DOI: 10.1016/j.athoracsur.2007.10.074 2008;85:854-860 Ann Thorac Surg

Krieger Leonard N. Girardi, Wilson Ko, Anthony J. Tortolani, O. Wayne Isom and Karl H.

Brant W. Ullery, Janey C. Peterson, Federico Milla, Martin T. Wells, William Briggs, Cardiac Surgery in Select Nonagenarians: Should We or Shouldn’t We?

http://ats.ctsnetjournals.org/cgi/content/full/85/3/854located on the World Wide Web at:

The online version of this article, along with updated information and services, is

Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. Copyright © 2008 by The Society of Thoracic Surgeons.

is the official journal of The Society of Thoracic Surgeons and theThe Annals of Thoracic Surgery

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ardiac Surgery in Select Nonagenarians:hould We or Shouldn’t We?

rant W. Ullery, BA, Janey C. Peterson, EdD, MS, Federico Milla, MD,artin T. Wells, PhD, William Briggs, PhD, Leonard N. Girardi, MD, Wilson Ko, MD,nthony J. Tortolani, MD, O. Wayne Isom, MD, and Karl H. Krieger, MD

epartment of Cardiothoracic Surgery, Center for Complementary and Integrative Medicine, Weill Cornell Medical College, New

ork, New York, and Department of Statistical Science, Cornell University, Ithaca, New York

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Background. Patients aged 90 years and older representrapidly growing subset of the population, many ofhom are functionally limited by cardiovascular disease.linical decision making about cardiac surgical interven-

ion in nonagenarians is hindered by a paucity of dataxamining survival outcomes in this population.Methods. A consecutive series of nonagenarians who

nderwent cardiac operations between 1995 and 2004ere retrospectively reviewed. Data collection includedaseline preoperative clinical status, intraoperative char-cteristics, and perioperative course. Area under theaplan-Meier survival estimate method was used to

alculate mean survival.Results. Cardiac surgical procedures were done in 49

atients (51% male); their mean age was 91.9 years (range,0 to 97 years). Operative mortality was 8% (n � 4).

ultivariate Cox proportional hazards models found

reoperative chronic renal insufficiency (hazard ratio

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ntegrative Medicine, Weill Cornell Medical College, 1300 York Ave, Box6, New York, NY 10021; e-mail: jcpeters@med.cornell.edu.

2008 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p �.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00;

� 0.033) were independently associated with death.verall mean survival was 5.1 � 0.5 years (median, 5.2

ears). Quality of life outcomes were similar to that ofwo related norm-based populations based on age andisease process.Conclusions. Cardiac surgical procedures can be per-

ormed safely and with therapeutic benefit in carefullyelected nonagenarians. We consider physiologic indi-ators, social factors, and patient preferences to be theain determinants in the patient selection process.ur results support the need for more proactive inter-

ention in symptomatic nonagenarian patients as itelates to earlier consideration of elective, rather thanmergency cardiac operations.

(Ann Thorac Surg 2008;85:854 – 61)

© 2008 by The Society of Thoracic Surgeons

uccessful outcomes in elderly patients after cardiacoperations have been well documented during the

ast three decades, beginning with the exploration ofardiac surgical intervention in septuagenarians by

eyer and colleagues [1] in 1975 and later in octogenar-ans by Rich and colleagues [2] in 1985. A host of reportsave since followed these landmark studies [3–9]. Inecent years, observational series of nonagenarians haveemonstrated that carefully chosen nonagenarians canndergo cardiac operations with favorable survival out-omes despite greater perioperative and postoperativeomplications compared with younger elderly groups10–16].

