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Ann Thorac Surg 2008;85:860-861. doi:10.1016/j.athoracsur.2007.11.001
© 2008 The Society of Thoracic Surgeons
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Original Articles: Cardiovascular

Invited Commentary

Cary W. Akins, MD

Cardiac Surgery, Massachusetts General Hospital, Cardiac Surgery - White 503, 55 Fruit St, Boston, MA 02114

(Email: cakins{at}partners.org).

Optimistic observers of America’s elderly contend that they have lifestyles more consistent with younger people of prior generations, "60 is not only the new 50 ... it’s the new 45" [1]. Extension of that philosophy to the truly elderly can be fraught with danger. Although surgeons realize physiologic age can differ from chronologic age, few suggest that today’s 90 is anything but yesterday’s 90. The reason resides in basic biology.

Saying "Americans live longer today" can be interpreted as false in one sense, yet true in another. By most accounts, advances in health care delivery have not increased the maximum lifespan for Homo sapiens by 1 minute; that is, genetics and environment impose an upper limit on length of life, organistic apoptosis, if you will. What health care improvements have accomplished is allowing more people to approach that maximum age. As we approach that age, the value of cardiac surgical interventions becomes harder to verify.

As one examines indications for cardiac surgery in increasingly older patients, one must address whether time of death is more important than quality of life before death. Prolongation of life is and should be the primary indication for cardiac surgery in younger patients, but for the truly elderly patient, quality of life should gain importance. The current study provides information about postoperative quality of life in only 12 survivors and does not describe the time to functional recovery. With genetically limited life expectancy, prolonged recovery from increased complications in someone older than 90 can make technical success a moot point.

While documenting the technical feasibility of cardiac surgery in highly selected nonagenarians, Ullery and colleagues [2] have correctly noted that financial feasibility needs to be studied. One difficulty for such an analysis will be to balance higher initial hospitalization costs against shorter life expectancy to justify (amortize) the intervention.

This study also highlights the paradoxical American approach to health care delivery in the elderly. Although most Americans will gladly engage in debate concerning the limitation of expensive health care in nonagenarians, that willingness disappears as soon as the patient in question is their spouse, parent, or elderly relative. As adult patients age, their personalized consent to cardiac surgery becomes increasingly important. A guilty child or unrealistic spouse is often a poor surrogate when assessing the risk–benefit ratio of cardiac surgery in nonagenarians, particularly for emergency interventions, emphasizing the value of advance directives.


   References
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 References
 

  1. Mundell EJ. HealthDay Newswww.healthday.comAccessed August 30, 2006.
  2. Ullery BW, Peterson JC, Milla F, et al. Cardiac surgery in select nonagenarians: should we or shouldn’t we? Ann Thorac Surg 2008;85:854-861.[Abstract/Free Full Text]

Related Article

Cardiac Surgery in Select Nonagenarians: Should We or Shouldn’t We?
Brant W. Ullery, Janey C. Peterson, Federico Milla, Martin T. Wells, William Briggs, Leonard N. Girardi, Wilson Ko, Anthony J. Tortolani, O. Wayne Isom, and Karl H. Krieger
Ann. Thorac. Surg. 2008 85: 854-860. [Abstract] [Full Text] [PDF]




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Right arrow Cardiac - physiology
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