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Ann Thorac Surg 2003;75:1215-1220
© 2003 The Society of Thoracic Surgeons

Original article: cardiovascular

Outcomes of cardiac surgery in nonagenarians: a 10-year experience

Matthew D. Bacchetta, MD, MBAa, Wilson Ko, MDa, Leonard N. Girardi, MDa, Charles A. Mack, MDa, Karl H. Krieger, MDa, O. Wayne Isom, MDa, Leonard Y. Lee, MDa*

a Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Cornell University Medical College, New York, New York, USA

Accepted for publication October 18, 2002.

* Address reprint requests to Dr Lee, Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Cornell University Medical College, 525 East 68th St, M-4, New York, NY10021, USA.
e-mail: lyl2003{at}med.cornell.edu


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: With an increasing awareness of health issues and greater emphasis on preventive medicine, the general population is living longer and healthier lives than ever before. Physicians are taking care of older patients, many of whom may require cardiac surgical procedures. Improving cardiopulmonary bypass technology allows for safer procedures with reduced morbidity and mortality even in older patients.

METHODS: We have performed a retrospective analysis of 42 consecutive nonagenarian patients who underwent open-heart procedures over a 10-year period (1993 to 2002) at our institution. Their demographic profiles, operative data, perioperative results, and long-term outcomes were recorded and analyzed.

RESULTS: Twenty-two women and 20 men with an age range of 90 to 97 years (mean, 91.4 years) had open-heart surgery over the study period. The complication rate was 67% overall, consisting of 7% respiratory (pneumonia, respiratory failure, reintubation), 7% hemorrhagic or embolic (postoperative bleeding, cerebral vascular accident), 12% infectious (wound infection, sepsis), and 31% new arrhythmia (atrial fibrillation, atrial flutter, ventricular tachycardia, ventricular fibrillation). Despite these complication rates, average hospital stay was 17.5 days (median, 11 days), with an intensive care unit stay of 12.0 days (median, 5 days). Thirty-day survival was 95% and survival to discharge was 93% (three deaths total; one cardiac arrest at hospital day 134 and two perioperative deaths; one ventricular arrhythmia, one cerebral vascular accident). The only statistically significant risk factor of mortality was emergency surgery. Currently, 81% are still alive an average of 2.53 years since surgery (range, 0.16 to 7.1 years).

CONCLUSIONS: With improving techniques and greater attention to detail, the select nonagenarian can safely undergo cardiac surgery.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Since its inception in the 1950s, cardiac surgery, using the heart-lung machine, has been routinely performed on a daily basis worldwide [1, 2]. As the age of the population increases with time due to greater preventive medicine measures and better medical therapies for chronic diseases, these procedures are being performed in an ever-aging population [3]. Based upon population studies, life expectancy at the age of 80 is 8.5 years, and at the age of 85 and over, it is 6.3 years [4]. In a 2000 report by the US Census Bureau, it is estimated that there are currently 1.6 million nonagenarians and 72,000 centenarians, and by the year 2050, that estimate will have risen to 8.8 million nonagenarians and 1.1 million centenarians [5]. It has been demonstrated that elective cardiac surgery can safely be performed in octogenarians with minimal increase in mortality, however, at a price of increased morbidity [6–14]. Here, we present our data for cardiac surgical procedures in nonagenarians.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Over a 10-year period (1993 to 2002), 42 consecutive patients who were 90 years of age or older underwent cardiac surgical procedures at the New York Presbyterian Hospital-Weill Medical College of Cornell University and its affiliates. A retrospective analysis of these patients was performed. Their demographic profiles, perioperative results, and long-term outcomes were recorded. Information was obtained through chart review, telephone interview, the National Death Index, as well as consulting with their primary care physician or cardiologist. Operative data were collected, which included bypass and cross-clamp time, type of surgery, as well as intraoperative transfusion requirements. The postoperative course of the patients was also followed for transfusion requirements, intensive care unit (ICU) length of stay (ICULOS), total length of stay (TOTLOS), 30-day mortality, survival to discharge, and current survival. As of December 2001, follow up was 100% complete.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Patient profiles
The average age of our nonagenarian population was 91.4 years (range, 90 to 97 years). Twenty of the 42 patients were male. The ejection fraction (EF) was 43%, with a range of 20% to 77%. The majority of these patients (52%) demonstrated New York Heart Association (NYHA) class III or IV angina. Three patients lacked preoperative NYHA classification documentation. The most common medical comorbidities were hypertension, 67%; congestive heart failure (CHF), 52%; history of arrhythmias, 38%; history of myocardial infarction, 31%; and chronic renal insufficiency, 21% (Table 1). Eight percent of the patients in this study, representing 3 of 42, had previous cardiac surgery.


