ORIGINAL ARTICLE – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 17 (2013) 340–344 doi:10.1093/icvts/ivt125 Advance Access publication 28 April 2013
Cardiac surgery in nonagenarians: not only feasible, but also reasonable?† Alexander Assmann, Jan-Philipp Minol, Arash Mehdiani, Payam Akhyari, Udo Boeken* and Artur Lichtenberg Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Duesseldorf, Germany * Corresponding author. Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Moorenstrasse 5, 40225 Duesseldorf, Germany. Tel: +49-211-8118331; fax: +49-211-8118333; e-mail:
[email protected],
[email protected] (U. Boeken). Received 5 October 2012; received in revised form 8 February 2013; accepted 13 February 2013
Abstract OBJECTIVES: Changes in the age profile of the population in the western world and improvement in surgical techniques and postoperative care have contributed to a growing number of cardiosurgical patients aged over 90. In periods when transapical and transfemoral aortic valve replacement were done, we aimed at evaluating the outcome of nonagenarians after conventional aortic valve replacement and cardiac surgery in general, and determining perioperative parameters to predict a complicated postoperative course. METHODS: Between 1995 and 2011, 49 nonagenarians (aged 91.2 ± 3.1 years) underwent cardiac surgery. A subgroup of 30 patients received aortic valve replacement alone (63%; n = 19), in combination with coronary artery bypass grafting (27%; n = 8) or other surgical procedures (10%; n = 3). Most of the patients suffered from combined aortic valve disease with a mean valve orifice area of 0.6 ± 0.3 cm2 and a mean antegrade pressure gradient of 86 ± 22 mmHg. RESULTS: Cardiac surgery in nonagenarians resulted in remarkable postoperative morbidity and an overall in-hospital mortality of 10% (n = 5). In the AVR subgroup, biological valve prostheses were implanted in 29 patients. In this subgroup, the length of stay was 2.9 ± 0.9 days in the intensive care unit and 17.0 ± 5.5 days in the hospital. The in-hospital mortality amounted to 13% (n = 4). Although several general preoperative risk factors of postoperative complications such as renal failure, low cardiac output syndrome and New York Heart Association Class IV were remarkably more frequent among the patients who died after the operation, the small cohort of non-surviving nonagenarians did not allow for significant differences. CONCLUSIONS: Cardiac surgery in the very elderly, particularly with regard to aortic valve replacement, carries a high risk of early morbidity and mortality. However, in selected nonagenarians, surgery can be performed with an acceptable outcome. The risk may even be reduced by an individual approach to the procedure. With regard to potential risk factors, the selection of these patients should be carried out very carefully. Keywords: Cardiac surgery • Aortic valve replacement • Nonagenarians • Operative mortality • Outcome
INTRODUCTION Increasing life expectancy and improvement in operative techniques as well as postoperative care have contributed to an increasing number of elderly and very elderly surgical patients. In 2010, >50% of all German cardiosurgical operations were performed in patients aged over 70 [1], while 15 years previously, this group accounted for only 28%. Likewise, the group of nonagenarians being considered for cardiosurgical procedures has increased and poses a challenge to surgical skills as well as technical facilities. Recent studies demonstrated an adequate operative outcome and even promising follow-up data for selected nonagenarians undergoing conventional cardiac surgery [2–4] and particularly aortic valve replacement (AVR) [5, 6]. On the other side, transapical † Presented at the 26th Annual Meeting of the European Association for Cardio-Thoracic Surgery, Barcelona, Spain, 27–31 October 2012.
and transfemoral approaches for AVR transcatheter aortic valve implantation (TAVI) offer a good alternative in very elderly patients with multiple comorbidities. In 2007, the first TAVI procedures in Germany were conducted and, 3 years later, the number had increased to 24% of all AVR patients [1]. The present study aimed at evaluating the outcome of nonagenarians undergoing cardiac surgery, and in particular conventional AVR in times of TAVI. Furthermore, we determined perioperative parameters to predict a complicated postoperative course, which may influence the preoperative decision between surgical, interventional or conservative treatment.
PATIENTS AND METHODS Retrospective data analysis included 49 nonagenarians who were operated on in our cardiosurgical centre from 1995 to
© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
A. Assmann et al. / Interactive CardioVascular and Thoracic Surgery
‘TOTAL’ all patients ≥90 years (n = 49). ‘AVR’ AVR patients ≥90 years (n = 30). In Tables 1 and 2, the pre- and intraoperative characteristics of all nonagenarians (group TOTAL), and nonagenarians who underwent AVR (group AVR), are depicted. Data were expressed as mean values and standard deviations for continuous variables or as percentages for categorical data. In order to identify the predictors of postoperative in-hospital mortality in the groups TOTAL and AVR, unpaired two-tailed Fisher’s exact tests, allowing for common surgical and cardiovascular risk factors, were utilized. Significance was assumed if P-values were
