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Ann Thorac Surg 2009;87:1379-1385. doi:10.1016/j.athoracsur.2009.01.045
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Cardiac Reoperation in Patients Aged 80 Years and Older

Markus Krane, MD*, Robert Bauernschmitt, MD, PhD, Andreas Hiebinger, Michael Wottke, MD, MPH, Bernhard Voss, MD, Catalin Constantin Badiu, MD, Rüdiger Lange, MD, PhD

Department of Cardiovascular Surgery, German Heart Center Munich, Munich, Germany

Accepted for publication January 20, 2009.

* Address correspondence to Dr Krane, German Heart Center Munich, Department of Cardiovascular Surgery, Lazarettstr 36, Munich, 80636, Germany (Email: krane{at}dhm.mhn.de).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: The benefit of cardiac surgery in octogenarians is well described. Today, nearly every second patient who undergoes cardiac surgery is older than 70 years. The time between primary cardiac surgery and reoperation is 7 to 13 years. Therefore, in the future we can expect to see an increasing number of reoperations in octogenarians.

Methods: We studied 71 patients (41 male) with a mean age of 83 ± 2.8 years, who underwent cardiac reoperation between 1994 and 2006. These patients were compared with 71 octogenarians who underwent primary cardiac operation. Patients were matched for age, sex, year of operation, and surgical procedure. Demographic profiles, operative data, long-term survival, and quality of life by the Short-Form 36-Item Health Survey questionnaire were analyzed.

Results: Average time between previous operation and reoperation was 10.8 ± 5.6 years (range: 1.7 to 30.6). The 30-day mortality rate was 14.7% in the reoperation group and 8.5% (p = 0.43) in the control group. Actuarial survival at 1, 3, and 6 years was 71% ± 5.5%, 60.5% ± 6.1%, and 30% ± 8.1% for patients who underwent cardiac reoperation; and 77.2% ± 5%, 58.3% ± 6.3%, and 36.3% ± 7.8% for matched octogenarians who underwent primary cardiac surgery (p = 0.68). No significant differences were found between groups regarding the physical health summarized score (40.7 ± 9.4 versus 39.1 ± 10; p = 0.55) and the mental health summarized score (51.9 ± 10.9 versus 48 ± 12.9; p = 0.24) of the Short-Form 36-Item Health Survey questionnaire.

Conclusions: Octogenarians exhibit a similar long-term survival and quality of life after primary and redo cardiac surgery. Therefore, cardiac reoperation should not be a contraindication per se in octogenarians.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
People aged 80 years and older are an increasing population. In 2050, more than 10% of the German population will be older than 80 years [1]. Parallel to the aging German population, nearly every second patient undergoing cardiac surgery is older than 70 years (from 24.9% in 1994 to 45.3% in 2005), and octogenarians undergoing open heart surgery increased from 2.3% in 1994 to 8.4% in 2005 [2]. Mean interval between primary cardiac operation and cardiac reoperation is 7 to 13 years [3, 4]. Therefore, we can expect more octogenarians for cardiac reoperation in the future.

Different studies reported higher rates for operative mortality and postoperative complications in octogenarians [5, 6] undergoing primary cardiac surgery. Alexander and colleagues [7] reported a significantly increased in-hospital mortality for coronary artery bypass graft surgery (CABG) [8.1% versus 3%]) and aortic valve replacement (AVR) plus CABG (10.1% versus 7.9%) among 4,743 octogenarians compared with younger patients (both p < 0.05). In their study, incidences of postoperative complications like renal failure, neurologic events, and perioperative myocardial infarction were also significantly increased among patients aged 80 years and older compared with younger patients (p < 0.05).

Only a few studies have investigated the outcome of octogenarians undergoing cardiac reoperation. These studies reported varying results (for example, an early mortality rate between 5.5% and 32%) or included only small patient numbers [8–11]. Because of a lack of information regarding reoperations in octogenarians, we analyzed our experience for postoperative outcome and long-term survival after reoperation. Furthermore, the current status of quality of life (QoL) was assessed using the standardized Short-Form 36-Item Health Survey Questionnaire (SF-36).


