Ann Thorac Surg 1997;63:1690
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Nevin M. Katz, MD
Division of Cardiothoracic Surgery Georgetown University Medical Center 3800 Reservoir Road, NW Washington, DC 20007-2197
See also page 1685.
This article documents well the effectiveness of cardiac operations in patients 90 years of age and over, but also the associated higher mortality, greater lengths of stay, and higher costs. Two important issues for the future are refinement of selection criteria and application of new techniques and patient care protocols.
Patients of advanced age tolerate complications poorly, and should complications occur, care may become exceedingly complex and costly, and the ultimate goal of restoring quality of life may be lost. Recognizing that surgical therapy can be quite effective in restoring quality of life in elderly patients but that health care resources are limited, the challenge is to refine selection criteria so that limited resources are maximized. The baseline characteristics of the patient group in the study by Blanche and colleagues suggest that a certain degree of selectivity was employed: there are relatively low incidences of peripheral vascular disease, renal dysfunction, diabetes mellitus, and ejection fraction less than 0.30. Unfortunately, the relatively small number of patients precluded application of multivariate statistical techniques. For example, it was not possible to study the effect of the the complexity of the procedure on outcome. Although summary data give the most persuasive conclusions as to risk factors, the study of individual cases may, in fact, provide important insight into specific preoperative and intraoperative factors that preclude a successful result. In this regard, it would be of interest to know the specific circumstances that were thought to cause the deaths due to postoperative heart failure.
This study extended over a 9-year period, and it was not possible to analyze the effect of recent advances in surgical techniques and patient care practices. Most rapid recovery protocols include prophylaxis against supraventricular arrhythmias. It is interesting to speculate, for example, if such a protocol would have decreased the relatively high incidence of supraventricular arrhythmias. Likewise, the recent practices of employing short-acting anesthetic agents and early extubation could have had an important effect on length of stay and associated costs.
This study emphasizes the importance of continuing developments in this field of cardiac surgery for elderly patients so that, in well defined circumstances, operation is considered appropriate, definitive treatment, rather than as treatment of last resort, preceded by multiple admissions for less effective therapy.
Related Article
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Cardiac Operations in Patients 90 Years of Age and Older
- Carlos Blanche, Jack M. Matloff, Timothy A. Denton, Steven S. Khan, Michele A. DeRobertis, Sharon Nessim, and Aurelio Chaux
Ann. Thorac. Surg. 1997 63: 1685-1690.
[Abstract]
[Full Text]
