Advanced age: a contraindication for triple-valve surgery?

With the changing age structure of the population, cardiothoracic surgeons must deal with an increasing number of patients suffering from degenerative valve disease. Septuagenarians with triple valve disease may be refused surgery due to a potentially high perioperative risk related to co-morbidities. The study aim was to elucidate the indications and compare outcome, with a focus on age-related mortality and morbidity.

Between December 1996 and July 2010, a total of 90 consecutive patients (45 males, 45 females; mean age 68 +/- 9 years; logistic EuroSCORE 21 +/- 16%) underwent triple-valve surgery at Hannover Medical School. Of these patients, 70% had degenerative disease, 19% endocarditis, and 11% a rheumatic cause, while 24% underwent cardiac redo-surgery. For further analysis, the cohort was divided into two groups according to age: < or = 70 years (n=44) and >70 years (n=46). The follow up was performed according to current guidelines for reporting mortality and morbidity after cardiac valve interventions, including a quality of life assessment (Minnesota Living With Heart Failure Questionnaire; MLHFQ).

Mortality among the patients was 16%, 24%, and 26% at 30, 60, and 90 days, respectively. The one-year survival was 69% for the whole cohort, and no difference was seen between the age groups. Follow up (mean 46 months) was complete in 96% of all patients who survived at least three months (n=67). Valve-related morbidity was low in both groups, with predominantly a recurrence of tricuspid insufficiency. The MLHFQ score was similar in both groups.

Triple-valve surgery is associated with a high perioperative risk. However, the acceptance of elderly patients for this surgery is not associated with a higher mortality or valve-related morbidity. The patients' quality of life was acceptable during follow up, and not affected by age. Hence, the refusal of surgery should depend not on old age alone but rather on an individualized assessment of the patient.