Reports targeting cardiac operations in nonagenariansre limited. The current data are insufficient to ade-uately assess early to mid-term outcomes of cardiacurgical intervention and guide clinical practice. In addi-ion, a variety of statistical methods and survival defini-ions have been used in reporting survival outcomes inrevious reports, leading to an inability to compareesults across the few existing studies in this area. This

ccepted for publication Oct 23, 2007.

ddress correspondence to Dr Peterson, Center for Complementary and

tudy reports a large series of nonagenarians at a singlenstitution and adds to the literature by reporting a longollow-up period. In addition, the current study reportsuality of life outcomes on a subset of survivors. We aim

o advance existing literature by offering a long-term,omplete statistical portrait of survival outcomes in no-agenarians. Furthermore, we aim to expand on previousfforts related to quality of life outcomes in thisopulation.

aterial and Methods

ll patients 90 years of age or older who underwentardiac operations between May 1995 and October 2004t New York Presbyterian Hospital-Weill Cornell Medi-al Center were identified. The medical records werehen retrospectively reviewed in 2005. Eligible cardiacperations included coronary artery bypass graftingCABG), valve replacement procedures, thoracic aorticrocedures, or combinations therein. Approval was ob-

ained from our Institutional Review Board to conducthis study. Individual patient consent was obtained onlyor those patients willing to participate in the quality ofife assessment; consent was not obtained in nonpartici-

ants because no patient was identified.

0003-4975/08/$34.00doi:10.1016/j.athoracsur.2007.10.074

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A retrospective analysis was performed using chartxtraction to assess preoperative clinical profile, intraop-rative characteristics, and postoperative status. Presencef coronary risk factors and comorbidities were recorded,nd the Charlson comorbidity index [17] was calculated.perative data were collected, including type of surgicalrocedure, bypass and cross-clamp times, and meanrterial pressure (MAP) during bypass. The perioperativend postoperative course was followed up for the occur-ence of complications or death, transfusion require-ents, use of inotropes and vasopressors, length of stay

LOS), and discharge plans.The current disposition of all patients was reassessed

n 2005 through chart review, or communication with theatient or the patient’s primary care physician, cardiolo-ist, or family members. The Social Security Death Index

able 1. Demographic and Clinical Characteristicsf Nonagenarians

ariable No. %

ex, male 25 51isk factorsHypertension 38 78Smoking history 17 35Hypercholesterolemia 16 33Arrhythmia 15 31Prior myocardial infarction 23 47Diabetes mellitus 9 18COPD 11 22Chronic renal insufficiency 10 20Prior CVA 7 14Peripheral vascular disease 12 24

resenting symptomsAngina 37 76Congestive heart failure 37 76

harlson index0–1 12 242–3 25 51�4 12 24YHA functional classI 1 2II 21 43III 17 35IV 10 20

VEF�0.50 13 270.30–0.50 31 63�0.30 5 10

rior interventionCABG 1 2Valve replacement 2 4Intraaortic balloon pump 5 10Abdominal surgery 19 39

ABG � coronary artery bypass grafting; COPD � chronic obstructiveulmonary disease; CVA � cerebrovascular accident; LVEF � left ven-

ricular ejection fraction; NYHA � New York Heart Association.

18] was used to locate lost patients. For survivors, the p

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edical Outcomes Study Short Form 12 (SF-12) Healthurvey, version 2 [19] was used to assess quality of life.

tatistical Analysisll data were imported and analyzed using R [20], Stata[21], and SAS 8e software [22]. For all analyses, statis-

ical significance was set at a p � 0.05. Differences inroportions were analyzed using �2 and the Fisher exact

est. Mean differences for continuous variables wereompared using Student t test. A Bonferroni correctionas used to adjust for multiple comparisons. A multivar-

ate Cox proportional hazards regression analysis Akaikenformation criterion (AIC) model selection procedure23] was undertaken to identify independent predictorsor survival. Survival curves were calculated using theaplan-Meier method to determine survival outcomes

or the cohort.Hazard ratios with corresponding 95% confidence in-

ervals (CI) and p values were calculated for univariateox regression models. Each of these analyses was strat-

fied by gender and robust standard errors were used24]. A forced AIC model selection procedure [25] wassed to select the three best fitting covariates for theultivariate model. In addition, robustness of the infer-

ntial results for the three variable Cox model wasssessed using a bootstrap methodology [26]. All of theox models were validated using Schoenfeld residuals

