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Interact CardioVasc Thorac Surg 2006;5:696-699. doi:10.1510/icvts.2006.138255 © 2006 European Association of Cardio-Thoracic Surgery
Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up
a Department of Thoracic and Cardiovascular Surgery, Université Pierre et Marie Curie Paris VI, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hopitaux de Paris, 47-83, Boulevard del'Hôpital, 75651 Paris Cedex 13, France Received 13 June 2006; received in revised form 24 August 2006; accepted 25 August 2006
*Corresponding author. Tel.: +33-1-42-16-56-43; fax: +33-1-42-16-56-39.
Nonagenarians represent a growing part of the population. However, it is assumed that they present a poorer functional class to cope with the stress inferred by surgical interventions. The aim of this study was to review our experience with nonagenarians concerning postoperative morbidities, mortality, and long-term survival status. Retrospective data from 30 consecutive nonagenarians who underwent cardiac surgery between January 1990 and December 2002, and their long-term follow-up was analysed. There were 18 women (60%) and 11 men. Left ventricle ejection fraction (LVEF) was 50.3±10.5%. Fifty percent of the patients were in NYHA functional class III or IV. There were nine coronary artery bypass grafting (CABG) procedures (30%), 16 aortic valve replacements (AVR), (53%), one double valve procedure and one replacement of infected intracavitary pace-maker leads. In-hospital mortality rate was 20% (6/30). Mean follow-up was 21.5±19 months (r: 2.2 to 68). Actuarial survival rate at 12, 24 and 60 months was 67%, 43% and 30%, respectively. Surviving patients referred quality of life as good, all but one were in NYHA functional class I. Nonagenarians undergoing cardiac surgery have higher mortality and morbidity rates than younger patients. However, in a carefully selected group of patients, the operative risk remains acceptable.
Key Words: Nonagenarians; Cardiac surgery; Long-term follow-up
In the 1960s the majority of open-heart surgeries for acquired cardiovascular disease was performed on patients in their fifth decade of life. Advances in anaesthesia, surgical technique and perioperative care have allowed surgery in the elderly patients. As well as in other European countries, life expectancy in France continues to increase; at the end of 2003 there were 1.1 million persons of 85 years old or more (1.8% of the population); by the year 2050 this figure will increase up to 4.47 millions representing 6.9% of the total population [1]; thus the number of nonagenarians exposed to cardiovascular diseases will grow. As cardiac surgeons we will be confronted to evaluate the surgical treatment in this group of patients. However, the perception by elderly patients, their families and the referring physician is that they may have lower functional reserve and more comorbidities than younger patients with an increased rate of complications or death. Yet, there are studies that show the benefits of cardiac surgery in octogenarians and very few others in nonagenarian patients [2–5]. Therefore, the purpose of this study is to review our experience with nonagenarians, regarding postoperative morbidity and mortality, long-term survival status and quality of life.
We retrospectively reviewed the records of all patients over the age of 90 years who underwent cardiac surgery at the Thoracic and Cardiovascular Surgery Department at La Pitié-Salpétriêre Hospital. Between January 1990 and June 2003, among 18,124 patients who underwent cardiac surgery, 30 were 90 years old or older at the time of surgery. Surgical procedures were performed with general anaesthesia through a median sternotomy; either under cardiopulmonary bypass (CPB) with cold-blood cardioplegia for myocardial protection; or OP-CABG procedure. All data were retrospectively collected from our prospectively added database and from patients' records. Coronary artery disease was defined as a reduction of vessel diameter by at least 70% on the coronary angiogram. Stenosis of 50% or more in the left main trunk was considered as double vessel disease in the absence of any other coronary stenoses. Hospital mortality was described as any death occurring within 30 days of the operation or during the same hospital admission other than the operation. Renal impairment was defined as a serum creatinine concentration higher than 120 µmol/ml. The presence of pulmonary congestion or opacities consistent with edema in the chest X-ray studies determined heart failure. Low cardiac output syndrome was defined as a need for inotropic drugs for more than 48 h in the postoperative period. The additive and logistic EuroSCORE ratings were calculated to assess postoperative risk. Survey was obtained through questionnaire interview sent to the referring physician and/or by phone interview of the patients. It was completed by the end of October 2004. Standard method incorporating the SAS® statistical software package version nine (SAS Institute, Cary, NC) was used. Kaplan–Meier survival curves were used for analysis of long-term survival. All relevant variables are expressed as mean ± standard deviation (mean±S.D.) unless stated otherwise.
