Survival and Quality of Life for Nonagenarians After Cardiac Surgery

doi:10.1016/j.athoracsur.2013.02.034

The Annals of Thoracic Surgery

Volume 95, Issue 5, May 2013, Pages 1598-1602

https://doi.org/10.1016/j.athoracsur.2013.02.034 Get rights and content

Background

Reports of cardiac surgery in the elderly have focused primarily on septuagenarians and octogenarians. There are very limited data regarding risk-adjusted models in nonagenarians.

Methods

From 1983 to 2011, patients with age 90 years or greater at the time of coronary artery bypass grafting (CABG) or valve surgery (aortic or mitral) were retrieved from a prospective institutional database. A Cox proportional hazard model was used to determine significant predictors of 5-year survival. In addition, a 12-month assessment of quality of life was conducted.

Results

The CABG-only (n = 46), valve-only (n = 55), or CABG-valve (n = 53) surgery was conducted in 154 patients. Demographic characteristics were similar in all groups except for congestive heart failure, which was more prominent in the valve-only or CABG-valve groups (p < 0.0001). The 30-day mortality was 8.8%, 12.8%, and 18.9% in the CABG-only, valve-only, and CABG-valve groups, respectively, without significant difference among groups (p = 0.35). At 5-years follow-up, the Kaplan-Meier survival curves do not show a difference among groups (p = 0.62). Cox proportional hazard model for 5-year survival identified age (hazard ratio [HR] = 1.25, confidence interval [CI] 1.09 to 1.43, p = 0.001, for 1-year increase), prior surgery (HR = 2.23, CI 1.23 to 4.64, p = 0.007), and prior stroke (HR = 2.39, CI 1.25 to 3.98, p = 0.01), as significant predictors of mortality. The 12-month quality of life questionnaire revealed an improvement in 83% of the patients, whereas only 4% reported a decline in cardiac status.

Conclusions

Survival in nonagenarians is comparable after CABG or valve surgery. Redo surgery, stroke, and increasing age are significant hazards for mortality. Nonagenarians can undergo cardiac surgery with acceptable mortality and quality of life.

Section snippets

Study Population

The Cardiothoracic Surgery Quality Assurance Database at the Cedars Sinai Medical Center, Los Angeles, California, was queried to identify all patients 90 years of age or older who underwent open-heart surgery from 1983 to 2011. Three surgical categories were defined as the following: isolated coronary artery bypass graft (CABG-only); isolated aortic or mitral valve repair or replacement (valve-only), and combined CABG with aortic or mitral valve repair or replacement (CABG-valve). All patients

Results

From 1983 to 2011, a total of 154 patients 90 years of age or greater underwent open-heart surgery. The mean age was 91.4 years (range, 90 to 97 years), 40.9% (63 of 154) were women, the mean EF was 0.518 (interquartile range [IQR] 40.0% to 60.1%), 11.7% (18 of 154) had diabetes, 19.5% (30 of 154) had renal insufficiency (creatinine > 1.5 mg/dL), 62.3% (96 of 154) had hypertension, 62.3% (96 of 154) had CHF, 9.1% (14 of 154) had a history of CVA, and 14.9% (23 of 154) had a history of prior

Comment

The present study reports the largest single-center experience of cardiac surgery in nonagenarians, presenting early and long-term outcomes, quality of life data, and a risk model of long-term survival. Lichtman and colleagues [8], using the Medicare Provider Analysis and Report (MedPAR) file, analyzed the trends and outcomes of 4,224 nonagenarian patients undergoing CABG. However, administrative databases commonly lack essential clinical information to develop reliable risk models, and

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Available at http://www.census.gov/population/www/projections/summarytables.html. Accessed on September...

