Should cardiac surgery be performed in octogenarians?

Clinical Results and Quality of Life after Nonelective Cardiac Surgery in Octogenarians

Background We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery.

Patients and Methods We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model.

Results The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1–39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0–1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30–51) for the elective patients and 42 (35–49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48–60) and 58 (52–60), respectively (p = 0.351).

Conclusion Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.

Transarterial aortic valve replacement with a self expanding stent in pigs

OBJECTIVES

To evaluate the feasibility of percutaneous aortic valve replacement without cardiac arrest in animal experiments.

METHODS

A self expanding nitinol stent, containing pulmonary valves from pigs in its proximal part, was implanted in six pigs (94-118 kg) by means of a 25 French catheter through the left subclavian artery under guidance of fluoroscopy and transoesophageal echocardiography. During stent deployment the original aortic valve was pushed against the aortic wall by the self expanding force of the stent while the new valve was expanded.

RESULTS

It was possible to replace the aortic valve in the beating heart in four pigs (67%) with no complication or relevant drop in blood pressure. The procedure failed in two pigs (33%) due to dysfunction of the catheter device in one case and to problems with correct positioning in the left ventricular outflow tract in the other. After successful stent valve implantation, dopamine was infused in doses of 5 microg/kg/min, 10 microg/kg/min, and 15 microg/kg/min. Cardiac output increased from 4.4 to 8.8 l/min and the mean arterial pressure rose from 79 to 105 mm Hg. The maximum peak to peak pressure gradient across the valve carrying stent reached a maximum of 8 mm Hg under dopamine infusion. All pigs were killed six hours after transvascular aortic valve replacement. The chest was opened, and the left ventricle and the ascending aorta were carefully inspected. There were no signs of malfunction of the implant, of damage of the aortic vessel wall, or of obstruction of the coronary ostia.

CONCLUSIONS

Percutaneous aortic valve replacement with a self expanding nitinol stent in the beating heart is possible. The device was safe under pharmacological stress test. After successful chronic animal experiments, this concept may become a feasible option for treating patients with relevant aortic valve disease but where open heart surgery would be risky.

Cardiac surgery in octogenarians and beyond

Should we do it, is it worthwhile, and who should decide?

Cardiac surgery in Australian octogenarians: 1996-2001

BACKGROUND

The number of octogenarians receiving cardiac surgery is increasing. Concerns regarding the outcomes and significant expense required to provide this service have not been addressed because no prospective medium term outcomes of Australian octogenarians have been published.

METHODS

Prospective analysis was undertaken of octogenarians having cardiac surgery from 1996 to 2001 in three hospitals of moderate case volume (400 patients per year) by: in-hospital audit and data acquisition, 1-year direct patient follow up in rooms, and a final follow up in late 2001 directly with the patient either in rooms or via telephone questionnaire.

RESULTS

Sixty-four patients had cardiac surgery. All patients were severely disabled by symptoms (CCVS: III-IV, NYHA: III-IV) preoperatively, 14% were advised not to proceed with a surgical option but did so. Total operative in-hospital mortality was 6.3% (elective: 0%, urgent: 10.5%, P = 0.05), major complications were few 10.9% (seven patients; stroke: 1.6%, deep sternal infection: 1.6%, myocardial infarction: 1.6%, reoperation: 4.8%). At 1 year, despite 95% being free of significant cardiovascular symptoms (CCVS/NYHA: I-II), nearly one in five (19%) would not have proceeded with the surgery. However, at the final follow up (mean time: 2.8 years), freedom from cardiovascular symptoms remained high (95%), 94% remained independent and their quality of life was significantly better than before surgery. Although 59% suffered worsening of additional medical conditions, these conditions had a minor impact on their quality of life. Ninety-eight per cent would recommend cardiac surgery. Actuarial survival for all patients and for hospital survivors at 4 years was 67.9 +/- 4.1% and 74.2 +/- 4%, respectively.

CONCLUSION

Medium-term follow up of Australian octogenarians who were offered cardiac surgery revealed that 94% remain independent and with an excellent quality of life. Age alone must not be a barrier to access to cardiac surgery.

Feasibility and risks of heart surgery in very elderly: analysis of 200 consecutive patients of 80 years and above

A continuing increase in the number of very elderly patients with symptomatic heart disease referred for cardiac surgery has been observed in the past. Since 1990 all patients of 80 years and above have been included in a prospective study. We report on the results of the first 200 consecutive patients (mean age: 82.2+/-2.1 years). Operative procedures ranged from isolated myocardial revascularization and valve replacement to very complex operations. In a majority of patients, the operations had to be performed as urgent or emergency cases because of advanced heart disease. Overall 30 day mortality was 9.5%. More than two thirds of patients needed treatment of perioperative complications. During long-term follow-up, cardiac surgery in octogenarians has proved to be very effective with excellent functional status and quality of life. Because of favorable results elderly patients should not be denied the benefits of cardiac surgery requiring utilization of significant medical resources.