24]. To account for censoring, the area under the Kaplan-eier survival estimate method [27] was used to calcu-

ate mean survival, and the median survival was calcu-ated from the 50th percentile of the Kaplan-Meierurvival estimate.

esults

atient Demographic and Preoperativelinical Profileshe baseline demographic and clinical profile is summa-ized in Table 1. The mean age of patients at the time ofurgery was 91.9 � 1.6 years (range, 90 to 97 years).reoperatively, 55% of patients demonstrated New Yorkeart Association (NYHA) functional class III or IV heart

ailure. The mean preoperative ejection fraction (EF) was.44 � 0.12 (range, 0.20 to 0.70). The most commonreoperative comorbidities were hypertension, 78%; con-estive heart failure (CHF), 76%; angina, 76%; and prioryocardial infarction, 47%. Six percent (3/49) of patients

ad undergone previous cardiac operations.

erioperative and Operative Characteristicshe procedures were CABG alone in 22 patients (45%;ean of 2.7 grafts per patient), aortic (AVR) or mitral

alve replacements (MVR) in 9 (18%), CABG/valve pro-edures in 15 (31%), ascending aortic aneurysm repairs in(4%), and CABG/ascending arch dissection repair in 1atient.Cardiopulmonary bypass (CPB) was used for 47 oper-

tions, and two CABG procedures were performed off-

ump. One-third of cases were emergencies, consisting

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f nine CABG, one AVR, three CABG/AVR, two ascend-ng aortic aneurysm repairs, and one CABG/ascendingortic aneurysm repair. The average bypass and cross-lamp times were 94.4 � 36 minutes and 52.7 � 25inutes, respectively.Most patients (88%) required transfusion periopera-

ively, with transfused patients receiving a mean of.97 � 3.0 U of packed red blood cells. Fifteen patients31%) required both fresh frozen plasma and platelets forerioperative bleeding. For patients who were placed onPB, MAP was maintained at 74 � 11 mm Hg (range, 52

o 90 mm Hg). Thirty-two patients (65%) required inotro-ic or vasopressor support during their perioperativeourse. Mean intensive care unit LOS was 10.8 daysmedian, 5 days; range 1 to 134 days), and the meanverall LOS was 20.1 days (median, 12 days; range, 4 to36 days).

n-Hospital Morbidity and Mortalityrrhythmia was the most common complication, occur-

ing in 57% of patients. One-third experienced respira-ory complications, and 25% of these patients requiredeintubation. Infection occurred in 18% of patients; of

able 2. Hazard Ratios for Single Variable Coxegression Models

ariableHazardRatio 95% CI p Value

hronic renal insufficiency 3.06 1.24–7.59 0.016a

jection fraction 0.97 0.95–1.00 0.031a

ge 1.25 0.94–1.66 0.125ew York Heart Association 1.71 1.10–2.65 0.017a

ongestive heart failure 1.42 0.60–3.39 0.424rior myocardial infarction 1.65 0.75–3.63 0.209ypertension 0.97 0.48–1.97 0.934ngina 1.71 0.70–4.15 0.236OPD 0.58 0.19–1.73 0.326eripheral vascular disease 0.40 0.14–1.08 0.071harlson comorbidity index 1.24 0.98–1.56 0.071otal cardiovascular morbidityb 1.82 1.12–2.95 0.015a

otal noncardiovascularmorbidityc

0.68 0.29–1.57 0.368

Statistically significant. b Includes prior myocardial infarction ortroke, congestive heart failure, diabetes, peripheral vascular disease, andhronic renal insufficiency. c Includes dementia, solid or hematologicalignancy with or without metastatic disease, lymphoma, ulcer, ac-

uired immunodeficiency syndrome, as well as pulmonary, hepatic, orheumatic disease.

OPD � chronic obstructive pulmonary disease.

able 3. Hazard Ratios for Multivariate Cox Proportionalazards Model

ariable Hazard Ratio 95% CI p Value

hronic renal insufficiency 4.88 1.53–15.55 0.007a

eripheral vascular disease 0.28 0.07–1.10 0.069jection fraction 1.03 1.00–1.06 0.031a

dStatistically significant.