3.1. Preoperative data The total number of nonagenarians undergoing cardiac surgery at La Pitié has been increasing in the last decade, with five patients operated on between 1990 and 1996, and 25 patients operated on from 1997 to 2003. There were 18 females (60%) and 12 males. Mean age was 91±1.3 years (r: 90–95). Mean left ventricle ejection fraction (LVEF) was 50.3±10.5%. Six patients (20%) had a LVEF under 40%. Their NYHA functional class was 2.5±0.6 and 50% of the patients were in NYHA functional class III or IV. Preoperative data are summarised in Table 1.
Emergency procedures were performed in 8 cases: 7 CABG (5 due to unstable angina, 1 to AMI and one to PTCA related accident) and 1 AVR due to pulmonary edema. One patient had a redo procedure. Table 2 summarises surgical procedures. In the isolated CABG group (n=9), seven patients had an OP-CABG procedure. Mean number of grafted vessels was 1.6±0.7 (r: 1–3) per patient. All the CABG patients had at least one ITA as a graft.
Sixteen patients underwent aortic valve replacement (AVR) and three others had AVR associated with CABG. The redo procedure patient underwent replacement of a mitral bioprosthesis, which degenerated over a 10-year period of time, associated with a tricuspid valve annuloplasty. Finally, one patient suffered intracavitary pace-maker leads endocarditis. The leads were removed under CPB through a right atriotomy due to the large vegetations attached to the leads. No aortic cross-clamp was needed, and the leads were replaced by epicardial ones. Three deaths occurred in the group of emergency patients (37%). One had an aortic valve replacement and experienced postoperative renal failure and morganella related pneumonia, leading to death on postoperative day 30. The two others were CABG patients. One experienced low cardiac output syndrome and ventricular fibrillation at day 2; and the other experienced sudden death after having left the hospital for the rehabilitation centre.In the group of non-emergency patients mortality rate was 14% (n=3/22). Two patients died after AVR: one had a sudden cardiac arrest at day 5 while she was doing well at the ward, and the other died from E. coli related pneumonia at day 13. Finally, the patient who had a redo mitral valve replacement and a tricuspid annuloplasty, presented with renal insufficiency and low cardiac output syndrome that led to multi-organ failure, and eventually death at day 23.
One of the criticisms of the additive EuroSCORE is that its estimate is lacking accuracy in higher risk patients [6]. In our patient population, minimum additive EuroSCORE was seven points in males and eight points in females (age over 90 years old), with a minimum logistic EuroSCORE of 6.55%. We studied the performance of the additive and logistic EuroSCORE by dividing the patients into two sub-groups setting an additive EuroSCORE ‘cutoff’ at 9 (low risk EuroSCORE
Seventeen patients, seven of whom were operated on an emergency basis, presented 25 postoperative complications. The most frequent adverse events were: low cardiac output syndrome 32% (n=8), renal impairment 8% (n=3), one of them requiring haemodialysis, AV blocs requiring pace-maker implantation 8% (n=2); there was 1 postoperative bleeding and 1 sternal disjunction, both requiring re-exploration. Postoperative atrial fibrillation amounted to 28%, whereas we observed no case of stroke (Table 4). Out of the 17 patients, only one was in the low risk group while all others were in the high risk group.
Mean follow-up was 21.5±19 months (r: 2.2–68). Actuarial survival rate at 12, 24 and 60 months was 67%, 43% and 30%, respectively (Fig. 1). In the follow-up period 13 patients died at a mean time of 15.4±9.7 months (Fig. 2). At follow-up 11 patients (36%) were still alive. All but one were in NYHA functional class I. Quality of life was referred by surviving patients as good and that they did not regret their choice.