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Patients
The study was approved by the Ethics Committee of the Technical University Munich, medical faculty (file number 2284/08). Data were selected from the electronic database of the Department of Cardiovascular Surgery of the German Heart Center Munich. Between 1994 and 2006, 71 patients aged 80 years and older underwent cardiac reoperation procedures. Preoperative demographic profiles, operative, and postoperative data were obtained from medical records. Late follow-up was obtained from questionnaires and from the German registration office. Data were analyzed and compared with octogenarians of a matched control group who underwent primary cardiac operation. Patients were matched for sex, age, operative procedure (reoperation of the study group versus first operation of the control group), and the year of operation. The study design was retrospective.

Short-Form 36 Health Survey Questionnaire
The SF-36 was used to evaluate the quality of life in the study and control group. The test is validated for different age groups, especially for elderly patients [12]. The SF-36 consists of 36 items grouped in eight general health categories: physical functioning, role-physical, role-emotional, social functioning, mental health, bodily pain, vitality, and general health. The number of possible responses per item varies from 2 to 6. The eight categories could be grouped into two summarized scores: the physical health score (physical functioning, role-physical, bodily pain, and general health) and the mental health score (role-emotional, social functioning, mental health, and vitality). For each category, scores are calculated and transformed to a scale from 0 to 100, with higher scores reflecting a better quality of life. The questionnaire evaluates the status of quality of life for the last 4 weeks. The SF-36 questionnaire was sent by mail to the survivors of both groups.

Statistical Analysis
Results are presented as mean ± 1 SD. Dichotomous variables are given as percentage. For comparisons of dichotomous variables, Fisher's exact test was used. The t test was used to compare continuous variables. Actuarial survival was calculated with the Kaplan-Meier method. Comparisons between groups were made by the log-rank test. To evaluate results of the SF-36, the t test for comparisons by means was used. Results of the SF-36 were presented as mean ± 1 SE. All statistical analyses were performed using SPSS 15 software (SPSS, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Demographics
Between 1994 and 2006, 71 patients (41 men and 30 women) underwent cardiac reoperation. Mean age of the study group was 82.97 ± 2.76 years, and that of the control group was 82.96 ± 2.74 years. During the study period, the number of patients undergoing cardiac reoperation increased continuously (Fig 1). Primary operative procedures of octogenarians who underwent cardiac reoperation are listed in Table 1. Between both groups, no significant differences were found for preoperative myocardial infarction, preoperative New York Heart Association functional classification, percentage of emergent or urgent surgery, prevalence of atrial fibrillation, renal failure expressed as a serum creatinine concentration greater than 1.3 mg/dL, diabetes mellitus, body mass index, hypertension, and hypercholesteremia. Demographics and preoperative concomitant diseases of the study group and the control group are shown in Table 1.


Figure 1
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  		Fig 1. Annual number of cardiac reoperations in octogenarians between 1994 and 2006.

 

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  		Table 1 Preoperative Characteristics
 
Intraoperative Data
Cardiac reoperation procedures of the study group and matched procedures of the control group are listed in Table 2. Mean time between previous operation and reoperation was 10.8 ± 5.6 years (range: 1.7 to 30.6). In the study group, average operative time was 282.5 ± 88.3 minutes compared with 198.5 ± 57.4 minutes in the control group. For patients who underwent cardiac reoperation, cardiopulmonary bypass time was 118.3 ± 43.3 minutes compared with 103.7 ± 42.3 minutes for patients who underwent primary cardiac surgery. Differences for operative time (p = 0.001) and cardiopulmonary bypass time (p = 0.045) between both groups were statistically significant. No differences between groups were found for aortic cross-clamp time (75 ± 29.8 versus 72.4 ± 22.4 minutes; p = 0.57).


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  		Table 2 Operative Characteristics
 
Hospital Morbidity
Hemodynamic instabilities requiring an intra-aortic balloon pump (IABP) were significantly increased in the study group compared with the control group (15.5% versus 5.6%; p = 0.049). The median length of intensive care unit stay was 4 days in both groups. The median length of hospital stay was 11 days for octogenarians undergoing cardiac reoperation and 10 days for octogenarians undergoing primary cardiac surgery. The difference failed to be significant (p = 0.09). Detailed postoperative characteristics of both groups are given in Table 3.