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hese, 50% (n � 5) were leg wounds at the harvest site,0% (n � 1) were at the sternotomy site, and 40% (n � 4)ere other types of infection requiring antibiotic treat-ent (eg, Clostridium difficile). Other postoperative com-

lications included renal failure, 18%; cerebrovascularccident, 10%; bleeding, 6%; and tamponade, 4%. Aermanent pacemaker was required in 16%. At least oneostoperative complication occurred in 76% of patients.The operative mortality, defined as death occurring

n-hospital or within 30 days after operation, was 8% (4 of9). One early death involved a 90-year-old woman whonderwent an elective three-vessel CABG and died fromardiac tamponade on postoperative day 3. A secondarly death occurred in a 90-year-old woman who had anmergency ascending aortic aneurysm repair and two-essel CABG. The patient experienced perioperativeleeding and ultimately died secondary to a cerebrovas-ular accident on postoperative day 8. The other twoarly deaths were a result of multiorgan failure second-ry to sepsis. One patient was a 93-year-old woman whonderwent an elective MVR and died on postoperativeay 12, and the other patient was a 90-year-old man whoad an emergency three-vessel CABG and died on post-perative day 132. The in-hospital mortality rate wasigher in patients undergoing emergency operations,3% (2 of 16) compared with patients undergoing electiveperations, 6% (2 of 33), but this difference was notignificant.

redictors of Mortalityingle variable Cox proportional hazards models foundreoperative chronic renal insufficiency (CRI), EF, sever-

ty of heart failure (ie, higher NYHA class), and increas-ng total cardiovascular comorbidity were associated withncreased mortality (Table 2). The forced AIC modelelection procedure selected CRI, peripheral vascular

ig 1. Survival curve (solid line) using Kaplan-Meier estimates for9 nonagenarians who underwent cardiac surgical procedures. Theashed lines are the 95% confidence intervals.

isease, and EF as the three best fitting covariates for the

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ultivariate model. As summarized in Table 3, multi-ariable Cox regression analysis demonstrated CRI (p �.007) and decreasing EF (p � 0.031) as independentredictors of death.

urvival Outcomessurvival curve for our cohort of 49 patients with 95%

Is is presented in Figure 1. Overall mean survival was.1 � 0.5 years (median, 5.2 years). Survival was notignificantly different between operation types. Actuarialurvival rates for 1, 2, and 3 years were 80% (95% CI, 0.69o 0.92), 69% (95% CI, 0.59 to 0.83), and 67% (95% CI, 0.54o 0.82), respectively.

In the follow-up period, 22 of the 45 patients whourvived to hospital discharge had died. Mean survivalime for those who died was 3.4 years (median, 3.0 years;ange, 0.1 to 8.8 years). Noncardiac causes were respon-ible for 36% (8 of 22) of patient deaths, specifically,erebrovascular accident in 2, respiratory failure in 1, andomplications from other surgeries or hospitalizations in. Four patients (18%) died from cardiopulmonary-elated causes, consisting of myocardial infarction in 1,ongestive heart failure in 2, and pulmonary embolism in. Ten patients died of unknown or undetermined causes.

uality of Lifet follow-up in 2005, the 23 patients who were still aliveere contacted, and the SF-12 was used to assess qualityf life. For these survivors, a mean of 4.0 years hadlapsed since their operation (median, 3.6 years; range,.2 to 9.5 years). The interview was completed by 12 of the3 patients (52%), with the remaining survivors unable toomplete the interview because of neurocognitive de-line in 7, refusal in 3, or language barrier in 1. Becauseo normative data exist for nonagenarians only, the

unctional status of our nonagenarian cohort was com-ared with available normative data for individuals aged

5 years or older, and no statistically significant differ- s

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nce was demonstrated in any of the domains of theF-12 (Fig 2). When compared with normative data foreart disease patients, our nonagenarian cohort reportedsignificantly higher score in the General Health domain

p � 0.01) and similar scores in the remaining domains.

