Cardiac surgery in nonagenarians and centenarians

Nonagenarians and centenarians are a rapidly growing segment of the population. No previous study has used a national database to compare outcomes in these patients to those of other groups undergoing cardiac surgical procedures.

The Society of Thoracic Surgeons National Database was used to review retrospectively 662,033 patients (5 patients more than 100 years of age; 1,092 patients 90 to 99 years; 59,576 patients 80 to 89 years; and 621,360 patients 50 to 79 years of age) who underwent cardiac surgical procedures from 1997 through 2000. These included 575,389 patients who had undergone coronary artery bypass grafting (CABG) only; 56,915 patients with CABG and concomitant mitral or aortic valve replacement or repair (CABG+VALVE); and 49,729 patients with mitral or aortic valve repair or replacement only (VALVE-only). A multivariate logistic regression model was developed to examine predictors of operative mortality in patients more than 90 years of age.

For CABG-only patients, operative mortality was 11.8% for patients more than 90 years of age, 7.1% for those 80 to 89 years, and 2.8% for those 50 to 79 years. The incidence of renal failure and prolonged ventilation was highest among patients more than 90 years of age (9.2% and 12.2%), compared with those 80 to 89 years (7.7% and 10.5%) or 50 to 79 years (3.5% and 6.0%). For VALVE-only patients and CABG+VALVE patients operative mortality for those more than 90 years of age was 11.4% and 12.0%, respectively, compared with 8.3% and 11.5% for those 80 to 89 years and 4.3% and 7.6% for those 50 to 79 years. The major preoperative risk factors for operative mortality among patients more than 90 years of age undergoing isolated CABG were as follows (C-index, 0.68): emergent/salvage: odds ratio, 2.26; 95% confidence interval, 1.38-3.69; preoperative intraaortic balloon pump: odds ratio, 2.79; 95% confidence interval, 1.47-5.32; renal failure: odds ratio, 2.08; 95% confidence interval, 1.12-3.86; peripheral vascular disease or cerebrovascular vascular disease: odds ratio, 1.39, 95% confidence interval, 0.96-2.02; mitral insufficiency: odds ratio, 1.50; 95% confidence interval, 0.93-2.41. Approximately 57% of the nonagenarians and centenarians lacked any of the first four risk factors and had an operative mortality of 7.2%.

Operative mortality and complication rates associated with cardiac surgical procedures are highest for nonagenarians and centenarians. But with careful patient selection, a majority of these patients have a lower risk of CABG-related mortality approaching that of younger patients.