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  		Table 3 Postoperative Characteristics
 
Thirty-Day Mortality Rate and Long-Term Survival
Follow-up was obtained for 98.6% patients (n = 140), with 2 patients being lost for follow-up. Thirty-day mortality was 14.1% in the group with cardiac reoperation compared with 8.5% in the control group. This difference was not statistically significant (p = 0.43). At 1, 3, and 6 years, survival of patients in the control group (77.2% ± 5%, 58.3% ± 6.3%, and 36.3% ± 7.8%, respectively) was not different (p = 0.68) compared with survival of patients who underwent cardiac reoperation (71% ± 5.5%, 60.5% ± 6.1%, and 30% ± 8.1%, respectively; Fig 2A). Owing to the heterogeneous structure of the study population the 30-day mortality rate and the long-term survival were calculated separately for matched patients undergoing CABG or AVR with or without CABG. The 30-day mortality rate for these patients was 8.7% in the reoperation group and 4.3% for primary operation (p = 0.34). Long-term survival of these patients at 1, 3, and 6 years in the control group (80% ± 6%, 57% ± 7.8%, and 38.6%, respectively) was also not different (p = 0.97) compared with patients who underwent cardiac reoperation (76.1% ± 6.3%, 65.6% ± 7.3%, and 32.6% ± 9.2%, respectively; Fig 2B).


Figure 2
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  		Fig 2. Actuarial survival of patients aged 80 years and older who underwent primary cardiac operation (dashed line) compared with octogenarians who underwent cardiac reoperation (solid line). (A) All patients of the study and control group. (B) Matched patients who underwent coronary artery bypass graft surgery or aortic valve replacement with or without coronary artery bypass graft surgery.

 
Quality of Life
Thirty-three patients in the group of cardiac reoperations and 35 patients in the control group are still alive. In the study group, 28 of 33 patients (84.8%), and in the control group, 30 of 35 patients (85.7%) were able to participate in the SF-36. No significant differences were found regarding the assessed variables: physical functioning, role-emotional, social functioning, mental health, bodily pain, vitality, and general health. Octogenarians undergoing cardiac reoperation scored higher for role-physical compared with patients of the control group (70.2 ± 7.6 versus 45.9 ± 4.5; Fig 3). The improved score for role-physical failed to be significant (p = 0.06). For physical health (40.7 ± 9.4 versus 39.1 ± 10; p = 0.55) and mental health summarized scores (51.9 ± 10.9 versus 48 ± 12.9; p = 0.24), no significant differences between the study group and the control group were found.


Figure 3
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  		Fig 3. Results of the Short-Form 36-Item Health Survey Questionnaire (SF-36) of the study group (black bars) compared with the control group (white bars). *p = 0.06. (BP = bodily pain; GH = general health; MH = mental health; PF = physical functioning; RE = role-emotional; RP = role-physical; SF = social functioning; VT = vitality.)

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Figure 1 describes the increasing numbers of cardiac reoperation among patients aged 80 years and older, correlating with the generally increasing numbers of cardiac operations among octogenarians [13, 14]. Gummert and colleagues [2] described an increasing population (24.9% in 1994 versus 45.3% in 2005) of patients aged 70 years and older who underwent first cardiac operation in Germany. In our study, the time between primary and cardiac reoperation was 10.8 ± 5.6 years. Therefore, in the future, cardiac surgeons will be confronted more frequently with patients aged 80 years and older requiring cardiac reoperation.

Postoperative Morbidity
Craver and colleagues [5] found a significantly increased rate for the requirement of an IABP in 601 octogenarians (3.7%) compared with younger patients (aged 70 to 79 years, 2.1%; aged 60 to 69 years, 1.5%). Gosh and colleagues [10] described, in 18 octogenarians who underwent cardiac reoperation, an incidence of 16.6% for the postoperative use of an IABP. These reported incidences for the use of an IABP in octogenarians for primary cardiac operation and cardiac reoperation are similar to our findings. Odell and colleagues [15] reported, in 145 patients with a mean age of 71 years who underwent AVR after previous CABG, a high incidence of 18.6% for the use of an IABP. In conclusion, octogenarians showed a higher incidence for hemodynamic instabilities requiring an IABP compared with younger patients. Octogenarians who underwent cardiac reoperation showed a higher rate for the use of an IABP compared with octogenarians who underwent primary cardiac surgery.

