[Is cardiac surgery feasible in heart failure patients older than 80 years?]

Octogenarians affected by chronic heart failure frequently present with multiple comorbidities and a certain degree of intrinsic frailty. These clinical features are associated with an increased operative risk and can nullify the improvements in survival and quality of life that can be obtained with modern surgical approaches. Accurate patient selection is therefore of crucial importance. To this purpose, many scores are available to define the surgical risk, while more efforts should be made to improve our knowledge regarding expected and actual quality of life. Given this highly complex scenario, a comprehensive Heart Team approach is strongly advisable, aimed at tailoring strongly individualized surgical programs. Indeed, in such fragile patients there is often no need to pursue a complete surgical therapy, and optimal results are obtained identifying and treating the culprit pathology, while wisely omitting to treat the unnecessary elements. Moreover, these patients take major advantages from preoperative clinical optimization and a step-by-step delayed approach. Given this premise, modern coronary artery bypass grafting, aortic valve replacement and mitral valve repair/replacement, which are the most frequent procedures in these patients, are feasible and reasonably safe and effective. New technologies are emerging to treat high-risk and inoperable patients, and promise to expand therapeutic frontiers for older chronic heart failure patients; these new devices, however, should never forget the Heart Team approach.