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Ann Thorac Surg 1997;64:606-614
© 1997 The Society of Thoracic Surgeons
Cardiac Surgical Unit, Massachusetts General Hospital, Boston, Massachusetts
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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Methods. Records of 600 consecutive patients 80 years old or older having cardiac operations between 1985 and 1995 were reviewed. Follow-up was 99% complete.
Results. Two hundred ninety-two patients had coronary grafting (CABG), 105 aortic valve replacement (AVR), 111 AVR + CABG, 42 mitral valve repair/replacement (MVR) ± CABG, and 50 other operations. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 17 (5.8%), 23 (7.9%) and 91 (31.2%); AVR: 8 (7.6%), 1 (1.0%), and 31 (29.5%); AVR + CABG: 7 (6.3%), 12 (10.8%), and 57 (51.4%); MVR ± CABG: 4 (9.5%), 3 (7.1%), and 16 (38.1%); other: 9 (18.0%), 3 (6.0%), and 23 (46.0%). Multivariate predictors (p < 0.05) of hospital death were chronic lung disease, postoperative stroke, preoperative intraaortic balloon, and congestive heart failure; predictors of stroke were CABG and carotid disease; and predictors of prolonged stay were postoperative stroke and New York Heart Association class. Actuarial 5-year survival was as follows: CABG, 66%; AVR, 67%; AVR + CABG, 59%; MVR ± CABG, 57%; other, 48%; and total, 63%. Multivariate predictors of late death were renal insufficiency, postoperative stroke, chronic lung disease, and congestive heart failure. Eighty-seven percent of patients believed having a heart operation after age 80 years was a good choice.
Conclusions. Cardiac operations are successful in most octogenarians with increased hospital mortality, postoperative stroke, and longer hospital stay. Long-term survival is largely determined by concurrent medical diseases.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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Current estimates suggest that by the year 2000 there will be 10,000,000 people in the United States (6% of the population) 80 years old or older [1]. Although life expectancy for all people who have reached the age of 80 years is greater than 8 more years, several reports have documented that more than a quarter of octogenarians are functionally limited by cardiovascular disease [2, 3].
As with many other cardiac surgical centers, we have noticed a significant increase in the number of octogenarian patients referred for consideration of cardiac surgical intervention, and this has occurred in spite of a growing managed care environment, where one might suppose that expensive interventions, like cardiac operations, would be limited in elderly patients. We, therefore, thought it appropriate to examine our results with cardiac operations in octogenarians.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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Unstable angina pectoris was defined as either (1) new onset of angina that is rapidly progressive in frequency and severity, (2) rapid acceleration of an anginal pattern that was previously stable and related to exertion, or (3) severe recurrent rest angina or a bout of intense pain resembling an acute myocardial infarction but without evolution of infarction by electrocardiogram or cardiac enzymes. Perioperative myocardial infarction was defined as either a new Q wave or the elevation of the myocardial fraction of creatine kinase in association with persistent ST segment changes or a new conduction abnormality. Urgent operations were defined as operative procedures performed in patients whose accelerated symptoms prompted urgent hospital admission for evaluation and who were judged to be too unstable to discharge before operative intervention. True emergency operations were defined as procedures performed in patients whose cardiovascular instability either required operative intervention outside of normal operating hours or displaced another patient on the surgical schedule. Stroke was defined as any neurologic deficit lasting longer than 24 hours, even if the deficit resolved before hospital discharge.
Follow-up
Follow-up clinical information about survival and subsequent cardiac events was obtained between February and June 1996 through direct communication with the patients. If subsequent hospitalization, death, or cardiac events had occurred, the patient's physician or appropriate hospital record department was contacted to document the events.
Of the 600 patients in the study, 555 (92.5%) survived hospitalization. Of these, 2 patients were lost to follow-up; thus follow-up was 99% complete. Mean follow-up was 3.2 years, and total follow-up was 1,903 patient-years.
