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Original Articles: Adult Cardiac

Invited Commentary

St. Joseph's Hospital, 640 Jackson St, MS11503k, St. Paul, MN 55101

(Email: robert.w.emery{at}healthpartners.com).

The article by Maganti and colleagues [1] is a contemporary and important contribution clearly delineating a cohort of patients at high risk for valve replacement, let alone a reoperation. Patients are surviving to very elderly ages and, as this report notes, are outliving the lifespan of prosthetic heart valves, including 75 of 112 reported patients with failed bioprostheses and an unnumbered subset of patients with failed valve repairs.

The mortality rate and 5-year survival of this population is quite acceptable. Unfortunately, the morbidity is not delineated except for postoperative bleeding at 10.5%, which carried an unacceptable 33% (5 of 15) mortality rate. Other surgical morbidities such as stroke, prolonged ventilation, or renal failure in the very elderly are debilitating, and the potential for such should be addressed preoperatively.

We have found frank discussions of realistic mortality rates and likely morbidity factors allow for more practical patient and family decision making regarding surgical procedures and allow us to often exceed expectations after an operation. Operating on the very elderly in our concept requires a team approach to care delivery providing preoperative conditioning (functional assessment and maximization through cardiac rehabilitation, respiratory training, nutrition optimization, and minimizing polypharmacy), obtaining maximization of other organ system function (geriatrics, coagulation, nephrology, and cardiology), timing of the surgical intervention (anesthesia, surgery), and postoperative recovery assistance (early extubation, minimizing narcotics as appropriate, cardiac rehabilitation, social services, and transitional care units). This team must be in place preoperatively, and full participation is a condition for operative intervention.

Further, all patients should have carotid ultrasound as a screening test to evaluate the likelihood of carotid disease, because transmitted murmurs are common. In our experience, emergency operations are eliminated, because the mortality rate of such operative procedures is prohibitive and rarely indicated.

Only by planning ahead will our profession be able to minimize morbidity and mortality and enhance the recovery of these increasingly numerous high-risk patients to an appropriate level and quality of life.

	References

Top References

 

1. Maganti M, Rao V, Armstrong S, Feindel CM, Scully HE, David TE. Redo valvular surgery in elderly patients Ann Thorac Surg 2009;87:521-526.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert W. Emery Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Emery, R. W. Articles by Hommerding, J. Search for Related Content PubMed PubMed Citation Articles by Emery, R. W. Articles by Hommerding, J. Related Collections Valve disease Related Article