Reply to Kalavrouziotis et al.

We appreciate the comments of Kalavrouziotis et al. [1]. Many reports have shown that the mortality of octogenarians undergoing cardiac surgery compared with that of younger patients is only moderately increased, but their morbidity is clearly higher. Reported mortality for septuagenarians and octogenarians undergoing primary isolated aortic valve replacement (AVR) ranges from 6.6 to 16.7%. Reported operative morbidity including atrial fibrillation in elderly patients (>70 years old) following AVR with or without coronary artery bypass was up to 64–76% [2,3]. In current practice, a significant number of elderly patients with symptomatic aortic stenosis (AS) are turned down for or not even referred for AVR due to unacceptable operative mortality or morbidity. The transapical approach for aortic valve implantation (AVI) is a new innovative approach and has now been performed at several centers in Europe and North America since we reported the first successful off-pump case in man. The transapical AVI program at our institution is approved by the Health Protection Bureau of Canada for compassionate use only in patients with symptomatic AS turned down for conventional AVR by two surgeons and without peripheral arterial access. Patients were declined AVR because of age and associated multiple co-morbidities or specific clinical problems, such as porcelain ascending aorta, end-stage lung disease (severe COPD), or multiple strokes with neurologic dysfunction. We agree that no single scoring system is uniformly accurate in predicting operative mortality and morbidity, particularly in octogenarian patients with multiple co-morbidities. Although the EuroSCORE has been widely used to predict surgical mortality, its accuracy is controversial [4,5]. Variable clinical definitions are largely dependent on institutional specific diagnostic standards, such as diagnosis of pulmonary hypertension, carotid stenosis, pulmonary disease, and etc. These definitions become inaccurate when the screening for these diseases is incomplete or different diagnostic standards are used. This may contribute to the observed variations in the accuracy of the EuroSCORE or other scoring systems in predicting operative risk. In our study, EuroSCORE was not used to determine candidacy for conventional AVR and was reported solely for purposes of a benchmark for comparison. Far more important in this elderly cohort is the clinical evaluation of the individual patient by an experienced surgeon. According to our 6-month and on-going follow-up data, we believe that reducing operative morbidity, rather than mortality, is the major benefit of transapical AVI. Our initial data demonstrated the feasibility of the transapical approach for AVI, and stability of prosthetic function during early follow-up. We would like to emphasize that at present transapical AVI appears a viable alternative for the group of patients who are turned down for conventional AVR. Ongoing evaluation and further development at selected sites are necessary before this new procedure can be applied across the board to other groups of patients. We completely agree that conventional AVR remains, for the present, the gold standard for treatment of patients with symptomatic AS. Even in the elderly patients with multiple co-morbidities, extremely careful selection of patients for this new procedure is crucial.

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