Relationship Between Aortic Valve Replacement and Old Age

Many factors can explain the most important increase of human life expectancy during the XXth century: better socioeconomic conditions, improved working conditions, development of preventive measures, less alcoholism, appearance of antibiotics, advances in medical practices, etc... At present, the fastest growing age group in western countries is people >80 years old; they will represent 9–10.5% of the population in those countries in 2050. Today, life expectancy at 80 years is, on average, 10 years for a woman and 7 years for a man in western countries (Health at a glance OECD indicators). This population is at high risk of cardiovascular disease (Assey, 1993). More specifically, aortic stenosis (AS) is the most frequent valvulopathy in adults ≥ 75 years old, being present in as many 4.6% (Nkomo et al., 2006). Progress made in anesthesia, surgery and intensive care explain why doctors, surgeons and cardiologists are less-and-less reluctant to propose aortic valve replacement (AVR) for older-and-older patients. However, for this very specific population, many questions remain to be answered before such surgery can be undertaken: What is the spontaneous evolution of the disease? Is there a therapeutic option other than surgery? What are the postoperative results in terms of morbidity and mortality? Will surgical treatment relieve the symptoms and improve the quality of life (QOL) at intermediate and long term? What are the complications and constraints associated with the prosthesis? Are those results universal? Will my patient become frail or disabled after surgery?

role of aging itself on organ decline is difficult to demonstrate.Indeed, a study on elderly individuals in very good health (old senior athletes) often had physiological cardiovascular system performances quite close to those of younger athletes but that is not the case for their osteoarticular system!Thus, the descriptions of so-called changes 'linked' to aging (i.e., frequent or typical of the old-old), be they histological or physiological performances, are the means of populations heterogeneous in terms of life style, exposures to personal or environmental risk factors and pathologies.When an attempt was made to show the same 'age-linked' changes exclusively in healthy aged or physically fit subjects, none was found (Somme et al., 2009).Hence, defining the slope of line 1 for individuals is difficult (Fig. 1), as it depends, organ by organ, on personal and environmental factors.Nevertheless, it could be useful to predict vulnerability, like an old person's response to treatment or knowing his/her level of physical activity, which is probably a better marker of physiological cardiovascular aging than chronological age.It is widely accepted that, for the young subject, cardiac function is the main parameter conditioning the maximal stress level, whereas for the elderly subject, it seems more often to be limited by respiratory function (Chan & Welsch, 1998).Finally, physiological aging can be represented as the functional state of adaptation mechanisms (or reserves) that are overwhelmed during stress or effort.These physiological particularities render the elderly more susceptible to acute diseases.This frailty should not limit access to intensive care for old patients, but should rather plead in favor of their adapted and early management.

1+2+3
1+2 1+3 1 Fig. 1.Organ decline (regardless of the organ) due to aging is represented by slope 1.Two types of events are able to shift this organ under the threshold (dashed line) of organ insufficiency: a chronic (according to slope 2) or acute disease (the steepest slope 3).Adapted from 1+2+3: how to be effective in geriatrics?(Bouchon, 1984)

