The echo Doppler spectrum of valvular abnormalities in the hospitalized octogenarian

Valvular disease in the elderly

As the incidence of valvular disease in the elderly is increasing, understanding of its pathogenesis and natural progression as well as surgical approaches and device technologies are improving. Future studies are needed to develop medical interventions that slow or halt the degenerative valvular processes associated with aging. In addition, mechanical approaches with lower operative risks should be explored and the search should continue for a valve substitute that is durable, hemodynamically efficient, easy to implant, and does not require anticoagulation. Hopefully, future intervention trials will include quality of life assessments such as symptoms, functional capacity and perceptions of well being. At present, the degenerative valvular processes must be followed closely by the clinician, and individual management decisions for the elderly based on the type and severity of valve disease, comorbid medical conditions, and the risks and benefits of intervention, along with patient preferences, rather than on the chronologic age of the patient. It is becoming clear that both survival and quality of life outcomes can improve by consideration of surgery at the onset of indications, before further deterioration eliminates the opportunity to provide benefit for the elderly patient with valvular disease.

Upper abdominal cancer surgery in the very elderly

From January 1981 to December 1987, 59 major upper abdominal operations were performed on 57 patients aged 80 to 90 years at Memorial Sloan-Kettering Cancer Center. Procedures for primary adenocarcinoma of the stomach, distal esophagus, pancreas, or hepatobiliary system were performed with curative intent or for palliation in 34 of 59 patients (58%) and bypass with limited or no resection in 13 of 59 patients (22%) patients. Emergency operations were performed in six (10%) patients for gastric bleeding, perforation, or outlet obstruction. Six (10%) patients underwent laparotomy for benign biliary obstruction (1), splenectomy for secondary thrombocytopenia (2), or gastrectomy for sarcoma (2) or lymphoma (1). Hospital mortality was 15% overall and 9% for major resections, 15% for bypass, and 67% for emergency procedures. Major complications occurred in 10 (20%) elective procedures. Mortality was associated with respiratory or cardiac failure while complications most commonly included arrhythmias and wound infection. Mean postoperative hospitalization was 18 days overall and 45 patients (76%) were discharged home. Median survival following major resection was 17.5 months but less than 2 months after bypass procedures. A protocol of pre-operative evaluation, intra-operative hemodynamic monitoring and postoperative intensive care has been formalized for use in elderly or poor-risk patients.