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  		Table 1. Comorbidities of Nonagenarians Undergoing Open Heart Surgery at New York Presbyterian Hospital-Weill Medical College of Cornell University

 
Operative characteristics
In all patients, the operative treatment was warranted by the severity of disease or failure of medical therapy to control their symptoms. Two coronary artery bypass graft (CABG) operations were performed off-pump, with 95% of the remaining cases utilizing cardiopulmonary bypass (CPB). Eighteen patients underwent CABG alone (mean number of grafts/patient, 2.7), and there were five aortic valve replacements (AVRs), 16 valve/CABG (10 AVR/CABG, three mitral valve replacements [MVR]/CABG, three AVR/MVR/CABG with an average of 1.8 grafts/procedure), and two ascending arch aneurysm repairs (one under circulatory arrest) (Table 2). Of the 42 patients, 9 (21%) were performed emergently, consisting of five CABG, two AVR/CABG, one AVR, and one ascending aneurysm. The average bypass time for the study population was 102 ± 43 minutes, and the cross-clamp time was 60 ± 32 minutes.


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  		Table 2. Operative Characteristics and In-Hospital Mortality by Procedure for Nonagenarians Undergoing Cardiac Surgical Procedures at the New York Presbyterian Hospital-Weill Medical College of Cornell University

 
Most patients (85%) required at least one unit of packed red blood cells (PRBCs) intraoperatively. This trend toward higher transfusions in this population is likely related to a lower threshold for transfusion and maintenance of higher hematocrits. The average transfusion was 3.1 ± 3.3 U of PRBC (range, 0 to 18 U), 0.9 ± 1.5 U of fresh-frozen plasma (FFP) (range, 0 to 6 U), and 3.7 ± 5.9 U of platelets (range, 0 to 24 U).

Postoperative outcome
Forty patients (95%) survived to day 30, with 93% surviving to discharge. Currently, 81% are still alive at a mean of 2.53 years since surgery (range, 0.16 to 7.1 years). There were two perioperative deaths, one after an episode of ventricular fibrillation (v-fib) on postoperative day 3, and the other from a stroke on postoperative day 8. The first death was a 90-year-old woman with an EF of 50% who had undergone an uneventful, elective three-vessel CABG, and on postoperative day 3, experienced a primary arrhythmic death. The patient who had died on postoperative day 8 was a 90-year-old woman who had undergone an emergent two-vessel CABG and suffered a perioperative stroke. Although she remained hemodynamically stable, the family ultimately withdrew care on postoperative day 8. The third hospital death occurred in a patient who had undergone an emergent three-vessel CABG and subsequently had multiple infectious complications, including pneumonia and klebsiella sepsis from a central line, chronic aspiration requiring a gastrostomy tube, renal failure requiring dialysis, and femoral pseudoaneurysm. On postoperative day 134, while awaiting operative repair of the pseudoaneurysm, the patient was found without vital signs unresponsive to full Advanced Cardiac Life Support (ACLS) protocol. In-hospital mortality of the group that had undergone emergency operations was 22% (2/9 patients) versus 3.0% (1/33 patients) in the group undergoing elective procedures (p = 0.05). The average ICULOS was 12.0 days (median, 5 days), postoperative LOS was 17.5 days (median, 11 days), and the TOTLOS was 19.8 days (median, 12 days) (Table 3).