Cited by (17)

Transcatheter Aortic Valve Implantation in Nonagenarians: Procedural Outcome and Mid-Term Results
2018, Heart Lung and Circulation
Citation Excerpt :
Data on cardiac surgery in nonagenarians is rare and demonstrates high mortality and morbidity at 30 days and in long-term follow-up. Reported early mortality rates ranged between 7 and 18%, and perioperative morbidity rates were up to 77% [11–14]. Results of the present study demonstrated that TAVI can be performed safely and effectively even in nonagenarians.
For nonagenarians with symptomatic severe aortic stenosis transcatheter aortic valve implantation (TAVI) has become a feasible therapeutic option. Therefore, the aim of this study was to evaluate the procedural outcomes and mid-term follow-up in this patient group and compare this to octogenarians.
From 1359 patients who underwent TAVI at our institution between March 2009 and February 2016, 82 patients were nonagenarians and 912 were octogenarians. In nonagenarians, mean age was 91.9 ± 1.4 years and compared to octogenarians showed a significantly higher logistic EuroScore (27.7 ± 14.8% vs. 23.1 ± 14.4, p = 0.005) and STS Score (8.5 ± 4.8% vs. 6.3 ± 6.7, p = 0.001).
There were no significant differences with regard to stroke rate, pacemaker implantation rate and major vascular complications between the two groups. Thirty-day mortality was 9.8% in nonagenarians and 4.1% in octogenarians (p = 0.04). At 1 year, all-cause mortality increased to 30.9% vs. 18.6% (n.s.).
Nonagenarians showed an increased periprocedural mortality during TAVI and higher mortality in follow-up compared to octogenarians. Age alone is not a predictive factor but indication for treatment should be carefully evaluated by the heart team on an individual basis.
Comparison of Outcomes of Transcatheter Aortic Valve Implantation in Patients ≥90 Years Versus <90 Years
2015, American Journal of Cardiology
Citation Excerpt :
Notwithstanding, despite technological improvements, both surgical aortic valve replacement (SAVR) and CABG are still associated with higher complications rate and mortality in nonagenarians compared to younger patients.15,16 However, it was recently demonstrated in 2 noncomparative reports that excellent procedural and long-term outcomes can be achieved after cardiac surgery in nonagenarians.17,18 TAVI have emerged as a new treatment option which improves the clinical course of patients with severe symptomatic AS that are inoperable or have high surgical risk.3,4
Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS) is increasingly performed in nonagenarians. There is scarce evidence on the feasibility and safety of balloon-expandable TAVI in this patient population. A total of 734 patients who underwent balloon-expandable TAVI at our institute were included in the study. We compared 136 patients who were aged at least 90 years at the time of TAVI (mean age 92.4 ± 2.4 years) with the remaining 598 younger patients (mean age 79.7 ± 7.8 years). Valve Academic Research Consortium 2 end points were compared between the 2 groups. Diabetes mellitus, coronary artery disease (CAD), peripheral artery disease (PAD), and chronic lung disease were significantly less prevalent in patients aged ≥90 years. In contrast, the prevalence of frailty, chronic renal failure, and atrial fibrillation was significantly higher in these patients. Device success was 96% in both groups. All-cause mortality at 30 days and 1 year was 2.9% and 12.5% versus 2.8% and 12.3% in patients aged ≥90 and <90, respectively (p = 0.95 for both). All major complication rates were similar between groups. Nonagenarians had higher rates of minor vascular complications (13.2% vs 7.7%; p = 0.04). In conclusion, performing balloon-expandable TAVI in carefully selected group of nonagenarians is feasible and offers clinical benefit comparable to patients aged <90 years. Advanced age, in the absence of significant co-morbidities, should not deter clinicians from evaluating patients for TAVI for severe AS.
Outcomes of Treatment of Nonagenarians With Severe Aortic Stenosis
2015, Annals of Thoracic Surgery
Citation Excerpt :
Lastly, in our study, both SAVR and TAVR patients enjoyed a significant increase in QOL after valve replacement. One study of nonagenarians looked at a QOL questionnaire sent 1 year after cardiac surgery, and an improvement in 83% of patients was reported [19]; however, baseline testing was not performed. At 1 year, PARTNER trial cohort A patients who underwent TAVR demonstrated a mean increase in KCCQ compared with baseline of 28.7, and SAVR patients demonstrated a mean increase of 26.8 [25].
