1
|
Seco M, Edelman JJB, Forrest P, Ng M, Wilson MK, Fraser J, Bannon PG, Vallely MP. Geriatric cardiac surgery: chronology vs. biology. Heart Lung Circ 2014; 23:794-801. [PMID: 24851829 DOI: 10.1016/j.hlc.2014.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Revised: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 01/25/2023]
Abstract
Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common risk factors associated with poorer outcome increases with age, recent studies suggest that outcomes in this population may be better than is widely appreciated. As such, in this review we have examined the current evidence for common cardiac surgical procedures in patients aged over 70 years. Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention, though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury. Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- and long-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomy AVR in the elderly can provide comparable survival to full-sternotomy AVR. More accurate risk stratification systems are needed to appropriately select patients for transcatheter aortic valve implantation. Mitral valve repair is superior to replacement in the elderly, although choosing the most effective method is important for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly has similar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and return to activity. In operative candidates, surgical repair is superior to percutaneous repair. Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiac surgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their "chronological age", without considering the patient's true "biological age".
Collapse
Affiliation(s)
- Michael Seco
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - J James B Edelman
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul Forrest
- Sydney Medical School, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Martin Ng
- Sydney Medical School, The University of Sydney, Sydney, Australia; Cardiology Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland
| | - Paul G Bannon
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- Sydney Medical School, The University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart & Lung Surgical Research, Sydney, Australia; Cardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, Australia; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia.
| |
Collapse
|
2
|
Ditchfield JA, Granger E, Spratt P, Jansz P, Dhital K, Farnsworth A, Hayward C. Aortic valve replacement in octogenarians. Heart Lung Circ 2014; 23:841-6. [PMID: 24751512 DOI: 10.1016/j.hlc.2014.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 02/23/2014] [Accepted: 03/05/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery "unsuitability" by analysing operative outcomes and long term survival following aortic valve replacement. METHODS Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent's Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19). RESULTS The average age was 82.7 ± 2.4 years. The mean logistic EuroSCORE was 18.86 ± 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II. CONCLUSIONS Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.
Collapse
Affiliation(s)
| | - Emily Granger
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| | - Phillip Spratt
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| | - Paul Jansz
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| | - Alan Farnsworth
- Department of Cardiothoracic Surgery, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| | - Chris Hayward
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, Sydney NSW 2010, Australia
| |
Collapse
|
3
|
Abstract
The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.
Collapse
Affiliation(s)
- Nigel E Drury
- Papworth Hospital, Department of Cardiac Surgery, Cambridge CB3 8RE, UK.
| | | |
Collapse
|