Elderly patients are often discouraged from undergoing cardiac surgery procedures owing to the perception of high mortality and poor functional outcomes. This study evaluates long-term survival and quality of life after cardiac surgery in octogenarian and nonagenarian patients.
We identified a 459 patient cohort greater than 80 years of age who underwent elective cardiac surgery at our institution from 1994 to 1999. Survival was assessed with Kaplan-Meier analysis and compared with an age-matched and sex-matched population cohort. Among survivors, quality of life was assessed 8 years postoperatively using the Medical Outcomes Study Short Form 12 Health Survey, version 2. Risk factors for mortality were identified with Cox regression.
Operative mortality was 4.1%. Actuarial postoperative 5-year and 10-year survival was 53% and 27%, respectively. When compared with age- and sex-matched general population data, relative survival (excluding operative deaths) was 90.4% at 5 years and 78.7% at 10 years. Risk factors for late mortality included age greater than 85, male sex, low body mass index, renal failure, and postoperative respiratory failure. Survivors' median quality of life mental health score was higher (55.2 versus 48.9; p<0.05) and physical health score was equivalent (39.3 versus 39.8; p=0.66) to the general elderly population.
Cardiac surgery in the very elderly patient can be performed with low operative mortality, excellent long-term survival, and postoperative quality of life exceeding that of the general elderly population.
"Despite its almost universal usage, cardioplegia in its current form is associated with potential downsides rendering those cardioprotective regimens a less than optimal choice in certain clinical situations and certain patient collectives. 25% of the population over 75 years suffers from symptoms of cardiovascular disease , and as the elderly represent the fastest growing population demographic in industrialized nations, the proportion of elderly patients being evaluated for cardiac surgery is only expected to increase (the average age of cardiac surgical patients increased from 55.8 years to 68.8 years in the course of the last decade ). In general, the elderly represent a comorbidly ill patient population with a higher perioperative risk. "
[Show abstract][Hide abstract] ABSTRACT: The idea of protecting the heart from ischemic insult during heart surgery to allow elective cardiac arrest is as old as the idea of cardiac surgery itself. The current gold standard in clinical routine is a high potassium regimen added either to crystalloid or blood cardioplegic solutions inducing depolarized arrest. Ongoing patient demographic changes with increasingly older, comorbidly ill patients and increasing case complexity with increasingly structurally abnormal hearts as morphological correlate paired with evolutions in pediatric cardiac surgery allowing more complex procedures than ever before redefine requirements for cardioprotection.
Many, in part adversarial, regimens to protect the myocardium from ischemic insults have entered clinical routine; however, functional recovery of the heart is still often impaired due to perfusion injury. Myocardial reperfusion damage is a key determinant of postoperative organ functional recovery, morbidity, and mortality in adult and pediatric patients.
There is a discrepancy between what current protective strategies are capable of and what they are expected to do in a rapidly changing cardiac surgery community. An increased understanding of the molecular players of ischemia reperfusion injury offers potential seeds for new cardioprotective regimens and may further displace boundaries of what is technically feasible.
BioMed Research International 09/2014; 2014:325725. DOI:10.1155/2014/325725 · 2.71 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Health-related quality of life (HRQOL) is an important endpoint following cardiac surgery. Particularly in older age, HRQOL, rather than longevity, is the primary goal of treatment. However, prospective studies describing recovery and HRQOL are still scarce. Aims: To explore recovery patterns and HRQOL in patients undergoing cardiac surgery, emphasizing older patients ≥75 years of age. Methods: In a prospective population-based study, 534 patients (23% ≥75 years) were consecutively included before surgery. HRQOL, medical and socio-demographic variables were measured by questionnaires at baseline, 6 and 12 months after surgery. HRQOL was measured by the Short-Form Health Survey (SF-36). Results: Five hundred and twenty patients were alive 12 months after surgery, 89% responded after 6 and 12 months. Older patients as well as younger patients had a clear overall improvement in HRQOL over the first year after cardiac surgery, more specifically during the first 6 months. The same pattern was found in self-reported NYHA class which improved from baseline to 6 months and stabilized between 6 and 12 months. The only SF-36 scale with different development was Role Physical where younger patients improved more than older patients. Before surgery, patients had substantially lower scores than the population norms. However, on most dimensions of HRQOL older patients reached the level of the norm population after surgery. Conclusion: A selected group of elderly patients can undergo cardiac surgery with excellent results concerning survival and HRQOL. This is of major importance both discussing health care resources and decision making concerning individual patients.
European Journal of Cardiovascular Nursing 06/2011; 11(3):322-30. DOI:10.1016/j.ejcnurse.2011.05.002 · 1.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Transcather aortic valve replacement (TAVR) has rapidly gained worldwide acceptance for treating very high-risk patients with symptomatic severe aortic stenosis. Two valve systems are currently in common use worldwide and under trial in the United States. The Edwards SAPIEN valve has completed its PARTNER trial and has been approved for use in nonoperative patients. The Medtronic CoreValve is currently completing its US pivotal trial. Both plan studies of intermediate-risk patients. The use of TAVR in Europe has grown rapidly and is now about 23% of the total aortic valve replacements done in which a tissue valve is chosen (generally patients over 60 to 65 years of age). This technology is used in a patient population that was either not receiving any surgical therapy due to extreme risk or was considered very high risk for conventional surgery. The procedure requires a highly trained TAVR team, advanced imaging, and the devices themselves, which are expensive. Medical device trials are generally designed to establish if the device works as planned. For TAVR in today's world of rising health care costs, the additional question of cost effectiveness is important to address. Fortunately, the PARTNER trial addressed this and the CoreValve trial has built this into the trial design as well. This article examines what is currently known about the cost-effectiveness of TAVR.
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