Eitz and associates [9] reported a significantly increased rate for rethoracotomy among 71 octogenarians who underwent redo AVR (11.3%) compared with primary AVR (1.4%). We found a comparable rethoracotomy rate of 9.9% among octogenarians who underwent cardiac reoperation.

Thirty-Day Mortality and Long-Term Survival
In our study population, the 30-day mortality rate among patients undergoing primary cardiac operation was 8.5%, and for cardiac reoperations it was 14.1%. The difference of the 30-day mortality rate was not statistically significant (p = 0.43), probably caused by the small patient number in our study population. Table 4 summarizes the operative mortality rate given as 30-day or hospital mortality rate of previously published studies on reoperation procedures in octogenarians [8–11]. The overall calculated operative mortality rate was 13.84% (31 of 224), comparable to our 30-day mortality rate of 14.1%.


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  		Table 4 Published Series of Cardiac Reoperations in Octogenarians
 
Previous studies on octogenarians undergoing primary open heart surgery revealed higher in-hospital mortality rate when compared with younger patients. Bardakci and colleagues [16] reported that 8,170 octogenarians who underwent CABG had a significantly increased in-hospital mortality rate of 5.1% as compared with 0.9% to 2.7% for younger patients (p < 0.001). Alexander and colleagues [7] also reported a significantly increased in-hospital mortality rate for 4,743 octogenarians who underwent CABG (8.1% versus 3%) or AVR plus CABG (10.1% versus 7.9%) compared with younger patients (both p < 0.05).

Results of studies comparing the early mortality rate among patients younger than 80 years between primary and cardiac reoperation are controversial. Sundt and colleagues [3] found no difference for the 30-day mortality rate among patients who underwent AVR with or without CABG as reoperation procedure (7.7%) compared with patients who underwent primary AVR plus CABG (6.3%) [3]. They concluded that the risk of AVR after previous CABG is similar to that for primary AVR plus CABG. In contrast, Salomon and coworkers [17] found a significantly increased operative mortality rate among patients younger than 80 years who underwent CABG as reoperation procedure (6.9%) as compared with patients who had CABG as their primary operation (2%).

Owing to the high operative mortality rate among octogenarians—in particular, among octogenarians who underwent cardiac reoperation—special emphasis has to be placed on surgical treatment options to improve the surgical outcome. During the last years, new transapical or percutaneous transarterial approaches for AVR were developed. Walther and colleagues [18] reported a study of 59 patients who underwent transapical AVR (aged more than 75 years) with a European System for Cardiac Operative Risk Evaluation (EuroSCORE) predicted risk for mortality of 27%. In their study, the actual 30-day mortality was 13.6% even for these high-risk patients. Grube and colleagues [19] reported a series of 86 patients (aged more than 75 years) undergoing percutaneous transarterial AVR with a 30-day mortality of 12%. In their study, the predicted EuroSCORE for mortality was 21%.

We were not able to identify preoperative risk factors for the early mortality among octogenarians who underwent cardiac reoperation because of an insufficient statistical power due to a limited patient number. For preoperative patient selection, different studies found reduced ejection fraction, previous myocardial infarction, preoperative renal insufficiency, urgent or emergency surgery, and chronic obstructive lung disease as independent predictors for the in-hospital mortality of octogenarians who underwent primary cardiac surgery [7, 13, 16, 20, 21]. He and colleagues [22] described emergency status (p = 0.0001), reduced ejection fraction (p = 0.0002), sex (p = 0.011), and history of arrhythmia (p = 0.023) as independent preoperative variables for the operative mortality in patients younger than 80 years who underwent cardiac reoperation.

