MITSOTAKIS SPEAKING

NEW YORK (Reuters Health) Jan 29 - Extreme old age itself is not a contraindication to cardiac surgery, but the patient's functional status, general physical condition, family support, and motivation should be taken into account when determining whether to operate, Italian researchers say.

Also, they write in the January 4 online issue of Circulation, outcomes in extreme old age are best after elective procedures at earlier stages of disease.

Age over 90 used to be an absolute contraindication to cardiac surgery, but with the aging population, surgeons are treating more cases of coronary or valvular disease in the oldest old, according to coauthor Dr. Giuseppe Nasso, from Anthea Hospital in Bari, and his colleagues.

To provide guidance for this "problematic field," the researchers reviewed a series of 127 patients, aged 90 and older (mean age 92, maximum 103), who had cardiac surgery between 1998 and 2008.

Surgery was refused to patients who were bedridden, without familial support, or who had a Duke Activity Status Index (DASI) of 10 or less. Operative mortality was defined as death within 30 days of surgery. Mean follow-up was 3.6 years (maximum 5 years).

Forty-five patients had nonelective surgeries. Overall, 60 study subjects had valve surgery, 49 had coronary surgery, and 18 had both valvular and coronary surgery. A total of 176 coronary grafts were implanted.

Seventeen patients (13.4%) died within 30 days, including 15 patients who had urgent surgeries. (By contrast, the New York State Department of Health reports that in 2006, 11,929 cardiac bypass surgeries were performed with a combined in-hospital and 30-day mortality rate of 1.92%.) When elective cases were analyzed separately, operative mortality was only 2.4%.

Fifty-four patients (42.5%) had at least one postoperative complication, with eight requiring intensive care unit readmission. The five-year mortality rate among survivors was 41%.

In multiple logistic regression analysis, nonelective presentation (OR 9.03, p < p =" 0.014)" p =" 0.03)">

New York Heart Association classifications improved after surgery in most patients.

The authors write, "Our experience strongly indicates that cardiac operations in these very elderly should not be considered beyond the limits of current practice but are supported if performed earlier and electively and if candidates are selected carefully."

They offer some additional suggestions: order preoperative physical therapy to improve pulmonary function; optimize nutritional status; and minimize pump time and cross-clamp time. In addition, their own protocols include reduction of priming volumes, use of biocompatible bypass circuits, and aggressive prevention of hemodilution and coagulation disorders.

Circulation 2010;121:208-213.