Surgery improves survival and provides a functional benefit over the continuation of medical therapy in elderly patients [7]. As the population's life expectancy continues to grow, an increasing number of nonagenarians will develop symptomatic coronary and valvular disease requiring surgical treatment in the coming years. As we observed in our series, Bridges et al. [3] have shown that patients over the age of 90, are more likely to have less diabetes, are less often obese, and have lower incidence of both hypercholesterolemia and chronic lung disease. They usually present higher incidence of systemic hypertension, cerebro-vascular disease and renal insufficiency than younger patients. Although there are only few reports about cardiac surgery in nonagenarians, their mortality rates vary from 7 to 18% [2,3,5,8]. As to risk factors for postoperative death: mitral valve replacement, emergency surgery, preoperative low EF, prolonged CPB time, NYHA functional class, combined procedures (CABG±AVR/MVR, double VR), prior CABG; all of them were mentioned as risk factors for increased in-hospital mortality. As we have seen in our series, the overall 30-day mortality rate was 20%, the major cause of death being cardiovascular complications (ventricular fibrillation and cardiac arrest), and pulmonary infection. Ko and colleagues [9] showed that elective CABG procedures had mortality rates comparable to those of younger patients; similarly in a report from Alexander et al. [10] emergency procedure was predictive of in-hospital mortality and Williams et al. [11] showed a mortality rate of 33.3% in emergency cases versus 9.6% in elective cases. In the present report, emergency procedure seemed to be a 30-day mortality predictor accounting for 50% of postoperative deaths, however, it is our opinion that emergency status alone does not contraindicate surgery. In nonagenarian patients, age alone accounts for a predicted logistic EuroSCORE mortality risk of 6.55% for male patients, as for females it rises to 8.89% without any other preoperative risk factor. In our series predicted logistic EuroSCORE mortality rate was 23.5% for the whole cohort, slightly higher than the actual mortality rate of 20%. The distribution between two groups at risk (low, high) showed that all deaths occurred in the high-risk group; thus, even though in this population age alone is an important mortality risk factor; the logistic EuroSCORE managed to identify patients at high risk. Inversely, Collart et al. [12], in a population of octogenarians who underwent aortic valve replacement, failed to show any difference in mortality rate for higher risk patients. Thus, in studies with a larger number of patients it would be mandatory to demonstrate the accuracy of this score in this high-risk patient group of nonagenarians. In the literature, reported morbidity rates are as high as 100% [2,3,5,8]. In the present study, the overall morbidity was 56%, 17 patients having 25 complications, which included: arrhythmias (AF, FV), haemodynamic (low output syndrome), infectious (sepsis, pneumonia) and haemorrhagic (postoperative bleeding). As we see in the present series, 16 out of 17 patients had various preoperative risk factors; proving that clinical condition prior to cardiac surgery may explain the morbidity rate. Some authors have shown that older age is strongly related to a neurological event [13], the latter being associated with a previous history of stroke and advanced atherosclerotic disease. In our series, we did not have any postoperative stroke, perhaps due to the fact that none of our patients had a history of previous stroke. Moreover, 58% of CABG procedures were performed off-pump, which may decrease the risk of stroke associated with CBP-CABG procedure [14]. Regarding CABG procedures, it has been shown that long-term results are better in those patients who have undergone myocardial revascularisation with the left internal mammary artery (LIMA) [15]. In this patient population the quality of saphenous vein conduit may be affected. Furthermore, the use of ITA avoids aortic implantation (the ‘no touch’ technique) and reduces saphenous vein harvesting site related complications. Thus, it is our belief that, whenever feasible, LIMA graft must be utilised, and be completed with venous graft only if necessary; as we have shown in the present series, the LIMA was utilised in 67% (8/12) of all CABG procedures. In the general population, life expectancy in nonagenarians is 2.5 and 3.5 years for men and women, respectively. In the present series, mean survival rate for those patients who survived the postoperative period was 19 months (r: 2.2–68) with three patients out of 24 (13%) surviving more than 60 months. Quality of life should be an important indicator in assessing any surgical treatment effectiveness, especially in elderly patients, as any intervention in the geriatric patient population should seek to improve functional independence. According to patient's comments during follow-up, it appears that their quality of life had improved and that they felt physically and emotionally better after their operation. Nonagenarians, when compared to the younger population, have higher mortality and morbidity rates. However, successful outcome can be expected in most patients with preserved cardiac function; thus surgical treatment can be offered in a carefully selected group of patients, and surgery should not be postponed in order to decrease the rate of emergency situations.
We would like to thank Mrs Martine Collomb for her assistance with the correction of this article.
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Abstract
1. Introduction
9, and high risk EuroSCORE 
10). Mean additive EuroSCORE was 11±2.73 (r: 7–19) and the logistic EuroSCORE was 23.5±16%. All deaths occurred in the high risk group (Table 