omment

he current study represents an encouraging addition tohe small body of literature examining outcomes amongonagenarian cardiac surgical patients. In this study, wexpand the assessment of therapeutic benefit to includeot only reduced morbidity and mortality but also in-reased survival and quality of life outcomes.

atient Selectionur cohort represents a highly selective subgroup ofonagenarians. Selection criteria were based on our 20ears of experience operating on elderly patients andere not guided by age alone. Previous reports have

hared in the observation that it is the physiologic statusf the patient, and not the chronologic age, that morelosely correlates with clinical outcome [10, 11]. Ourreoperative evaluation of patients focused on the levelf physiologic and social functioning, the individualatient’s operative risk, and the patient’s personal moti-ation to undergo a surgical procedure.All patients in our study presented preoperatively with

ignificantly reduced cardiac function (eg, angina, CHF)efractory to medical treatment resulting in an expected-month survival of approximately 10%. Physiologic fac-ors considered by the surgeon included baseline livernd renal function, EF, cognitive resilience, previousardiac surgery, and ambulatory status. Assessment ofocial functioning included emotional and tangible socialupport, social integration and community involvement,s well as activity level. Utilization of home health

Fig 2. Quality of life for nonage-narians (black bars) comparedwith patients aged 75 years andolder (gray bars) and those withheart disease (clear bars) rated bythe Medical Outcomes StudyShort Form 12 (SF-12) HealthSurvey. * The nonagenarian co-hort scored significantly higher inthe general health domain com-pared with heart disease patients(p � 0.01). a Mean SF-12 scoresfor a sample of about 850 individ-uals in the general population 75years of age or older [19]. bMeanSF-12 scores for a sample ofabout 650 individuals in the gen-eral population with heart disease(mean age, 65.6 years; female,50.8%) [19].

ervices, such as a nursing home or assisted-living cen-

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er, by itself did not preclude operation. In general, ourxclusion criteria consisted of an operative risk of 50% orore, severe liver or renal disease, an inability to ambu-

ate semi-independently or communicate, and radio-raphic evidence of significant gray matter loss or recenterebrovascular accident.

rends in Perioperative Mortalitypart from Bridges and colleagues’ report [28], seventher studies have examined outcomes in nonagenariansndergoing cardiac procedures (Table 4) [10–16]. Thearliest of these investigations date back to the 1990s andogether demonstrate a mean operative mortality of 12%range, 7% to 18%) [10–12, 14]. Results of the currenttudy closely reflect the operative mortality of 7% re-orted in previous work at our center [15] and support

he hypothesis that carefully selected nonagenarians canafely undergo cardiac surgical intervention with mortal-ty rates that approach those of younger elderlyopulations.Independent predictors of mortality after cardiac op-

rations among nonagenarians are beginning to be elu-idated. Bridges and colleagues [28] identified five majorreoperative risk factors for operative mortality using aational database: emergency/salvage procedures, in-

raaortic balloon pump, renal failure, peripheral vascularisease or cerebrovascular disease, and mitral insuffi-iency. An earlier report [15] also found emergencyperation to be a significant risk factor in this population.e corroborated these original findings by reporting

reoperative CRI as an independent predictor of mortal-ty, with a 4.9-fold increase in the odds of dying.

ostoperative Morbidity: An Ongoing Concernespite the promising downward trend in overall mor-

ality, postoperative morbidity remains a significant con-ern. Our review of existing literature found reportedostoperative morbidity among nonagenarians undergo-

ng cardiac procedures of 56% to 100% [10–13, 15, 16].Recent investigations have concentrated on methods of

educing complications after cardiac operations, includ-ng two studies demonstrating the efficacy of prophylac-

able 4. Summary of Literature on Cardiac Surgery in Nonag

eries, First Author Time FramePatients,

No.Morbid

(%)

sai, 1994 [14] 1983–1993 15 . . .amuels, 1996 [10] 1987–1995 14 71lanche, 1997 [11] 1986–1995 30 �70iller, 1999 [12] 1987–1996 11 100

dwards, 2003 [13] 1986–2000 35 77acchetta, 2003 [15] 1993–2002 42 67evy Praschker, 2006 [16] 1990–2002 30 56urrent series 1995–2004 49 76

