title: Clinical outcome after triple-valve operations in the modern era: are elderly patients at increased surgical risk?
abstract: BACKGROUND
  Despite modern advances in surgical care, triple-valve surgery (TVS) remains a challenge and carries a mortality of 10% to 20%. No validated risk score is available for TVS, and the effect of advanced age is unknown. This study examined our results in the modern era with the aim of identifying perioperative predictors of adverse outcomes.
  
  
  METHODS
  Between 1997 and 2013, 131 patients (mean age, 67.2±13.4 years) underwent TVS at our institution. Sixty-eight patients (51.9%) were aged 70 years and older. The most common etiology for aortic and mitral disease was degenerative (77.1%), rheumatic (10%), and endocarditis or prosthetic-related, or both, in the rest. Tricuspid valve disease was functional in 96%. New York Heart Association functional class III/IV was present in 69.4%, and 24% had had previous cardiac operations. One or more concomitant cardiac procedures were performed in 77 patients (58.8%), including coronary revascularization in 54. All aortic procedures were replacements, 14 patients required a prosthetic root conduit and 7 thoracic aorta replacement. Mitral replacements were used in 55%, repairs in 45%, and 96.2% of tricuspid procedures were repairs. Univariate and multivariate analyses were used to determine predictors of adverse outcomes.
  
  
  RESULTS
  The 30-day and hospital mortality was 10.6% (n=14). Major complications occurred in 70 (53.4%). Univariate analysis identified New York Heart Association functional class III/IV (p=0.04), preoperative renal failure requiring dialysis (p=0.04), urgent operation (p=0.04), intraaortic balloon pump placement (p=0.02), and postoperative low cardiac output (p<0.0001) as predictors for early death. Proximal aortic operations, urgent operation, and New York Heart Association class IV correlated with increased early mortality (p<0.04) in patients aged 70 and older in addition to their decreased overall survival and decreased likelihood of discharge to home. Overall actuarial survival at 1, 5, and 10 years was 84.5%, 75%, and 45%, respectively.
  
  
  CONCLUSIONS
  TVS remains a surgical challenge in the modern era. Despite a trend of increasing age and surgical risk, the early mortality rate and long-term survival remain respectable. Advanced age is associated with increased perioperative risk, but age per se should not be a contraindication for TVS.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky. Electronic address: pagnis@bellsouth.net.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Pagni
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Ganzel
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Ramesh
authors.initials: R
authors.lastname: Singh
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Erle H
authors.initials: EH
authors.lastname: Austin
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Christopher
authors.initials: C
authors.lastname: Mascio
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Matthew L
authors.initials: ML
authors.lastname: Williams
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Phani V
authors.initials: PV
authors.lastname: Akella
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Louisville, Louisville, Kentucky.
authors.forename: Jaimin R
authors.initials: JR
authors.lastname: Trivedi
mesh_terms: D000367:Age Factors; D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications* / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery*; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D014261:Tricuspid Valve / Q000601:surgery*
keywords: 35; CABG; CPB; EF; EuroSCORE; European System for Cardiac Operative Risk Evaluation; HR; ICU; NYHA; New York Heart Association; PAP; SD; TIA; TVS; cardiopulmonary bypass; coronary artery bypass graft; ejection fraction; hazard ratio; intensive care unit; pulmonary artery pressure; standard deviation; transient ischemic attack; triple-valve surgery