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Cardiac Surgery in Nonagenarians
Abstract & Commentary
By Andrew J. Boyle, MD, PhD
Source: Speziale G et al. Operative and middle-term results of cardiac surgery in nonagenarians. A bridge toward routine practice. Circulation. 2010;121:208-213.
Cardiac surgery carries greater risk in older patients. Nonagenarians are a growing part of cardiology practice as our population ages. While age > 90 years has previously been considered a contraindication to cardiac surgery, more recently, surgeons have been operating on selected nonagenarians who have high functional status. To determine the factors associated with adverse outcomes in this age group, Speziale et al present their retrospectively collected surgical data on nonagenarians undergoing cardiac surgery over a 10-year period from eight centers in Italy. In carefully selecting their patients, they routinely use the Duke Activity Status Index in all patients presenting for surgical evaluation. They considered a score less than 10 an absolute contraindication to surgery and a score of 10-15 as a relative contraindication. Furthermore, they refused surgery to those who were bed-bound and those without strong family support.
A total of 127 patients with a mean age of 92 years (range 90-103) underwent cardiac surgery coronary artery bypass grafting (CABG), valve surgery, or both. This represented 1.2% of their total surgical volume during that time period. Importantly, over one-third of cases were non-elective. Overall 30-day surgical mortality was 13.4%. This compared favorably with the expected mortality based on the logistic EuroSCORE (21.3 6.1). Mean follow-up time was 3.6 years (range 7 months to 5 years). The total mortality at the end of follow-up was approximately 50%. Post-operative complication rates were high, occurring in 54 patients (42.5%); these included eight ICU readmissions, five surgical revisions, 17 cases of respiratory failure, 22 cases of acute renal failure, 11 neurological complications, 38 post-op arrhythmias, and two sternal wound infections. There were no differences in mortality or complication rates according to the types of surgery. Multiple logistic regression identified non-elective presentation (odds ratio 9.3, p < 0.001) and previous myocardial infarction (odds ratio 4.1, p = 0.014) as independent predictors of post-op complications. The ICU and total hospital lengths of stay were prolonged (10.2-4.1 days in ICU, 29.2-5.6 days in hospital). Despite the high mortality, complication rates, and length of stay, those who survived experienced improvement in symptoms. Comparing baseline to end of follow-up, the percentage of patients in each NYHA class were as follows: I- 10.8% vs. 44.6%; II-27.7% vs. 41.5%; III-44.6% vs. 12.3%; IV-16.9% vs. 1.5%. The authors conclude that although the complication rate is high, cardiac surgery in nonagenarians can achieve functional improvement at the price of considerable operative and follow-up mortality. Cardiac operations are supported in the very elderly if the surgery is performed early and electively.
Advanced age is associated with higher complication rates for most procedures and operations. Thus, cardiac surgery, which carries significant risk even in young healthy patients, has traditionally not been offered to the very elderly. Furthermore, many cardiac surgeries are performed to increase life expectancy, which may be unrealistic in elderly patients with other co-morbidities. However, whether cardiac surgery should be offered to those nonagenarians who are highly functional remains unknown. Studies like these, although limited by their retrospective nature and lack of control group, demonstrate that even in very rigorously selected, highly functioning nonagenarians, surgical mortality, complication rates, and length of stay are very high. As nonagenarians become a more common part of cardiology practice, which they inevitably will, discussing therapeutic options with them must include these high-mortality and complication rates. Symptomatic improvement can be seen in those who survive, but the price is high.