Threshold of old age
In practice, old age is defined 2 ways: that set by a chronological age and a dynamic approach taking into consideration the evolution of the health of the population.
The fixed chronological age definition (around 65-75 years for young-old; between 75-80 and 85-90 for the old-old, and >85-90 for the oldest-old) is the most extensively used in the medical literature.It has the advantages of enabling comparisons between published historical data and not encouraging interpretation.However, it does not account for the evolution of life expectancy at 60 years and, even less, its evolution without handicap(s).Indeed, life expectancy for a 60-year-old man in France increased from 15.4 to 21.7 years between 1950 and 2010.This prolongation obviously has an impact on the premonitory usefulness of aggressive therapies, like cardiac surgery after 60 years during that interval.
A dynamic definition of the old-age threshold can take those aspects into consideration.
Several can be proposed but one seems readily accessible: survival at life expectancy at birth (Table 1).If we accept this definition, the percentage of 'aged' individuals (so defined) in France did not increase between 1950 (~11%) and 2010 (~9%), because life expectancy rose more quickly than the number of aged persons.Age has always been identified as a major risk factor for mortality after cardiac surgery (Roques et al., 2003;Shroyer et al., 2003), but the mean age of operated patients is rising.Indeed, surgery on octogenarians is performed daily in western countries.Are there some limits for age and cardiac surgery?Florath et al. (2010) identified >84 years as an important independent risk factor for mortality 6 months after AVR for octogenarians.However, some publications indicated that surgeons seem less-and-less reluctant to operate on nonagenarians (Edwards et al., 2003;Praschker et al., 2006).During the 1980s, the age limit for cardiac surgery was progressively increased >80 years without drama considering outcomes (Edmunds et al., 1988).Should the story repeat itself for nonagenarians or even centenarians in the future?
Concerning the intermediate-term prognosis, crude results were good (Table 3), particularly compared with the natural course of SAS (Schwarz et al., 1982).At 5 years, survival ranged from 52% (Florath et al., 2010) to 82% (Stoica et al., 2006) for populations whose mean age at surgery was 83 years.Some authors reported a 30% 10-year survival rate with a Kaplan-Meier median-survival estimate of 7.4 years (Thourani et al., 2008).Many studies also showed that, compared to an age-and sex-matched population, prognoses were comparable in different western countries: France (Maillet et al., 2009) and Sweden (Sjögren & Thulin, 2004).Stoica et al. (2006) found that the standardized mortality ratio (observed postAVR mortality/observed mortality for matched population) was 45.6% in favor of the surgical population in the UK, with 5-year survival rates of 82.1% for the surgical group versus 55.9% for a general population with the same age-sex distribution (p<0.001).The most common causes of late death were dominated by malignancy (20.5%), non-valve related cardiac failure (18.5%), valve-related stroke (18%) and pneumonia (11%) in a cohort of 1100 elderly patients included in the UK Heart Valve Registry.It must be kept in mind that onethird of the patients with malignancy died within 18 months after cardiac surgery.That observation emphasizes the improved preoperative cancer screening of elderly patients before AVR (Asimakopoulos et al., 1997).

Impact of AVR on QOL among octogenarians
Improving QOL is one of the most important aims of AVR especially for octogenarians.Authors of retrospective studies concluded that QOL was good after AVR at intermediate term but, in many studies, preoperative QOL had not been evaluated (Maillet et al., 2009;Sundt et al., 2000).Using the medical outcomes study Short Form-36 (SF-36), Sundt et al. (2000) showed that the QOL of a surgical population with a mean age of 84 years was comparable to that predicted for the general population >75 years old.Olsson et al. (1996), prospectively compared QOL evolution for 2 groups of patients referred for isolated AVR; 30 octogenarians vs 30 patients 65-75 years old.At 1-year postAVR, octogenarians, despite their more compromised preoperative status, had markedly regressed symptoms, and their physical abilities and general well-being were of a similar magnitude to those of the younger patients.Those improvements appeared as of 3 months.With mean follow-up of 8.3±1.9 years, Sjögren & Thulin (2004) found long-term postoperative QOL to be comparable to that of an age-matched population.In addition, Huber et al. (2007) showed that 97% of the survivors lived in their own homes.Finally, 81% had no or few self-perceived restrictions in their daily activities (Kohl et al., 2007), 93% felt much better after the operation and 81% of octogenarians had few disabilities in daily activities (Huber et al., 2007).Also, QOL was not affected by the constraints entailed by treatment(s) associated with the type of prosthesis.Indeed, after postoperative month 3, >90% who had received a bioprosthesis were in sinus rhythm and were taking only low-dose aspirin.Vicchio et al. (2008) compared the QOL of 62 octogenarians with bioprosthetic valves vs 98 with mechanical valves during a mean follow-up of 3.4 ± 2.8 years and found that the prosthesis type had no impact on their QOL.

