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Open-heart surgery in octogenarians
L H Edmunds1, L W Stephenson, R N Edie
1Department of Surgery, School of Medicine, University of Pennsylvania, Philadelphia 19104.
Insights
Open-heart operations can be effective for selected octogenarians with severe cardiac symptoms. While early mortality exists, long-term survival is promising, with most survivors experiencing improved functional status.
Area of Science:
- Cardiology
- Cardiac Surgery
- Geriatric Medicine
Background:
- Open-heart surgery in octogenarians (patients 80 years and older) presents unique challenges due to age-related comorbidities.
- Historically, advanced age has been a contraindication for complex cardiac procedures, leading to undertreatment of severe cardiac conditions in this population.
Purpose of the Study:
- To evaluate the safety and efficacy of open-heart operations in octogenarian patients.
- To identify preoperative factors associated with early mortality and long-term survival.
- To assess the functional outcomes and quality of life after cardiac surgery in this elderly cohort.
Main Methods:
- A retrospective review of 100 consecutive octogenarian patients undergoing open-heart operations between July 1976 and May 1987.
- Analysis of patient demographics, cardiac diagnoses (aortic valvular disease, coronary artery disease, mitral valvular disease), New York Heart Association (NYHA) functional class, and indications for surgery.
- Evaluation of early postoperative outcomes (mortality, complications) and long-term survival, including functional status at follow-up.
Main Results:
- Twenty-nine patients (29%) died within 90 days of operation. Preoperative factors associated with early death included NYHA Class IV disease, previous myocardial infarction, cachexia, and emergency operation.
- Forty-three patients had no complications other than atrial arrhythmias and were discharged in a mean of 11.5 days.
- Among survivors, common serious complications included low cardiac output, myocardial infarction, bleeding requiring reoperation, renal insufficiency, pneumonia, and prolonged intubation.
- Long-term actuarial survival was predicted at 59% at three years and 54% at five years.
- Of the 54 surviving patients, 53 had improved functional status (NYHA Class I or II).
Conclusions:
- Open-heart surgery is a viable therapeutic option for carefully selected octogenarian patients with severe, unmanageable cardiac symptoms.
- Despite significant early risks, a substantial proportion of octogenarian survivors experience long-term benefit and improved functional capacity.
- Risk stratification and patient selection are crucial for optimizing outcomes in this elderly surgical population.
Abstract:
One hundred consecutive patients 80 years of age or older consented to and subsequently underwent open-heart operations at our institution between July 1976 and May 1987. Fifty of the patients had aortic valvular disease (28 with coexisting coronary artery disease), and 41 had isolated coronary artery disease. Eight patients had mitral valvular disease, and one had a dissecting aortic aneurysm. Ninety had Class IV disease that was functional, ischemic, or both. The most compelling indications for operation in 85 patients were unstable or postinfarction angina, syncope, acute pulmonary edema, or cardiogenic shock. Twenty-nine patients died soon after operation (within 90 days). New York Heart Association Class IV disease, previous myocardial infarction, cachexia, and emergency operation were preoperative variables associated with early death. Forty-three patients had no complications except for atrial arrhythmias and were discharged from the hospital a mean (+/- SD) of 11.5 +/- 3.7 days after operation. Low cardiac output, acute myocardial infarction, reoperation for bleeding, renal insufficiency, pneumonia, and prolonged endotracheal intubation were the most common serious postoperative complications. Twenty-eight patients who survived postoperative complications were discharged 24.9 +/- 19.6 days after operation. Seventeen patients died 2 to 104 months after discharge from the hospital. Actuarial calculation predicts the survival of 59 percent of patients at three years and 54 percent at five years. Of the 54 patients still alive at this writing, 53 have disease within New York Heart Association and Canadian Cardiovascular Society Classes I or II. For selected octogenarians with unmanageable cardiac symptoms, operation may be an effective therapeutic option.