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ICVTS on-line discussion A

DHZB - German Heart Institute Berlin, 13353 Berlin, Germany

Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up

eComment: In their well-written article [1], the authors treat a topic of increasing importance, cardiac surgery in patients older than 90 years of age. Every surgeon will sooner or later be confronted with the difficult question of whether or not to operate on a very elderly person. This development nicely illustrates the advancement of our specialty: In the 1980s there was a flood of papers reporting that cardiac surgery in septuagenarians is justified, in the 1990s this was extended to octogenarians, and now we reach out to patients almost 100 years of age. There is no doubt that this is technically feasible, but it also raises the ethical and socioeconomic question of whether treatment decisions in elderly patients should be made on a different basis than those in younger ones. After all, discussions on whether to provide (or to reimburse) intensive medical care such as major surgery to patients of very advanced age have repeatedly flared up in several countries.

Reading Praschker and colleagues' paper, I have noticed a few points that, in my opinion, deserve to be further discussed: First, the patient cohort clearly does not represent the expected average health status of very elderly persons. That there were only one patient with diabetes, three patients with impaired renal function, less than one third of the patients with hypertension, and presumably no patient with dementia indicates that a positive selection has occurred. This might be either "natural", that is, only healthy individuals reach that advanced age, and/or iatrogenic, meaning that only those were accepted for surgery who were in good overall condition. In this context, it would be helpful to hear about those nonagenarians who presented with theoretically operable heart disease but were not considered acceptable candidates for surgery. Second, the average number of grafts in CABG patients was only 1.6, ranging between 1 and 3. With less than 2 grafts done per patient, one wonders why interventional treatment was not preferred. Third, overall survival was 43% at 18 or 19 months, which means that more than half of the patients died within 18 months, before they reached the general life expectancy of 2.5 to 3.5 years. Given that 22 operations were non-emergency cases, one wonders whether a similar result with acceptable quality of life would not have been achieved without surgery, too. To better judge the necessity of surgery, one would need more detailed data on disease-related symptoms as well as hemodynamic measurements such as pressure gradients and orifice area in aortic valve disease patients. NYHA classification alone is surely not enough. In summary, we clearly need surgical outcome analyses such as that presented by Dr. Praschker et al. as a basis for our own decision-making and to help our patients and their families decide for themselves. But we also need to collect and share the data of those we chose not to operate on to offer our colleagues and our patients valid guidelines.

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1. Praschker BL, Leprince P, Bonnet N, Rama A, Bors V, Lievre L, Pavie A, Gandjbakhch I. Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up. Interact CardioVasc Thorac Surg 2006; 5:696–700.[Abstract/Free Full Text]

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