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Operative and middle-term results of cardiac surgery in nonagenarians: a bridge toward routine practice
Giuseppe Speziale1, Giuseppe Nasso, Maria Cristina Barattoni
1Gruppo Villa Maria Hospitals of Care and Research, Bari, Italy.
Insights
Cardiac surgery in nonagenarians (patients over 90) is feasible, offering functional improvement despite high complication and mortality rates. Early, elective procedures with careful patient selection improve outcomes.
Area of Science:
- Cardiology
- Geriatric Medicine
- Thoracic Surgery
Background:
- Age over 90 is often a contraindication for cardiac surgery.
- Nonagenarians represent a growing patient population with complex clinical needs.
- Analysis of surgical outcomes in this demographic is crucial for decision-making.
Purpose of the Study:
- To analyze the operative and 5-year results of cardiac surgery in patients aged 90 years and older.
- To provide data to inform the complex decision-making process for nonagenarian cardiac surgery.
- To contribute to the development of guidelines for cardiac operations in the very elderly.
Main Methods:
- Retrospective review of 127 patients aged >=90 years undergoing cardiac surgery (1998-2008).
- Kaplan-Meier survival analysis and multiple logistic regression.
- Inclusion of valvular surgery, coronary artery bypass grafting, and combined procedures.
Main Results:
- Mean age was 92 years; mean logistic EuroSCORE was 21.3%.
- Operative mortality was 13.4%; 42.5% experienced postoperative complications.
- Nonelective priority predicted a complicated postoperative course and operative mortality.
Conclusions:
- Cardiac surgery in nonagenarians can lead to functional improvement but carries significant operative and follow-up mortality.
- Appropriate patient selection, earlier intervention, and elective surgery are recommended.
- Outcomes suggest that carefully selected nonagenarians can benefit from cardiac operations.
Background:
Age >90 years represents in many centers an absolute contraindication to cardiac surgery. Nonagenarians are a rapidly growing subset of the population posing an expanding clinical problem. To provide helpful information in regard to this complex decision, we analyzed the operative and 5-year results of coronary and valvular surgical procedures in these patients.
Methods And Results:
We retrospectively reviewed 127 patients aged >or=90 years who underwent cardiac surgery within our hospital group in the period 1998 to 2008. Kaplan-Meier and multiple logistic regression analyses were performed. A longer follow-up than most published studies and the largest series published thus far are presented. Mean age was 92 years (range, 90 to 103 years). Mean logistic EuroSCORE was 21.3+/-6.1. Sixty patients had valvular surgery (including 11 valve repairs), 49 patients had coronary artery bypass grafting, and 18 had valvular plus coronary artery bypass grafting surgery (55 left mammary artery grafts implanted). Forty-five patients (35.4%) were operated on nonelectively. Operative mortality was 13.4% (17 cases). Fifty-four patients (42.5%) had a complicated postoperative course. There were no statistically significant differences in the rate and type of complications between patient strata on the basis of type of surgery performed. Nonelective priority predicted a complicated postoperative course. Predictors of operative mortality were nonelective priority and previous myocardial infarction. Kaplan-Meier survival estimates at 5 years were comparable between patient groups on the basis of procedure performed.
Conclusions:
Although the rate of postoperative complications remains high, cardiac surgery in nonagenarians can achieve functional improvement at the price of considerable operative and follow-up mortality rates. Cardiac operations in these very elderly subjects are supported if appropriate selection is made and if the operation is performed earlier and electively. Our results should contribute to the development of guidelines for cardiac operations in nonagenarians.
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