Statistical Analysis
To separate out the impact of different cardiovascular pathologies on early and late events, we divided the patient population into five groups: (1) CABG = 292 patients who had isolated coronary artery bypass grafting (although concomitant carotid endarterectomy was allowed), (2) AVR = 105 patients who had an isolated aortic valve replacement (although additional left ventricular myomectomy for asymmetric septal hypertrophy was allowed), (3) AVR + CABG = 111 patients who had an aortic valve replacement plus coronary artery bypass grafting, (4) MVR ± CABG = 42 patients who had a mitral valve replacement or repair with or without concomitant coronary artery bypass grafting, and (5) other = 50 patients, of whom 27 had multiple valve replacement, 10 had thoracic aortic aneurysm resection, 5 had postinfarction ventricular septal defect closure, 4 had excision of myxoma, 3 had left ventricular aneurysm resection, and 1 had a pulmonary embolectomy, all alone or in combination with other procedures.
To describe the long-term results, actuarial curves for mortality were obtained by the actuarial life-table method [4]. Because actuarial mortality rates for the United States population calculated by each year of age over age 85 years are not available, we generated an actuarial survival curve using data available from age 80 to 85 years [5] that was projected to allow us to include the 64 patients in our study more than 85 years of age. The statistical method used to create the actuarial curve past age 85 years is described in Appendix 1.
To calculate total cardiac event-free survival, we counted the following complications as events: hospital death, late cardiac-related death, perioperative or late myocardial infarction, perioperative or late stroke, late percutaneous coronary angioplasty, late anticoagulant-related bleeding, or late bacterial endocarditis.
To evaluate the impact of internal mammary artery grafting versus all vein grafting on the CABG patients who had a primary revascularization procedure, we eliminated the CABG patients whose operation was a reoperative procedure, leaving 163 patients receiving at least one internal mammary artery graft and 108 who received all vein grafts. The generalized Wilcoxon test was used to compare the two actuarial survival curves.
To assess the predictors of hospital death, hospital stroke, and late death, we inserted multiple risk factors into a stepwise logistic regression algorithm, BMDP program PLR [7]. Predictors of prolonged postoperative hospital stay were assessed by linear regression of the log postoperative hospital stay. Factors tested as predictors of various events are listed in Appendix 2.
All mean values in the tables are expressed as the mean value ± standard deviation.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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, along with the annual hospital mortality rate.
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. The age range of our patients was 80 to 94 years, with 8 patients being age 90 years or older.
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. During preoperative evaluation 52 patients (9%) admitted that they had previously refused surgical intervention but had reconsidered that option when their symptoms became more severe.
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. Of the 216 patients having either AVR or AVR + CABG, 26 (12%) had pure aortic regurgitation, and the remaining 190 (88%) had either pure aortic stenosis or stenosis plus regurgitation. Of the 42 patients having either a mitral valve replacement or repair, 31 (74%) had pure mitral regurgitation, and the remaining 11 (26%) had either pure mitral stenosis or stenosis plus regurgitation.
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. The highest incidence of reoperative procedures occurred in the MVR ± CABG (26%) and other (20%) patient groups. Concomitant carotid endarterectomy was performed in 20 patients (3.3%). Of the 105 patients in the AVR group, 85 received a bioprosthetic valve and 20 a mechanical prosthesis, whereas of the 111 patients in the AVR + CABG group, 97 received a bioprosthesis and 14 a mechanical valve. Of the 42 patients in the MVR ± CABG group, 18 received a bioprosthetic valve, 15 a mechanical prosthesis, and 9 a reconstruction. Of the 292 patients in the CABG group, 174 (60%) received at least one internal mammary artery graft.
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. The association of coronary artery disease with stroke is readily apparent. Figure 1
contains the graph of annual hospital mortality. There has been an important decline in hospital mortality with increasing experience.
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. Of note is the significant negative impact of postoperative stroke on both hospital and late survival and also length of hospital stay.
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. Actuarial survival and actuarial cardiac event-free survival are compared with the survival curve for the general United States population 80 years old or older in Figure 2. Only at the first year is the actuarial survival of the study population statistically lower than the general octogenarian population (p < 0.05). Actuarial survival curves of the study population according to sex are compared with those for the sex-matched general United States population in Figures 3 and 4. Compared with the general United States male octogenarian population, our male study patients had a survival that was actually better at 5 years, although not statistically significant. Compared with the general United States female octogenarian population, our female study patients had a survival that was lower than the general population at all years, again not statistically significant, except at year 1. However, the actuarial survival for our female patients was better than that for male patients at each year, although not statistically significantly so.