Indicates in-hospital or 30-day surgical mortality rate. b Mean survivied in-hospital). c In the absence of data censoring (i.e. assuming all

ic amiodarone in the reduction of postoperative arrhyth- v

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ias and arrhythmia-related mortality [29, 30]. Inddition, reports have suggested a host of perioperativetrategies to curtail the development of postoperativeulmonary dysfunction and nosocomial infection (eg,neumonia), including optimization of pulmonary dys-

unction in at-risk patients [31, 32], use of the off-pumpechnique in at-risk patients and those with advancedulmonary disease [33], and use of immunotherapy as andjunct to antibiotics in the setting of refractory pulmo-ary infection [34]. Substantial risk reduction of nosoco-ial infection has also been associated with perioperative

econtamination of the nasopharynx and oropharynx [35].Our current management incorporates several other

erioperative strategies to optimize postoperative out-ome. In our opinion, the two most important strategiesn this population relate to the maintenance of higherfusion pressures while on CPB [36] as well as the

undamental understanding that cardiac procedures inonagenarians should center on repair of the life-

hreatening lesion only. To that end, we limit bypass andross-clamp times. Transfusion requirements are alsodjusted to maintain a hematocrit above 30%. Finally, wese an aggressive approach to extubation to promotearly ambulation and physical therapy.

urvival Outcomesurvival outcomes represent an important measure ofperative success among nonagenarians. The currenttudy offers a comparison between available data in thisopulation [10–16]. This comparison demonstrates im-rovement in the field over time relative to similarrevious reports.Mean survival of nonagenarians surviving to discharge

as been previously reported to be between 1.6 [16] and.9 [10] years, and Blanche and colleagues [11] reported aedian survival of 2.6 years. The current study demon-

trates continued survival gains, with an overall meannd median survival that exceeds 5 years. Natural lifexpectancy for our cohort (mean, 91.9 years) is 2.76 yearsor men and 3.94 for women [37]. Thus, our data demon-trate that nonagenarians can successfully undergo car-iac operations with the potential to surpass or, at the

ians

Mortalitya

(%)

Survival, Years Actuarial Survival Rates (%)

Mean Median 1-Year 2-Year 3-Year

13 . . . . . . 87 73 537 2.9b . . . . . . . . . . . .

10 . . . 2.6 81 75 . . .18 2.5b . . . . . . . . . . . .17 . . . . . . 74 74 . . .7 . . . . . . . . . . . . . . .

20 1.6b . . . 67 43 . . .8 5.1c 5.2c 80 69 67

atients surviving to discharge only (denominator excludes patients whotients died), mean survival is 3.5 years (median, 3.1 years).

enar

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uality of Life as a Marker of Operative Successith limited health care resources in a growing managed

are environment, cardiac surgery in nonagenarians re-uires a critical assessment of health-related quality of

ife measurements. Tsevat and colleagues [38] exploredealth values of the very old and determined that lon-evity may not be the primary therapeutic end point inhis population. Indeed, there has been a recent move-

ent in the field of medicine toward better appreciationf qualitative outcomes [39, 40].Quality of life after cardiac operations in nonagenari-

ns has not been well described. In their follow-up on 27perative survivors, Blanche and colleagues [11] reported9% were satisfied with their overall perceived functionalmprovement. Miller and colleagues [12] also noted sat-sfactory and sustained improvements in all nine of theirperative survivors. In the present study, we demon-trate that select nonagenarians are capable of achievingavorable quality of life outcomes similar to that ofvailable normative data for two related populationsased on age (ie, 75 years or older) and the diseaserocess (ie, heart disease).