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  		Table 3. Length of Stay and Survival Data of Nonagenarians Undergoing Cardiac Surgical Procedures at the New York Presbyterian Hospital-Weill Medical College of Cornell University

 
Postoperative complications were moderately increased when compared with our average population (Table 4). Twenty-eight patients (67%) had at least one complication, including arrhythmias, respiratory failure, infection, bleeding, or stroke. Arrhythmia was the most common complication, affecting 31% of our study population, the vast majority of which were atrial fibrillation and atrial flutter, largely responding to medical management. Fourteen percent (6/42 patients) ultimately required the placement of a permanent pacemaker. No patient required an Automatic Internal Cardiac Defibrillator. Five patients (12%) experienced respiratory complications, 2 with pneumonia and 3 with respiratory failure requiring reintubation, 1 of whom ultimately required tracheostomy. Other complications included hemorrhage (3/42) manifested as postoperative bleeding, two of which required operative reexploration; infection (5/42) consisting of one sternal infection requiring debridement, two leg infections treated with conservative management, and 1 patient with central line klebsiella sepsis that responded to line removal and intravenous antibiotics; and finally, one stroke resulting in death.


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  		Table 4. Postoperative Complications of Nonagenarians Undergoing Cardiac Surgical Procedures at the New York Presbyterian Hospital-Weill Medical College of Cornell University

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
There has been an increasing body of literature to support cardiac surgical procedures in the elderly, with initial reports of patients 70 years and greater (Table 5). There is a trend toward reduced mortality in more recent reports, with improving techniques and technologies related to patient selection, cardiopulmonary bypass, myocardial protection, and perioperative care. Undoubtedly, as the number of nonagenarians increases yearly across the country, surgeons will more frequently be asked to evaluate the possibility of undergoing cardiac surgery, provided that the surgeon, patient, and patient’s family understand that this patient group is at higher operative risk and greater risk of postoperative complications based solely on their age.


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  		Table 5. Summary of Literature on Cardiac Surgery in Elderly Patients

 
Four of the more recent studies of late septuagenarians and octogenarians report overall in-hospital mortality rates of 3.2%, 9.1%, and 13.5%, respectively [10, 15, 16]. Although there is only a small body of literature regarding cardiac surgery in nonagenarians, mortality rates have ranged from 7% to 18%, with morbidity ranging from 70% to 100% [17–19]. Our current study demonstrates an in-hospital mortality of 7% and a 30-day mortality of 5% in 42 consecutive patients over a 10-year period. Ko and associates [7] reported a decreased EF as well as emergency operation as two independent risk factors for mortality in octogenarians undergoing CABG. Rose and associates [20] associated the higher mortality rate in CABG patients more than 70 years of age with noncardiac organ failure. In a multivariate analysis of 182 octogenarians, Kolh and associates [12] found that NYHA functional class, urgent procedures, prolonged CPB, and, in patients undergoing AVR, previous percutaneous aortic valvuloplasty significantly increased the risk for in-hospital death. In the current report, the major cause of death was attributable to cardiovascular causes (cardiac arrest, ventricular arrhythmia, CVA) and was limited to the patient group undergoing CABG only. Emergency operation was a predictor of in-hospital mortality, with a sevenfold increase when compared with the elective group (22% vs 3.0%). EF did not seem to be a significant predictor of increased in-hospital mortality, with a range of 40% to 55% for patients who died in-hospital.