Eitz and colleagues [9] reported that for 71 octogenarians with AVR reoperation, long-term survival at 1 year and at 3 and 5 years was 76.1%, 70.8%, and 57%, respectively, compared with 87.3%, 70.4%, and 51.3%, respectively, for octogenarians who underwent primary AVR. The difference for actuarial survival was not statistically significant (p = 0.646). These findings are similar to our results regarding differences in long-term survival between octogenarians who underwent primary surgery and cardiac reoperation.

In summary, cardiac surgery for octogenarians is related to a higher 30-day mortality rate compared with younger patients. Cardiac reoperation is probably associated with a higher operative mortality compared with primary cardiac surgery. There are no established independent risk factors for operative mortality of octogenarians undergoing cardiac reoperation. Therefore, established independent risk factors for operative mortality of octogenarians who underwent primary cardiac surgery and established independent risk factors for patients who underwent cardiac reoperation have to be taken into account for patient selection. Transapical or transcatheter AVR were possible surgical treatment options to improve the high operative mortality rate of octogenarians who need aortic valve replacement as a reoperation procedure.

Quality of Life
In addition to survival, the evaluation of the postoperative quality of life provides more complete information about the outcome after cardiac surgery. We used the SF-36 to evaluate the QoL. The retrospective study design did not allow the comparison of QoL between preoperative and postoperative status, so it cannot be concluded whether the scores reflect an improvement in QoL.

Blanche and colleagues [8] reported that, among octogenarians who underwent cardiac reoperation, 80% to 90% of the survivors had an improvement and a satisfying functional status after cardiac reoperation, whereas 5% to 15% noted no real changes after cardiac reoperation. The data were evaluated by a formal and validated QoL questionnaire. Fruitman and colleagues [23] also used the SF-36 for evaluation of the QoL in 103 octogenarians who underwent cardiac surgery. They described for role-physical and role-emotional significantly increased scores for octogenarians compared with a general population. Tseng and coworkers [24] reported their results with 70 of 159 survivors aged between 70 and 89 years who underwent aortic valve replacement. Their study population scored better for seven of eight categories compared with a general population. For the mental health score alone, their study population showed a clearly decreased score compared with the standard population aged 75 years and older of the SF-36. Both studies also used the SF-36 to evaluate the QoL after cardiac surgery procedures in a retrospective study design.

Quality of life of octogenarians undergoing primary cardiac surgery is comparable to an age-related general population. Quality of life for octogenarians undergoing cardiac reoperation is similar to that for octogenarians undergoing primary cardiac surgery. For the evaluation of an improvement in QoL after cardiac surgery, further prospective trials with a preoperative and postoperative comparison are necessary.