Late outcomes of open heart surgery in patients 70 years or older

BACKGROUND

The purpose of this study is to examine the long-term survival and quality of life, including the influence of comorbidities, in patients 70 years of age and over after open heart surgery.

METHODS

This was a retrospective study of 401 consecutive patients, who were 70 years of age or older at the time of surgery. Survival and quality of life of these patients were measured at 6- to 8-year follow-up.

RESULTS

The 5-year survival rate was 85%, and was comparable with the age- and gender-matched West Virginia population. Survival declined with increasing preexisting comorbidities. Of the 176 respondents completing the quality of life (SF-36) survey, most scores were similar to or substantially better than the US population normative scores for individuals 70 years of age or older.

CONCLUSIONS

Survival rates vary by presence or absence of specific comorbid conditions. Quality of life in the appropriately selected elderly after open heart surgery appears to be similar to the US population normative scores.

Aortic valve replacement in the octogenarians: perioperative outcome and clinical follow-up

OBJECTIVES

To determine long-term results of aortic valve replacement (AVR) in patients 80 years old or older, and assess the factors influencing perioperative outcome.

METHODS

Data were reviewed on 83 consecutive octogenarians, undergoing aortic valve replacement between 1992 and 1997. There were 66 women and 17 men (mean age: 82.8 years). Fifty-seven patients (69%) were in New York Heart Association (NYHA) class III-IV and six had previous myocardial infarction. Three patients had previous percutaneous aortic valvuloplasty. There were 19 urgent procedures (23%). Coronary artery bypass grafting (CABG) was performed on 21 patients (25%). Possible influence of preoperative and operative variables on early and late mortality was performed with univariate and multivariate statistical analysis, and survival was estimated with the Kaplan-Meier method.

RESULTS

Operative mortality was 13% (9% for AVR, 24% for AVR-CABG). Postoperative complications were respiratory failure in 19 patients, atrial fibrillation in 19, hemodialysis in four, myocardial infarction in four and stroke in two patients. Five patients required pacemaker insertion for permanent atrioventricular block. Median hospital stay and intensive care unit stay were 19.8 +/- 12.2 days and 7.9 +/- 3.4 days, respectively. Multivariate predictors of hospital death (P < 0.05) were percutaneous aortic valvuloplasty, NYHA class IV, and urgent procedure. Mean follow-up was 26.5 months. Survival at 1, 2, and 5 years was 98.5 +/- 1.4% (63 patients at risk), 93.4 +/- 3.2% (47 patients at risk), and 78.2 +/- 6.9% (six patients at risk), respectively. Preoperative myocardial infarction and urgent procedure were independent predictors of late death. At most recent follow-up, 91% were angina free and 81% were in class I-II.

CONCLUSIONS

Aortic valve replacement in octogenarians can be performed with acceptable mortality. These results stress the importance of early operation on elderly patients with aortic valve disease. Both long-term survival and functional recovery are excellent.

Aortic valve replacement in the elderly. Risk factors and long-term results

OBJECTIVE

The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life.

SUMMARY BACKGROUND DATA

Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life.

METHODS

This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 +/- 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool.

RESULTS

Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 +/- 2% (198 patients at risk), 69.3 +/- 3.4% (89 patients at risk), and 41.2 +/- 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health.

CONCLUSIONS

Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.

Results of coronary angioplasty in patients aged 75 years and older

We studied a group of 47 patients greater than or equal to 75 years old. The mean age was 77 +/- 1.5 years and there were 28 (60 percent) male patients. Multivessel disease was present in 72 percent. Angioplasty was successful in 93 percent of 90 stenoses and in 30 percent of ten total occlusions. Single vessel angioplasty was done in 53 percent of patients, double vessel in 28 percent and triple vessel in 19 percent. Incomplete or absent revascularization was present in 47 percent and 9 percent, respectively. Primary clinical success was accomplished in all patients with single vessel disease; in 85 percent of patients with double vessel disease, and in only 52 percent of patients with triple vessel disease. Complications were highest in patients with triple vessel disease: 14 percent mortality and 5 percent emergency CABG. The follow-up at one year showed 91 percent survival. The PTCA is a valid alternative method of revascularization in elderly patients with single and double vessel disease. The results in triple vessel disease are less encouraging.