Limitations of those studies
However, all those studies had some limitations.Indeed, all of them were retrospective except for Olsson et al. (1996).Only those by Asimakopoulos et al. (1997) and Stoica et al. (2007), representing UK registry results, were multicenter investigations.Very few studies specifically and exclusively evaluated the outcomes of isolated AVR for SAS (Asimakopoulos et al., 1997;Leonteyv et al., 2009;Thourani et al., 2008).Some studies mixed AVR with CABG or other operations, whereas others mixed AVR for SAS or severe aortic insufficiency (i.e., Stoica et al., 2006;Sundt et al., 2000).The sample sizes also varied widely from one study to another: ranging from 24 (Bashour et al., 1990) to 1100 patients (Asimakopoulos et al., 1997).Lastly, those studies retrospectively covered long periods, lasting 5 (Sundt et al., 2000) to 16 years (Elayda et al., 1993).

Decision-making
Those results must be interpreted carefully, keeping in mind that octogenarians with SAS referred to a surgeon are highly selected, as that decision-making is complex.Bouma et al. (1999) showed that only 59% of the patients who should have had an AVR according to international guidelines (Bonow et al., 2006) were actually offered surgical treatment.They were mainly symptomatic, >80 years old and had high transaortic valve gradients.On the other hand, Iung et al. (2005) observed that a decision not to operate was made for 33% of SAS patients.Multivariate analyses retained left ventricular ejection fraction and age (OR 1.84 for 80-85 year olds, OR = 3.38 for those ≥85 years) as being significantly and independently associated with the decision not to operate.Neurological dysfunction was the only comorbidity associated with that decision.During 2007, Freed et al. (2007) retrospectively studied the outcomes of SAS patients referred to their echocardiography laboratory.Among the 106 SAS patients, only 31% underwent surgery.The most common reasons symptomatic SAS patients did not undergo AVR were: their symptoms were thought to be unrelated to AS, too high surgical risk and/or patients refused (Freed et al., 2010).

Promises of a new approach: TAVI
In light of increasing life expectancy, the high incidence of AS in the elderly, the fact that many SAS patients are denied surgery, and because of improved endovascular technology, a new therapeutic approach using new devices is rapidly evolving, becoming widespread and would revolutionize AS treatment: TAVI.After successful animal experimentation, Cribier et al. (2002) successfully performed the first human implantation of a balloon-expandable aortic valve prosthesis.Two TAVI devices are now under postmarketing surveillance in Europe: the balloon expandable Edwards SAPIEN™ prosthesis (Edwards Life-Sciences, CA) and the self-expandable CoreValve Revalving prosthesis™ (Medtronic Inc, MN).Two approaches are used: anterograde with transapical (TA) access or retrograde with transfemoral (TF) access.Two videos illustrating the TAVI procedures are available at www.NEJM.com.