In conclusion, cardiac reoperation for octogenarians showed a high early mortality. Therefore, the decision for cardiac reoperation has to be carefully made with respect to established independent risk factors for octogenarians undergoing primary cardiac surgery and established risk factors for cardiac reoperation. Primary cardiac surgery and cardiac reoperation for octogenarians showed a similar long-term survival and QoL. Therefore, cardiac reoperation should not be a contraindication per se for patients aged 80 years and older, and this kind of surgery should not be reserved for younger patients alone.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Eisenmenger M, Pötsch O, Sommer B. [11. koordinierte Bevölkerungsvorausberechnung Deutschlands bis 2050.]Wiesbaden: Statistisches Bundesamt; 2006.
  2. Gummert JF, Funkat A, Beckmann A, Hekmat K, Ernst M, Krian A. Cardiac surgery in Germany during 2005: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery Thorac Cardiov Surg 2006;54:362-371.
  3. Sundt TM, Murphy SF, Barzilai B, et al. Previous coronary artery bypass grafting is not a risk factor for aortic valve replacement Ann Thorac Surg 1997;64:651-658.[Abstract/Free Full Text]
  4. Akins CW, Hilgenberg AD, Vlahakes GJ, Madsen JC, MacGillivray TE. Aortic valve replacement in patients with previous cardiac surgery J Card Surg 2004;19:308-312.[Medline]
  5. Craver JM, Puskas JD, Weintraub WW, et al. 601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups Ann Thorac Surg 1999;67:1104-1110.[Abstract/Free Full Text]
  6. Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R. Cardiac surgery in octogenarians. Peri-operative outcome and long term-results. Eur Heart J 2001;22:1235-1243.[Abstract/Free Full Text]
  7. Alexander KP, Anstrom KJ, Muhlbaier LH, et al. Outcomes of cardiac surgery in patients > or = 80 years: results from the National Cardiovascular Network J Am Coll Cardiol 2000;35:731-738.[Abstract/Free Full Text]
  8. Blanche C, Khan SS, Chaux A, et al. Cardiac reoperations in octogenarians: analysis of outcomes Ann Thorac Surg 1999;67:93-98.[Abstract/Free Full Text]
  9. Eitz T, Fritzsche D, Kleikamp G, Zittermann A, Horstkotte D, Körfer R. Reoperation of the aortic valve in octogenarians Ann Thorac Surg 2006;82:1385-1391.[Abstract/Free Full Text]
  10. Ghosh P, Holthouse D, Carroll I, Larbalestier R, Edwards M. Cardiac reoperations in octogenarians Eur J Cardiothorac Surg 1999;15:809-815.[Abstract/Free Full Text]
  11. Kirsch M, Nakashima K, Kubota S, Houel R, Hillion ML, Loisance D. The risk of reoperative heart valve procedures in octogenarian patients J Heart Valve Dis 2004;13:991-996.[Medline]
  12. Lyons RA, Perry HM, Littlepage BNC. Evidence for the validity of the Short-Form 36 Questionnaire (SF-36) in an elderly population Age Ageing 1994;23:551-567.
  13. Akins CW, Daggett WM, Vlahakes GJ, et al. Cardiac operations in patients 80 years old and older Ann Thorac Surg 1997;64:606-615.[Abstract/Free Full Text]
  14. Kirsch M, Guesnier L, LeBesnerais P, et al. Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy Ann Thorac Surg 1998;66:60-67.[Abstract/Free Full Text]
  15. Odell JA, Mullany CJ, Schaff HV, Orszulak TA, Daly RC, Morris RJ. Aortic valve replacement after previous coronary artery bypass grafting Ann Thorac Surg 1996;62:1424-1430.[Abstract/Free Full Text]
  16. Bardakci H, Cheema FH, Topkara VK, et al. Discharge to home rates are significantly lower for octogenarians undergoing coronary artery bypass graft surgery Ann Thorac Surg 2007;83:483-489.[Abstract/Free Full Text]
  17. Salomon NW, Page US, Bigelow JC, Krause AH, Okies JE, Metzdorff MT. Reoperative coronary surgery. Comperative analysis of 6591 patients undergoing primary bypass and 508 patients undergoing reoperative coronary artery bypass. J Thorac Cardiovasc Surg 1990;100:250-259.[Abstract]
  18. Walther T, Simon P, Dewey T, et al. Transapical minimally invasive aortic valve implantation. Multicenter experience. Circulation 2007;116(Suppl 1):240-245.
  19. Grube E, Schuler G, Buellesfeld L, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome J Am Coll Cardiol 2007;50:69-76.[Abstract/Free Full Text]
  20. Peterson ED, Cowper PA, Jollis JG, et al. Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years or older Circulation 1995;92(Suppl 2):85-91.[Abstract/Free Full Text]
  21. Williams DB, Carrillo RG, Traad EA, et al. Determinants of operative mortality in octogenarians undergoing coronary bypass Ann Thorac Surg 1995;60:1038-1043.[Abstract/Free Full Text]
  22. He GW, Acuff TE, Ryan WH, He YH, Mack MJ. Determinants of operative mortality in reoperative coronary artery bypass grafting J Thorac Cardiovasc Surg 1995;110:971-978.[Abstract/Free Full Text]
  23. Fruitman DS, MacDougall CE, Ross DB. Cardiac surgery in octogenarians: can elderly patients benefit?. Quality of life after cardiac surgery. Ann Thorac Surg 1999;68:2129-2135.[Abstract/Free Full Text]
  24. Tseng EE, Lee CA, Cameron DE, et al. Aortic valve replacement in the elderly. Risk factors and long-term results. Ann Surg 1997;225:793-804.[Medline]

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