Because nonagenarians with aortic stenosis (AS) often present as frail with more comorbid conditions, long-term outcomes and quality of life are important treatment considerations. The aim of this report is to describe survival and functional outcomes of nonagenarians undergoing treatment for AS by surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR).
This is a retrospective analysis of all patients aged 90 years or more undergoing treatment for AS between 2007 and 2013 at two centers. Outcomes were compared between SAVR and TAVR. Long-term survival was compared with an age- and sex-matched population from the Social Security Actuarial Life Table.
In all, 110 patients underwent treatment for isolated AS (20 SAVR and 90 TAVR). Mean age was 91.85 ± 1.80 years, and 50.9% were female. The Society of Thoracic Surgeons mean predicted risk of mortality was 11.11% ± 5.74%. Operative mortality was 10.9% (10.0% SAVR; 11.1% TAVR); 2.7% of patients had a stroke. The TAVR patients were more likely to be discharged home (75.9% versus 55.6% for SAVR, p = 0.032). Mean follow-up was 1.8 ± 1.5 years, with a 1-year and 5-year survival of 78.7% and 45.3%, respectively, which approximated the US actuarial survival. There was a significant improvement in quality of life as measured by the Kansas City Cardiomyopathy Questionnaire at 1 year compared with baseline.
Treatment of AS approximates natural life expectancy in select nonagenarians, with no significant difference in long-term survival between SAVR and TAVR. Importantly, patient quality of life improved at 1 year. With appropriate selection, nonagenarians with severe AS can benefit from treatment.
Assessment of frailty in cardiovascular disease: A necessary challenge
2020, Revista Colombiana de Cardiologia
En el escenario clínico es cada vez más frecuente la atención de pacientes adultos mayores, lo cual es un desafío debido a la presencia de mayor comorbilidad y de condiciones o síndromes geriátricos (fragilidad, sarcopenia, caídas) que usualmente los acompañan. La fragilidad es un síndrome común en el paciente anciano, en quien existe una disminución de la reserva fisiológica que genera vulnerabilidad frente a factores estresantes. Su prevalencia aumenta a la par con la expectativa de vida, y tiene un impacto significativo en la salud pública ya que estudios han demostrado que se asocia con mayores tasas de hospitalización, desenlaces adversos quirúrgicos, mortalidad y costos para los sistemas de salud.
Se hace una revisión actualizada de la relación existente entre la fragilidad y la enfermedad cardiovascular. El conocimiento sobre fragilidad sirve como guía para tomar decisiones y como objeto de investigación de un segmento de una población con gran crecimiento.
The care of elderly patients is becoming increasingly more common in the clinical setting. This presents a challenge due to there being increased comorbidity and the presence of geriatric conditions or syndromes (frailty, sarcopenia, falls) that usually accompany them. Frailty is a common syndrome in the elderly patient, in which there is a decrease in physiological reserve that can lead to vulnerability to stress factors. Its prevalence increases on a par with life expectancy, and has a significant impact on public health since studies have demonstrated that it is associated with higher hospital admission rates, adverse surgical outcomes, mortality, and costs for the health systems.
An update review has been made on the existing relationship between frailty and cardiovascular disease. Knowledge about frailty will serve as a guide to make decisions and as an objective in the investigation of an increasingly growing segment of the population.
Investigation of the Effect of Nurse Counseling With Mechanical Valve Replacement Patients
2024, Research and Theory for Nursing Practice
Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study
2022, Frontiers in Cardiovascular Medicine

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Original articleAdult cardiacSurvival and Quality of Life for Nonagenarians After Cardiac Surgery

Background

Methods

Results

Conclusions

Section snippets

Study Population

Results

Comment

Am Heart J

J Thorac Cardiovasc Surg

Am J Cardiol

J Am Coll Surg

Ann Thorac Surg

Arch Gerontol Geriatr

Ann Thorac Surg

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Original article
Adult cardiac
Survival and Quality of Life for Nonagenarians After Cardiac Surgery