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. The advantage in 5-year survival for the 163 patients who received at least one internal mammary artery graft compared with the 108 who received all vein grafts (72.2% versus 62.3%) just failed to be statistically significant (p = 0.06).
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COMPLICATIONS.
Cardiovascular mortality and morbidity that occurred during the period of follow-up for the 555 hospital survivors were as follows:
Compared with the rates of late congestive heart failure and stroke, there were relatively few late interventions required in hospital survivors.
To better examine the risks of late thromboembolism and anticoagulant-related bleeding in our octogenarians who had valvular operations, we segregated the incidents and linearized rates of late thromboembolism and bleeding according to both valve position and type of prosthetic valve in Table 8.
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Although 315 (57%) of the 555 hospital survivors were discharged from the hospital to a rehabilitation facility, at the time of follow-up of the surviving 382 patients, 329 (86%) were living at home or with family. In addition, of the survivors, 9 men (ages 81 to 90 years; mean age = 84.5 years) reported that they were still gainfully employed!
Additionally, the total patient population had a cardiac event-free survival of 61.6% at 5 years (see Fig 2).
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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In addition, longer-term results of cardiac operations in octogenarians can now be assessed. With an overall 5-year actuarial survival, including hospital mortality, of 63%, which is identical to that for the general United States octogenarian population, it seems probable that survival of octogenarians with cardiovascular disease can be positively influenced by successful cardiac operations, especially in men, although because of possible selection bias we have not proved this contention.
Of at least equal importance to the elderly as survival is quality of life. In this study 87% of survivors felt as good or better than before their operation, and an equal percentage believed in retrospect that having decided to have a cardiac surgical procedure after age 80 years had been a good choice. Further reflecting this enhanced quality of life, at a mean of 3.2 years postoperatively 86% of survivors were still living at home or with their families. Finally, the cardiac event-free survival at 5 years of 61.6% compares favorably with the overall survival of the total study group at 5 years of 63.1% (see Fig 2).
During the almost 10 years of the study, there were several important trends, the most obvious being the increasing number of octogenarians having cardiac operations each year. With this increasing experience in operating on octogenarians came improvement in hospital mortality; of the first 100 patients in the study 11 (11%) died, whereas of the last 100 patients only 5 (5%) died.
To put these results into perspective, Table 9 lists published series with more than 150 octogenarian patients who had coronary artery bypass grafting [8–13]. In another study of coronary artery bypass grafting between 1987 and 1990 in 24,461 octogenarians taken from the Medicare Provider Analysis and Review, in-hospital mortality was 11.5% [14]. Our hospital mortality rate of 5.8% is a little lower than the cumulative rate of 8.8% from the other series, whereas our stroke rate is slightly higher. One reason for our higher stroke rate may be the definition of stroke used in the various studies. Unlike some studies, our report includes not only those who had a fixed neurologic deficit, but also those who had a reversible ischemic neurologic deficit, that is, a neurologic deficit that lasted at least 24 hours but that resolved by the time the patient was discharged. In fact of the 43 patients counted as suffering a postoperative stroke, 9 fully resolved their deficits in the hospital, leaving 34 (5.7%) with neurologic deficits unresolved at hospital discharge.
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contains the results of aortic valve replacement in octogenarians from three published series with more than 150 patients [10, 15, 16]. The results are skewed by the differing percentages of patients in each series having other concomitant procedures. Our hospital mortality of 7.8% is less than the cumulative rate of 11.7% from the other series, probably due at least in part to the more recent time frame of our study.
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Another trend over the course of the study interval was the shortening of postoperative hospital stay in more recent years. For the first 50 hospital survivors in the study, the median postoperative hospital stay was 14.5 days (mean stay = 18.6 days), whereas for the last 50 hospital survivors, the median stay was 7 days (mean stay = 10.1 days). Looking at one portion of this shortened hospital stay, although mean intensive care unit stay was 5.1 days for the total study, it was only 3.1 days for the last 50 patients. In an era of increasing managed care a shortened hospital stay will favorably affect the relative risk/benefit ratio for cardiac operations in octogenarians.
Another trend, which also mirrors our overall cardiac surgical practice, is an increasing percentage of patients in the CABG group who received at least one internal mammary artery graft. Of the first 50 CABG patients, only 4 patients (8%) received an internal mammary artery graft, whereas of the last 50 CABG patients, 45 (90%) did. The benefits associated with internal mammary grafting in older patients, especially improved long-term survival (see Fig 5), have also been suggested by Gardner and colleagues [18] and Morris and coworkers [13].