Specific TAVI-related complications
The results of all studies demonstrated that TAVI can be implanted safely, with intraprocedural mortality now a mean of 1% (Webb et al., 2009;Tamburino et al., 2011).Implantation failure is becoming rare, with the successful implantation rate ≥98% in the most recent studies (Bleiziffer et al., 2009;Tamburino et al., 2011).Changing the surgical approach during the intervention has also become very rare.Coronary obstruction rarely complicates valve implantation (<1%).Valve positioning is challenging, particularly when the distance between the annulus and the coronary artery is short, as the native valve may be pushed against the coronary ostium ( Lefèvre et al., 2011).Some complications seem to be related to the access route used.With TF access, major vascular complications occur in 6.8-11.7% of the cases (Bleiziffer et al., 2009;Webb et al., 2009).However, technological advances have permitted sheath-size reduction from 24F to 18F, thereby allowing a percutaneous procedure with locoregional anesthesia and fewer vascular injuries.Improved screening, case selection and experience should surely lower the vascular injury rate further.Second, 10% of the patients suffer clinical strokes (Grube et al. 2007).In a recent diffusionweighted, magnetic resonance imaging study on TAVI patients, the risk of diffuse cerebral embolism was 72.7%, with patients frequently having multiple new but clinically silent brain lesions.Although cerebral embolism was extremely common in the TF-TAVI cohort, the clinical stroke rate was 3.6% (Ghanem et al., 2010).It was suggested that TA-TAVI might be associated with fewer cerebral embolic events.However, results are controversial and further studies with larger cohorts are needed.Two mechanisms are involved: aortic atheroemboli and valvular calcific emboli.The elderly are at particularly high risk for perioperative neurological events because of advanced cerebral ischemic disease present preoperatively (Wang et al., 2010).For both accesses, annulus measurement is challenging.Indeed, no gold standard currently exists for aortic annular measurement but transesophageal echocardiography provides accurate data to guide valve sizing before implantation (Messika-Zeitoun et al., 2010).Paravalvular aortic regurgitation is common after TAVI but remains stable at late follow-up (Webb et al., 2009).In the PARTNER study, moderate-or-severe perivalvular leakage was present in 11.8% of the patients at 30 days and 10.5% at 1 year (Leon et al., 2010).However, postprocedural paravalvular aortic regurgitation ≥2+ (HR 3.79) mainly affected later outcomes between 30 days and 1 year (Tamburino et al., 2011).Conduction abnormalities are frequent after TAVI (Roten et al., 2010).The occurrence of atrioventricular block requiring pacemaker insertion at 30 days seems lower with the Edwards SAPIEN™ (<5%) (Lefèvre et al., 2011) than the CoreValve™ (up to 30%) (Jilaihawi et al., 2009).One possible explanation could be that the CoreValve™ was designed to be seated lower than the SAPIEN™ valve and might compress the underlying conduction system.However, based on a cohort of 67 patients (41 received CoreValve™ and 26 SAPIEN™), Roten et al. showed that the sole independent risk factor for complete atrioventricular block after TAVI was preexisting right bundle branch block (Roten et al., 2010).Because prosthesis sizing is a critical issue, to avoid perivalvular leakage and valve migration, "over sizing" of TAVI might have increased the risk of atrioventricular block (Bleiziffer et al., 2009).Further investigations are mandatory.
The results of some studies showed that the postoperative and short-term outcomes were worse for patients treated with TA than TF access, because the former were more severely ill and had more severe comorbidities.The Logistic EuroSCORE predicted risk was significantly higher for TA than TF, respectively: 35% vs 25% (p=0.01), as did STS-PROM 10.3% vs 8.7% (Webb et al., 2009).In-hospital mortality was 8% for the TF group vs 27% for TA group, with respective 1-year survival rates of 74±11% vs 60±13% (Al-attar et al., 2009).At 1 year, the European PARTNER study results were comparable (Lefèvre et al., 2011).

