Cardiac surgery can be performed ‘carefully’ in nonagenarians
Click Here to Manage Email Alerts
Data show nonagenarians who underwent open heart surgery experienced no difference in operative mortality or in-hospital complications compared with octogenarians, researchers reported.
In a single-center database analysis, the researchers said the findings can serve as benchmark for risk stratification for cardiac surgery in this high‐risk population.
“With the progressive elderly population expansion, several studies have investigated cardiac surgery in the elderly, particularly in septuagenarians and octogenarians, and demonstrated favorable morbidity, mortality and quality of life,” Mohamed F. Elsisy, MD, of the department of cardiovascular surgery at Mayo Clinic, and colleagues wrote in the study background. “However, there is a dearth of data regarding outcomes of cardiac surgery in nonagenarians. The few studies that have been published are limited by small sample sizes with variable survival rates precluding meaningful risk stratification in this group of patients.”
In a retrospective study, Elsisy and colleagues analyzed data from 134 patients who were nonagenarians and underwent open heart surgery from 1993 to 2019, using the Society of Thoracic Surgeons database. The median age of patients was 92 years and 51% were women. Researchers included three surgical categories: isolated CABG, combined CABG and valve replacement or repair surgery, and isolated valve replacement or repair surgery.
Researchers compared outcomes, including operative mortality, defined as death occurring within the first 30 days after surgery, between nonagenarians and patients aged 80 to 89 years (n = 4,077). Median follow-up was 4 years.
The findings were published in the Journal of Cardiac Surgery.
Data comparable between groups
The researchers observed a stable incidence of cardiac surgery in nonagenarians over time, with a rate of 0.4% from 1993 to 2000, 0.5% from 2001 to 2010 and 0.4% from 2011 to 2019.
Valve surgery and CABG plus valve surgery were higher in nonagenarians compared with octogenarians, with rates of 44.8% vs. 35.6% and 39.6% vs. 30.7%, respectively. However, incidence of CABG was lower among nonagenarians vs. octogenarians (15.7% vs. 33.8%; P < .01). Urgent or emergent surgery status was similar between groups (P = .7), as was operative mortality (nonagenarians, 6%; octogenarians, 4.6%; P = .5) and hospital complications.
“Cardiac surgery can be performed in carefully selected nonagenarians with acceptable morbidity and mortality,” the researchers wrote. “This study represents one of the largest center single‐center experiences providing information regarding morbidity and mortality, and therefore can be beneficial in the development of risk stratification for patient selection and counseling patients and their families. Functional capacity and frailty testing will likely be increasingly used in decision‐making before cardiac surgery in the elderly.”
Rethinking operative strategies
In a related commentary, Sara Pereira, MD, professor of surgery in the division of cardiothoracic surgery at the University of Utah Health in Salt Lake City, wrote that the incidence of surgical aortic valve replacement in the Mayo cohort of nonagenarians and octogenarians declined to 0.3% during the study period, with all surgical AVRs performed in 2011.
“This brought operative mortality of surgical AVR down to 4% from 1993 to 2011, with comparable transcatheter AVR mortality of 1% from 2011 to 2019 in the reported group,” Pereira wrote. “The STS Predicted Risk of Mortality risk scores underrepresented the 30‐day mortality in nonagenarians in this patient cohort.”
Pereira said cardiac operations for older adults will continue to become more complex as transcatheter technologies grow, adding that preoperative risk assessment, frailty testing, functional status and structural heart team approach are important.
“Individualized patient and family discussions with palliative care teams are instrumental in clearly delineating postoperative expectations and goals of care, which aids the decision‐making process,” Pereira wrote.
Reference:
Collapse
Read more about
Click Here to Manage Email Alerts