Although mortality can be minimized, hospital morbidity remains a significant problem in elderly patients undergoing cardiac surgical procedures. In Ko and associates’ study [7], morbidity ranged from 14% for elective to 67% for emergency CABG in octogenarians. In our review of the literature on octogenarian patients, we found reported postoperative morbidity to range from at least 20% to 68%, and 30-day mortality to range from 6% to 29% [21–24]. In an evaluation of advanced age on neurological risk of CABG, Tuman and coauthors [25] found an incidence of postoperative neurological events to be 8.9% for patients 75 years of age and older, 3.6% for ages 65 to 74 years, and 0.9% for ages less than 65 years. In the present study, the overall morbidity was 67%, representing 28 of the 42 patients having complications, including arrhythmias, respiratory (pneumonia, respiratory failure), infectious (wound, sepsis), and hemorrhagic or embolic (postoperative bleeding, CVA).

Operative considerations
The patient selection in this age group is critical, which has been well demonstrated in studies of cardiac surgery in the elderly population in general. The literature supports our observation that emergency operation was a positive predictor of increased in-hospital mortality when compared with a purely elective group. Ko and associates [7] demonstrated mortality rates of 33.3% for emergent cases, 13.5% for urgent cases, and 2.8% for elective cases in octogenarians undergoing CABG. Similarly, in a report by Alexander and associates [11], preoperative shock, preoperative hemodynamic assist device, or emergency procedures were all predictive of in-hospital mortality after CABG in octogenarians. Patients who were considered poor operative candidates were not offered surgical intervention. Emergency procedures in this population were not undertaken due to the high morbidity and mortality seen at our institution, which has also been corroborated in the literature. A history of multiple strokes, or any stroke that has left a physical deficit rendering a patient nonambulatory without assistance, were also excluded. We also consider severe end-organ dysfunction or insufficiency contraindications to operation because of the systemic stress and inability to tolerate the large fluid shifts involved in most open-heart procedures. These include hemodynamic (preoperative inotropic or pressor support), pulmonary (room air PCO2 > 50, PO2 < 60; forced expiratory volume in 1 second < 1.0 L; inability to clear secretions or if the patient is intubated), renal (on dialysis or if creatinine > 2.5), hepatic (evidence of elevated PT/PTT due to hepatic disease, Child’s B or greater), or social factors (long-standing alcohol or drug abuse, noncompliance with medical therapies).

Cardiothoracic surgeons must make prudent use of selection criteria in this population group lest the morbidity and mortality of the surgery become unacceptably high. The authors strongly recommend that surgical intervention be limited to the very elderly after they have exhausted their medical options and meet selection criteria. Flippant disregard of stringent criteria would lead to an unacceptably high rate of morbidity and mortality in this population.

Operative and postoperative care strategies were tailored to maximize recovery and minimize morbidity. Based upon previous studies conducted at our institution, our current practice is to maintain high perfusion pressures for elderly patients while on CPB [26, 27]. In this study, the mean perfusion pressure for the nonagenarians was maintained at 72 mm Hg. Consistent with Wu and associates’ [28] study of elderly patients with an acute myocardial infarction, our postoperative hematocrits were kept above 30% to maximize oxygen-carrying capacity. Bypass and aortic cross-clamp times were minimized. Finally, extubation criteria were liberalized and physical therapy was initiated early. Nonagenarians had longer ICULOS than younger patients, as part of a deliberate strategy to more closely monitor their postoperative recovery.

Conclusions
The literature supports offering surgical treatment to a select population of elderly patients who are disabled by their ischemic or valvular heart disease. Successful outcome can be expected in most patients with retained cardiac function, although surgical morbidity may be higher and the ICULOS and hospitalization longer, which ultimately translates into higher cost. Despite the lower safety margin for surgical treatment in the nonagenarian, the favorable outcome may justify the risk in a carefully selected group of these patients.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Rinku Uberoi, MD, for assistance in the collection of patient data.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

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Leonard N. Girardi
Charles A. Mack
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O. Wayne Isom
Leonard Y. Lee
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ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
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