Risk assessment and patient selection
TAVI development has highlighted the complexity of risk assessment and patient selection.At present, TAVI is indicated only for SAS patients ineligible for conventional AVR, but the definition of "ineligible" remains vague.TAVI was initially designed to treat old-old patients, mean age 81-86 years (Bleiziffer et al., 2009;Tamburino et al., 2011), with high Logistic EuroSCORE predicted risk ≥20%, mean range 22-29% (Grube et al., 2007;Webb et al., 2009) or STS-PROM score ≥10%, mean range 16-23% (Al-attar et al., 2009;Bleiziffer et al., 2009) or with contraindication(s) for surgery.Logistic EuroSCORE and STS-PROM scores are increasingly being used to estimate operative mortality based on cardiac and extracardiac factors.The STS-PROM score appears to be more reliable than the EuroSCORE for predicting outcomes of high-risk AVR patients.However, STS-PROM tends to underestimate mortality (Dewey et al., 2007).A meta-analysis showed EuroSCORE to have low discrimination ability for valve surgery and it slightly over predicted risk (Parolari et al., 2010), particularly for octogenarians referred for AVR (Leontyev et al., 2009).Both scores share the same limitations: predictive ability is limited for high-risk patients, who represented only a small proportion of the population used to derive them.They do not take into account the surgical results in a given institution, relationship between volume and mortality, and the impact of progress concerning surgical techniques, cardiopulmonary bypass, anesthesia and intensive care.The scores also fail to evaluate fully the high-risk patient because they do not integrate a very important element: clinical judgment.Indeed, many factors that negatively influence prognosis are not considered: cirrhosis, impact of body mass index, chest irradiation, chest deformation, multivalve surgery, porcelain aorta, previous CABG and vascular tortuosity for TAVI.It is estimated that neither the Logistic EuroSCORE nor STS-PROM would have classed approximately one-quarter of the patients at high risk and yet they were refused surgery because of such factors (Webb et al., 2009).For the specific SAS octogenarian population, it seems that the development of a new specific scoring classification is necessary (Florath et al., 2010), especially one including demographic variables, such as nutritional status, disability, dementia and frailty.

Unanswered questions concerning TAVI
TAVI is not suitable for all patients ineligible for conventional AVR and patients referred for TAVI are also highly selected.In a cohort of 469 SAS patients referred for participation in a TAVI trial, 362 (77.1%) patients did not meet the inclusion/exclusion criteria.The main exclusion criteria were low STS-PROM score <10% (72 patients), peripheral vascular or aorta disease (58 patients), aortic valve area >0.8 cm 2 (54 patients), significant coronary artery disease (43 patients) and renal failure (25 patients).Among those 362 patients, 75 (20.7%)had 2 exclusion criteria and 26 (7.1%) had 3 exclusion criteria.Eighty-eight patients underwent surgery and 274 were treated medically, 177 of whom had BAV.At 2 years, the mortality rate was significantly lower for the surgical group vs the medically treated group, respectively, 28.1% vs 53.4% (p<0.001)(Ben-Dor et al., 2010).Another TAVI limitation is also the high incidence of severe coronary artery disease among elderly SAS patients that also influences prognosis and requires specific treatment.Long-term durability of TAVI must now be demonstrated.TAVI provides acceptable hemodynamic results up to 3 years (Webb et al., 2009).At present, outcomes reflect comorbidities rather than cardiac status (Tamburino et al., 2011).Patient selection is a major concern for long-term durability evaluation of TAVI.Future studies should include patients with expected life expectancy unrelated to cardiac disease >5 years.At 2 years, survival was 60.9% in the study by Webb et al. (2009); what will the sample size be at 5 years?With the learning curve, technological improvement and better patient selection, TAVIrelated morbidity should decline, particularly concerning vascular injuries, strokes, pacemaker implantation and perivalvular leakage.The next step for TAVI for SAS management should be its direct comparison with surgery for high-risk patients without contraindication(s) for surgery, and then for intermediateand low-risk patients.Historical comparisons, case-control studies, propensity-score matching (Johansson et al., 2011) or comparison with spontaneous evolution are not able to answer these questions adequately.Multicenter, randomized-controlled trials should answer them (prognosis, durability, specific morbidity, etc…) in few years, thereby allowing the widespread development of this very promising technique.

