Heart surgery in patients aged eighty years and above: Determinants of morbidity and mortality

Escalating medical costs, limitation of resources and the necessity to provide cost-effective medical care have created a need for systematic risk stratification and cost-benefit analyses in the background of an ongoing discussion. Results of heart surgery in octogenarians have been evaluated in a prospective single-center study since 1990. 101 consecutive patients (55/101 = 54.5% female) aged 80 years and above (median: 81 years; interquartile range [IQR]: 80.0 - 82.5, total range [TR]: 80-92 years) undergoing open heart surgery at our institution between January 1990 and March 1996 were included into this prospective study. Prior to surgery, most patients were severely symptomatic being in functional NYHA classes either III (56.4%) or IV (31.7%). 61/101 (60.4%) patients underwent isolated coronary artery bypass grafting (CABG), 23 (22.8%) had aortic valve replacement (AVR), 14 patients (13.9%) had CABG combined with AVR or double valve replacement and 3 (3.0%) had mitral valve repair. Follow-up (median: 23.0 months, IQR: 10.5-39.0, TR: 1-72) was focused on long-term morbidity and quality of life. The impact of preoperative and operative risk factors on morbidity and mortality was determined by uni-and multivariate statistical analysis. The 30-days overall mortality in this study was 7.9%. The postoperative course was uneventful for 27 (26.7%) of our patients. Univariate risk factors of postoperative mortality were: left main stem disease (p less than or equal to 0.044), ejection fraction < 45% (p less than or equal to 0.006), preoperative intensive care unit (ICU) (p less than or equal to 0.002), urgent OF emergency operation (p less than or equal to 0.034). The only independent predictor of operative mortality was preoperative ICU-stay (p less than or equal to 0.008). Significant risk factors for the number of postoperative complications in the multivariate analysis were: prior stroke (p less than or equal to 0.04), diabetes mellitus (p less than or equal to 0.02), New York Heart Association (NYHA) class IV symptoms (p less than or equal to 0.002) and prolonged crossclamping time (p less than or equal to 0.001). Mean postoperative length of stay in the ICU was 3.9 +/- 3.9 days. Late morbidity was not related to postoperative complications. Cumulative survival was 87.9%, 79.5% and 72.9% at one, two or five years, respectively. After hospital discharge, 67/93 patients (82.8%) were in NYHA functional class I or II. Cardiac surgery in Very elderly patients can be performed with acceptable operative risk and a favorable longterm outcome. The individual patient risk-profile including significant co-morbid conditions and severity of the heart disease predicts not only survival but the extent of perioperative morbidity.