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Ann Thorac Surg 2004;78:754
© 2004 The Society of Thoracic Surgeons
Herzzentrum Leipzig, Struempellstrasse 39, Leipzig 04289, Germany
e-mail: gumj{at}medizin.uni-leipzig.de
To the Editor:
Edwards and Taylor [1] reported outcomes in one of the largest series of nonagenarian patients undergoing cardiac surgical intervention. They found that in 35 nonagenarians who had aortic valve replacement, there was an apparent significantly higher risk of early mortality (17%) and morbidity (77%).
Outcomes evaluation in elderly patients is fundamental to our current understanding and planning of future health-care resource utilization because the current patient population is aging, and an increasing number of elderly patients are facing clinically important cardiovascular problems. It is estimated that the average 80-year-old person will live an additional 8 years and that 40% of them have symptomatic cardiovascular disease [2, 3].
However, few studies on nonagenarians exist, and most report varying outcomes, but do not critically address clear indications for cardiac interventions and their impact on quality of life rather than survival [4, 5]. It is common to assume in younger patients, a trade-off between a perioperative risk and a longer-term benefit often not observed for a few years [6]. However, this may not hold true for elderly patients in whom the perioperative risks are higher and whose chances of living long enough to experience the long term-benefits are smaller [6].
Edwards and Taylor did not provide detailed information on all patients in their study. They limited their analysis to only 51% (18/35) of patients. Information on all patients might have allowed one to identify trends and possibly risk factors for mortality and morbidity in nonagenarians. Despite these limitations, the 17.1% 30-day mortality rate among the 35 patients, 89% of whom underwent an elective procedure, suggests significant risks associated with cardiac surgical intervention in nonagenarians.
At our center, we evaluated outcomes in a group of 10 consecutive nonagenarians who underwent a variety of cardiac surgical interventions ranging from minimally invasive direct coronary artery bypass grafting to combined aortic valve, mitral valve, and coronary artery bypass grafting procedures. Contrary to the study by Edwards and Taylor, a majority of the procedures were performed on an urgent basis with an average EuroSCORE of 11 (range, 8–14), which is predictive of a mortality rate of 25% or higher. There were no intraoperative deaths, but many patients sustained major complications resulting in a freedom from death or major morbidity of only 25% and a mortality rate of 40%. Our findings confirmed that urgency is a well-known predictor of poor outcome in elderly patients [7].
One must be careful in interpreting the results from studies evaluating outcomes in nonagenarians because all involve small, select populations. This does not mean that cardiac procedures should be withheld from nonagenarians, but it indicates that we must pay increasing attention to preoperative patient selection to improve outcomes. All efforts should be made to address this problem by a variety of approaches such as combining data from multiple centers to increase statistical power or using meta-analysis techniques to combine already available publications to identify risk factors.
References
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