Frailty and geriatric evaluation of octogenarians for SAS management 4.1 Frailty
To evaluate better an individual's situation on which the final therapeutic decision generally depends, the concepts of frailty or vulnerability are the themes of several international gerontology publications.We highlight that, at present, no consensual definition of frailty exists (Bergman et al., 2007;Karunananthan et al., 2009).However, the various authors agree that frailty is a state of susceptibility to aggression, which explains that, for a given health event, despite the same management and apparently sufficiently similar health status, the individuals will have very different outcomes.Thus, frailty is always defined as a function of the event that serves as the judgement criterion: falls, loss of autonomy, institutionalization, death… It is also defined by the time at which it is assessed.Therefore, an effective definition over the long term (Province et al., 1995) might not be operative to distinguish individuals in terms of consequences of hospitalization (Gill et al., 2004).Regardless of the definition retained, the authors defined a certain number of common characteristics (Rockwood, 2005): frailty is a continuous state that is not simply present or absent; it is not the consequence of single organ involvement; the clinical manifestations are multiple.It can be recognized clinically, with that identification being considered the threshold of entry into frailty, the occurrence of the negative event marking the end of frailty in relationship to this factor (institutionalization or handicap, for example).The definitions of frailty are multiple (Ferrucci et al., 2004), but the most used are those that refer to the diminished physiological reserves, with a core event being the development of sarcopenia.This type of definition has shown its efficacy to predict the loss of autonomy, institutionalization or death in a cohort of patients with cardiovascular diseases but not initially handicapped and followed for 1 year (Fried et al., 2004).Its effect can be associated with those of a disability and comorbidity, even though none of these 3 dimensions is superimposable or sufficient alone to explain the outcome (Fried et al., 2004).According to those authors' definition (Fried et al., 2004), at least 3 criteria among the following must be satisfied to be qualified as 'fragile': diminished gripping force of the dominant hand, the feeling of fatigue/exhaustion, slower walking speed and nonintentional weight loss.Each of the elements is evaluated according to precise criteria.Such a definition could prove useful to study the long-term outcome of patients after cardiac surgery.In addition, this type of definition conceptually excludes the cognitive, sociofamilial and psychological dimensions of frailty (Fried et al., 2004).To take those dimensions into account, 2 types of solutions are proposed: an inventory of the situations at risk that can be extremely complex and overall clinical judgment, whose pertinence concerning loss of autonomy and death were recently validated (Jones et al., 2005).

Frailty and cardiac surgery
The concept of frailty and its clinical use in surgery in general and, more specifically, cardiac surgery, has recently appeared in the literature.Two recent studies (Afilalo et al., 2010;Lee et al., 2010) documented that frailty increased the risk of complications after cardiac surgery independently of age and included information from standard prognostic scores.Pertinently, those 2 studies are complementary.Indeed, Afilalo et al. (2010) defined frailty as requiring assistance to accomplish at least one essential life activity, a diagnosis known of dementia or limited mobility.Although their definition can be debated on a conceptual level, because it mixes disability and fragility, it has the advantage of being clinically operational.The existence of a frailty phenotype, as defined, was independently associated with mortality (OR 1.8 [95% CI 1.1-3.0]),institutionalization and discharge from that facility (OR 6.3 [95% CI 4.2-9.4])and intermediate-term survival (OR 1.5 [95% CI 1.1-2.2]).Lee et al. (2010) defined frailty more precisely and more sensitively: walking speed tested as a mean time needed to go 5 m during 3 consecutive tries (limited to 6 seconds).Their definition is directly in line with the conceptual frailty-sarcopenia model.In their study, the risk of postoperative morbidity-mortality was multiplied by 3.05 [95% CI 1.23-7.64]for frail patients, even after adjustment for the STS-PROM score.In addition, frailty defined in this way doubled the risk of institutionalization or a prolonged stay there.Finally, in a manner not entirely clear, the risks linked to frailty are greater for women than men.The results of those studies confirmed the findings of others concerning non-cardiac surgery, i.e., that such a definition of frailty is associated with "geriatric syndromes" (Robinson et al., 2009), sarcopenia (Makary et al., 2010) or a more holistic score-based definition (Dasgupta et al., 2009).In all those cases, the frailty phenotype was independently associated with age and other known prognostic factors of higher risk of morbidity and/or mortality.Only authors of rare studies have envisaged frailty's appearance as a surgical consequence.Researchers of a single center study supported that hypothesis and strongly recommended that the appearance of that phenotype should be considered in future outcome investigations because this fragility is linked even more strongly to QOL than self-reported overall assessments of "health status" (Maillet et al., 2009).We would also like to underscore the areas of uncertainty that persist today and that represent as many research projects.Afilalo et al.'s (2010) and Lee et al.'s (2010) examinations of potential relationships between a frailty phenotype and outcomes after cardiac surgery were based on large majorities of patients (>60%) who underwent simple coronary artery bypass surgery.Even though the type of intervention was entered into the model, the phenotype's effect on valve-surgery complications (and even more so for the newer interventional techniques) warrants further clarification.The models currently used in cardiac surgery are mainly based on the frailty-sarcopenia concept.The contributions of other frailty dimensions to explaining outcome (biological, psychological, environmental and social) are also worthy of more detailed exploration.Finally, the available studies focused on subjects who were certainly old (>70 years), but the usefulness of the scores and the thresholds applied undoubtedly need to be adapted for the oldest-old (>85-90 years).