Although 183 (85%) of our AVR and AVR + CABG patients and 27 (64%) of our MVR ± CABG patients received a bioprosthetic valve or valve repair, some of our patients received a mechanical valvular prosthesis. The late complications of thromboembolism and anticoagulant-related bleeding listed in Table 8, as expected, generally favor bioprosthetic valves in the aortic position and bioprosthetic valves or valve repair in the mitral position. One cannot draw any far-reaching conclusions from these data, however, because the valve choice was not randomized, some of the population subsets are small, and the follow-up occurred only once at a mean of over 3 years, which implies that our data underestimate the actual occurrence of these complications.
One observation about our long-term results (see Table 7) is that the negative impact on late survival of younger patients with valvular heart disease who also have coronary artery disease, as noted by Jones and associates [19], seems to not be as important in octogenarians. One reason for this may be found in the multivariate predictors of late death, namely renal insufficiency, postoperative stroke, chronic obstructive lung disease, and congestive heart failure. In octogenarians late death is due more to concurrent medical conditions than to their heart disease. In addition our follow-up only extended to 5 years.
With a growing proportion of our United States population being composed of patients 80 years old and older, with the high incidence of heart disease in the elderly, and with the increasing impact of managed care on the delivery of medical services, the relative value of cardiac operations in octogenarians will become an increasingly important issue. If we, as cardiac surgeons, can continue to improve our operative mortality and morbidity rates, accomplish these goals with shorter postoperative hospital stays, and document favorable long-term survival with good quality of life, then the performance of cardiac operations will continue to be an appropriate therapeutic endeavor in octogenarians significantly limited by their heart disease.
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Appendix 1. Projection of Survival in Patients Older Than 85 Years |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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 | (1) |
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Next we tabulated the age distribution of our octogenarian population at the time of operation, with total patients at each year of age from 80 to 94 years for men and women in separate columns. Using the above equations each pair of columns was projected forward 1 year for each of 5 years. The count, n(i + 1, j + 1), in each new row i + 1 in a new year's column j + 1 was computed from the prior year's count for one year's less age as follows:
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where a(i) is the age in row i of the distribution table. The mortality p(a(i)) is computed according to sex by the above equations. When this year-to-year projection forward of the surgical population distribution according to the United States expected mortality has been repeated for each of 5 years, the male and female columns are added and summed across all ages and then rounded to get the total expected surviving population for that year. At the worst this log-linear projection of the United States mortality data for 9 years beyond the available age range will underestimate the expected mortality of the United States sample similar to our octogenarian population because the ln(p(a)) curve versus a shows a very slight upward curvature when plotted for ages down to 70 years.
The United States mortality projected in this way for a population distributed identically to our sample of octogenarian patients was compared with our actual cardiac surgical survival curves as estimated by the actuarial life-table method. In each of 5 years subsequent to the index operation, t tests were used to test the hypothesis that the survival rates between the general population and our cardiac surgical patient sample are identical. For conservative estimates, ie, least favorable to our surgical patients, five separate t tests were performed for each sex without adjustment for multiple comparison. Standard errors of survival proportion in our population were estimated by the BMDP actuarial life-table program, and standard errors of the projected United States equivalent population were estimated from standard formulas for standard errors of proportions [6]. Degrees of freedom for each t test were taken as the size of the subset from which each proportion was estimated.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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We express our appreciation to Barbara J. Akins, BSN, and Annetta L. Boisselle, BSN, for their help in data acquisition and management, and to John B. Newell, Director of the Cardiac Computer Center, Massachusetts General Hospital, for his assistance in the statistical evaluations.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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Address reprint requests to Dr Akins, Massachusetts General Hospital, White 503, Fruit St, Boston, MA 02114
