 |
| 2019 October | 8 | 3 | 11 |
| 2019 September | 18 | 11 | 29 |
| 2019 August | 10 | 3 | 13 |
| 2019 July | 11 | 10 | 21 |
| 2019 June | 24 | 31 | 55 |
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