tudy Limitationshis study shares in the limitation of previous studieselating to small sample size and the ability to generateultivariate predictors of death from the data therein.oreover, the heterogeneity of surgical interventions in

ur cohort precludes similar statistical analyses by oper-tion type. The retrospective nature of this review alsoerves as a limitation because the absence of a controlroup prohibits the comparison of alternative treatmentsuring the same time period. In addition, our quality of

ife investigation included a small, self-selected group ofurvivors and represents only a cross-sectional assess-ent in the postoperative setting.

ardiac Surgery: Should We or Shouldn’t We?lthough some clinicians will challenge the benefit of

urgical intervention in nonagenarians, cardiac sur-ery may represent a more efficacious therapeuticodality given that optimal medical treatments and

ercutaneous coronary intervention (PCI) have failedo reduce the elevated risks in elderly patients. Previ-us studies have reported a high risk of restenosis forlderly patients undergoing PCI as well as higherortality rates after PCI than conventional open-heart

perations [41– 45].The multifactorial nature of the increased morbidity

nd mortality observed in nonagenarians likely extendseyond the age-related decline in physiologic function.he suggestion that worse surgical outcomes may be a

unction of biased selection and subsequent delayedeferrals is not without merit [4, 11]. Moreover, delayinglective operations in elderly patients as result of lateeferral may increase the likelihood of future emergencyurgical intervention should invasive measures be later

ursued.

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Despite significant progress in achieving better sur-ival outcomes, the debate regarding cardiac surgery inonagenarians will likely persist until such interventionan reliably demonstrate additional improvements inong-term survival, and more important, quality of life.uture efforts should aim to further improve resultsoward those obtained in younger patients. Longitudinalnvestigations on the topic of long-term, health-relateduality of life in this population are warranted and will

ikely play an increasingly important role in the evalua-ion of the efficacy of cardiac operations in elderlyatients.

onclusionsespite increased perioperative morbidity, carefully se-

ected nonagenarians can undergo cardiac operationsnd achieve favorable quality of life and survival out-omes that restore their projected life expectancy. Agelone is not an absolute contraindication to surgicalntervention; patient selection remains the ultimate pre-ictor of clinical outcome. Accordingly, our results sup-ort the potential for more proactive intervention inymptomatic nonagenarians as it relates to earlier con-ideration of elective, rather than emergency cardiacurgery.

eferences

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6. Davis WJ 3rd, Vaynblat M, Chiavarelli M, et al. Open heartsurgery in patients 85 years and older. J Card Surg 2004;19:7–11.

7. Alexander KP, Anstrom KJ, Muhlbaier LH, et al. Outcomesof cardiac surgery in patients � or � 80 years: results fromthe National Cardiovascular Network. J Am Coll Cardiol2000;35:731–8.

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NVITED COMMENTARY

ptimistic observers of America’s elderly contend thathey have lifestyles more consistent with younger peoplef prior generations, “60 is not only the new 50 . . . it’s theew 45” [1]. Extension of that philosophy to the trulylderly can be fraught with danger. Although surgeonsealize physiologic age can differ from chronologic age,ew suggest that today’s 90 is anything but yesterday’s 90.he reason resides in basic biology.Saying “Americans live longer today” can be inter-

ccounts, advances in health care delivery have notncreased the maximum lifespan for Homo sapiens by 1

inute; that is, genetics and environment impose anpper limit on length of life, organistic apoptosis, if youill. What health care improvements have accomplished

s allowing more people to approach that maximum age.s we approach that age, the value of cardiac surgical

nterventions becomes harder to verify.As one examines indications for cardiac surgery in

ncreasingly older patients, one must address whether

0003-4975/08/$34.00doi:10.1016/j.athoracsur.2007.11.001

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DOI: 10.1016/j.athoracsur.2007.10.074 2008;85:854-860 Ann Thorac Surg

Krieger Leonard N. Girardi, Wilson Ko, Anthony J. Tortolani, O. Wayne Isom and Karl H.

Brant W. Ullery, Janey C. Peterson, Federico Milla, Martin T. Wells, William Briggs, Cardiac Surgery in Select Nonagenarians: Should We or Shouldn’t We?

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