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAppendix 1. Projection of...AcknowledgmentsReferences |
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C. Muneretto, A. Negri, G. Bisleri, J. Manfredi, A. Terrini, M. Metra, S. Nodari, and L. D. Cas Is total arterial myocardial revascularization with composite grafts a safe and useful procedure in the elderly? Eur. J. Cardiothorac. Surg., May 1, 2003; 23(5): 657 - 664. [Abstract] [Full Text] [PDF]
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M.-B. Edwards and K. M. Taylor Outcomes in nonagenarians after heart valve replacement operation Ann. Thorac. Surg., March 1, 2003; 75(3): 830 - 834. [Abstract] [Full Text] [PDF]
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R. G. Demaria, M. Carrier, S. Fortier, R. Martineau, A. Fortier, R. Cartier, M. Pellerin, Y. Hebert, D. Bouchard, P. Page, et al. Reduced Mortality and Strokes With Off-Pump Coronary Artery Bypass Grafting Surgery in Octogenarians Circulation, September 24, 2002; 106(12_suppl_1): I-5 - I-10. [Abstract] [Full Text] [PDF]
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Y. Kawachi, A. Nakashima, Y. Toshima, S. Kimura, and K. Arinaga Outcome of Cardiac and Thoracic Aortic Operation in Patients Over 80 Years Old Asian Cardiovasc Thorac Ann, March 1, 2002; 10(1): 12 - 15. [Abstract] [Full Text] [PDF]
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L.A. Pierard Cardiac surgery in octogenarians: who, when and how? Eur. Heart J., July 2, 2001; 22(14): 1159 - 1161. [PDF]
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P Kolh, A Kerzmann, L Lahaye, P Gerard, and R Limet Cardiac surgery in octogenarians. Peri-operative outcome and long-term results Eur. Heart J., July 2, 2001; 22(14): 1235 - 1243. [Abstract] [PDF]
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C. Hagl, J. D. Galla, D. Spielvogel, S. L. Lansman, R. Squitieri, C. A. Bodian, M. A. Ergin, and R. B. Griepp Is aortic surgery using hypothermic circulatory arrest in octogenarians justifiable? Eur. J. Cardiothorac. Surg., April 1, 2001; 19(4): 417 - 423. [Abstract] [Full Text] [PDF]
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S. C. Stamou and P. J. Corso Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future Ann. Thorac. Surg., March 1, 2001; 71(3): 1056 - 1061. [Abstract] [Full Text] [PDF]
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B J Bouma, J H P van der Meulen, R B A van den Brink, A E R Arnold, A Smidts, L H Teunter, K I Lie, and J G P Tijssen Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in the Netherlands Heart, February 1, 2001; 85(2): 196 - 201. [Abstract] [Full Text]
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B. Iung VALVE DISEASE: Interface between valve disease and ischaemic heart disease Heart, September 1, 2000; 84(3): 347 - 352. [Full Text] [PDF]
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 A. Loeckinger, A. Kleinsasser, K. H. Lindner, J. Margreiter, C. Keller, and C. Hoermann Continuous Positive Airway Pressure at 10 cm H2O During Cardiopulmonary Bypass Improves Postoperative Gas Exchange Anesth. Analg., September 1, 2000; 91(3): 522 - 527. [Abstract] [Full Text] [PDF]
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S. C. Stamou, G. Dangas, M. K.C. Dullum, A. J. Pfister, S. W. Boyce, A. S. Bafi, J. M. Garcia, and P. J. Corso Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups Ann. Thorac. Surg., April 1, 2000; 69(4): 1140 - 1145. [Abstract] [Full Text] [PDF]
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R. Pretre and M. I Turina VALVE DISEASE: Cardiac valve surgery in the octogenarian Heart, January 1, 2000; 83(1): 116 - 121. [Full Text] [PDF]
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P. Kolh, L. Lahaye, P. Gerard, and R. Limet Aortic valve replacement in the octogenarians: perioperative outcome and clinical follow-up Eur. J. Cardiothorac. Surg., July 1, 1999; 16(1): 68 - 73. [Abstract] [Full Text] [PDF]
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C. Blanche, S. S. Khan, A. Chaux, T. A. Denton, M. Sandhu, T.-P. Tsai, and A. Trento Cardiac reoperations in octogenarians: analysis of outcomes Ann. Thorac. Surg., January 1, 1999; 67(1): 93 - 98. [Abstract] [Full Text] [PDF]
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M. J. R. Dalrymple-Hay, A. Alzetani, S. Aboel-Nazar, M. Haw, S. Livesey, and J. Monro Cardiac surgery in the elderly Eur. J. Cardiothorac. Surg., January 1, 1999; 15(1): 61 - 66. [Abstract] [Full Text] [PDF]
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