Contribution of geriatric evaluation to AVR decision-making
All of the above underscore the complexity of decision-making and follow-up of the oldestold when AVR becomes necessary, and support an interdisciplinary approach bringing together cardiologists, surgeons, geriatricians, anesthesiologists and intensivists.However, convincing data on the impact of a geriatric approach in this setting are still lacking.The geriatrician is most probably in an ideal position, in terms of professional competence, to detect frailty, but the impact of this identification on the decisions to be made and, even more so, on the outcomes are not yet documented.As we have seen, it is also likely that the consequences of cardiac surgery, beyond its cardiovascular impact, are multidimensional (Maillet et al., 2009).It seems highly probable that an overall approach, like that proposed by geriatricians in another context (Rydwik et al., 2008), would contribute to improving the outcomes of individuals, not only in functional terms but also nutritional, psychological, social and even cognitive aspects.

Adapted rehabilitation
Rehabilitation after cardiac surgery is not less effective in the elderly than young patients (Macchi et al., 2007;Pasquali et al., 2001) and improves the outcome, even though information on the oldest-old are scarce (Pasquali et al., 2001).Indeed, it seems, for the aged patient, that rehabilitation after cardiac surgery should not be postponed and should be prolonged (Macchi et al., 2009).This is especially true for women >80 years who achieve a gain in functional autonomy 1 year after the intervention (Barnett & Halpin, 2003).Some authors recommend particular preoperative precautions, notably respiratory.The preoperative identification of frail patients could also be a pertinent way to select patients likely to benefit the most from specific programs, e.g., early mobilization in the intensive care unit (Needham, 2008).Multidimensional rehabilitation programs also achieved favorable results (Eder et al., 2010;Mazza et al., 2007;Opasich et al., 2010), which, in addition, proved their safety and efficacy in terms of rehabilitation, nursing needs, mobility capability, muscle force, equilibrium and, last but certainly no least, duration of stay.

Conclusion
Surgical AVR for SAS in octogenarians is the treatment of choice and is performed daily, with good intermediate-term results, despite high postoperative morbidity.In the very near future, TAVI should profoundly modify the treatment strategy for SAS.Despite all the improvements since the beginning of cardiac surgery, much progress remains to be achieved in all the steps: improving patient selection, more accurately stratifying the risks, choosing the best treatment, limiting morbidity regardless of the technique used, and proposing a personalized and adapted rehabilitation program.New scoring systems, including specific markers for elderly patients (disability, frailty, etc…), should be developed.A multidisciplinary approach, including surgeons and cardiologists, along with geriatricians, intensivists and rehabilitation specialists, would contribute to achieving all those improvements.The scarcity of scientific literature on the link between age (and particularly old-old age >85 years), outcomes and the frailty-syndrome subset opens vast avenues for future research.

Table 1
. 1950 to 2010: Evolution of life expectancy in France and the aged population

Table 2 .
Postoperative mortality rates after AVR with/without CABG for octogenarians between 1976

Table 3 .
Intermediate-term AVR outcomes of octogenarians