Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes

Clin Geriatr Med 22 (2006) 559–574

Cardiac Surgery in the Elderly: Indications and Management Options to Optimize Outcomes Vincent Conti, MD*, Scott D. Lick, MD Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA

Cardiovascular disease remains the most common cause of morbidity and mortality in the United States, with coronary artery disease and congestive heart failure the leading etiologies, particularly in the elderly [1,2]. Although medical treatment and percutaneous interventions have become more effective, surgical procedures, primarily coronary artery bypass graft (CABG) and cardiac valve repair and replacement, frequently are the best options for many older patients to improve their longevity and their quality of life [3–6]. As this has become more evident and as improved operative techniques and perioperative management have evolved during recent years, cardiac surgery increasingly is offered to the older population. Although this trend has been strongest in the United States, reports of relatively large series of patients in their seventh and eighth decades of life from other countries support the idea that cardiac surgery in the elderly increasingly is accepted as safe and beneficial in patients who are chosen properly [7–14]. There is a major difference, however, in attitudes in various countries, which can be illustrated by comparing experiences reported in the United States with those from the United Kingdom and Canada [15,16]. In a description of cardiac valve procedures in advanced elderly patients, in particular those over age 90, a report from England analyzed the entire United Kingdom registry from the late 1980s and the 1990s [15]. An average of approximately one patient 90 years or older was operated on each year in the United Kingdom in the late 1980s and early 1990s, which increased to approximately 5 per year in the late 1990s. This can be contrasted to the experience in the United States as reported by the Society of Thoracic Surgeons database in the 4-year period

* Corresponding author. E-mail address: [email protected] (V. Conti). 0749-0690/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cger.2006.04.001 geriatric.theclinics.com

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from 1997 to 2000 [17]. Even though this database does not include all United States cardiac surgical centers, there were more than 100 patients each year aged 90 and greater who underwent isolated valve or combined coronary valve procedures during the late 1990s. This same difference in approach for elderly patients undergoing CABG after acute myocardial infarction existed in Canada [16], but more recent reports from Canada [9,12,13] indicate a significantly more liberal use of cardiac surgery in the elderly, thus closing the differences relative to the United States. Indications for operationdgeneral considerations A central factor in the decision regarding when and whether or not to perform cardiac operations in the elderly is a realistic estimate of the risk of the procedure versus the projected benefits. In general, risk is higher with increasing age for all procedures and, on the benefits side, the decreased longevity with increasing age changes the strength of the indication for operation when prolonging life is considered the operative indication rather than disabling symptoms. Therefore, the clearest indication for operation in the elderly age group is the presence of symptoms that compromise the quality of life when these symptoms are the result of the cardiac lesion to be corrected and likely to resolve or improve with successful operation. When significant symptoms related to the cardiac lesion are not present, then the indication for operation comes under the category of ‘‘prophylaxis.’’ It is done, therefore, to improve longevity by preventing cardiac-related mortality or to prevent future cardiac events, especially acute myocardial infarction and deterioration of left ventricular function. For this to be a valid indication for operation, the risk of the operation must be low, the protective effect of the operation must be significant, and the expected longevity of patients, considering age and general medical condition, must be reasonably long. Examining survival curves in patients, such as those who have three-vessel coronary disease with moderate left ventricular dysfunction initially assigned to CABG versus medical therapy [18] in the classic randomized coronary artery surgical study, a significant survival benefit is seen at approximately 4 to 5 years after operation (Fig. 1A). Patients were asymptomatic or minimally symptomatic at randomization, but all these patients were less than or equal to 65 years of age. Therefore, when dealing with patients over 80 years of age with the expected perioperative mortality in the range of 7% rather than 2.5% (Fig. 1B) [19], extrapolating the same survival curves with medical versus surgical therapy, a significant survival benefit may be evident only beyond 7 years, which is longer than the average life expectancy in this age group [20]. For this indication for operation of increasing longevity and preventing future events to be valid, the risk with continued medical therapy must be considerably higher than in that seen in younger age groups, and the perioperative mortality and the protective effect of the operation must yield a survival expectation superior to that of continued medical therapy.

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A

N

EF < 0.50 77

81

78

100

82

75

71

37 100

59

77

N

80

80

Percent Survival

76

80

75 72

69

60

58

60 36

40

40 Legend Surgically Assigned Medically Assigned

20

20 0

0 0

1

2

3

4

5

6

7

100

99

99

97

100

99

95

96

92

88

84

91

87

83

79

70

Year

% Survival

P = 0.012

B In-Hospital Mortality (%)

14

PCI CABG

12 10 8 6 4 2 0 65

70

75

80

85

90

Patient Age (Yrs) Fig. 1. (A) Survival in patients who had 3-vessel disease and ejection fractions less than 0.50. After 7 years of patients assigned to surgical therapy, 84% are alive compared with 70% of those assigned to medical therapy (P ¼ .012). (From Killip T, Passamani E, Davis K. Coronary artery surgery study (CASS): a randomized trial of coronary bypass surgery. Eight years followup and survival in patients with reduced ejection fraction. Circulation 1985;72[Suppl V]:V107; with permission.) (B) Inpatient mortality after PCI or CABG as a function of patient age from a pooled analysis of several databases compromising more than 48,000 patients who had PCI and more than 180,000 patients who had CABG. (From Peterson ED, Alexander KP, Malenka DJ, et al. Multicenter experience in revascularization of very elderly patients. Am Heart J 2004;148:489; with permission.)

There are other general considerations regarding risk versus benefit that are important particularly in the elderly. A limited life expectancy resulting from important comorbid diseases or severe frailty argues against major cardiac or other surgeries. Particular attention is needed to avoid selecting patients for surgery who have dementia. Cognitive dysfunction preoperatively is

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a predictor of further cognitive dysfunction after operation [21]. Considering the deterioration in the quality of life that occurs with progressive dementia for patients and their families, the value of performing cardiac surgery in this situation is unclear. Other conditions that may preclude significant benefit include malignancy that limits patient survival, other noncardiac conditions causing significant disability, such as severe pulmonary disease, and severe irreversible deterioration in cardiac function such that cardiac symptoms are not reasonably expected to improve substantially with operation. There are few conditions that create prohibitive risk to cardiac surgery and some of these are listed in Box 1. Patients who have severe disabling pulmonary disease [22] and those who have hepatic disease with Child-Pugh class B or C [23–25] nearly always have excessive risk. Although these determinants of risk apply to all age groups, the threshold for these to become an absolute contraindication for operation must be lower in the elderly.

Timing of operation Optimizing preoperative functional status Nearly as important as whether or not to offer surgery to older patients is the decision regarding the timing of operation. When elderly patients are hospitalized, they are at augmented risk for the consequences of general physical deconditioning, nutritional compromise [26,27], and the effects of recent cardiac decompensation. Optimizing functional status preoperatively should reduce perioperative mortality and morbidity. Specifically, older patients who have been hospitalized for any length of time suffer frequently from physical deconditioning because of prolonged bed rest and lack of physical activity. Nutritional support usually is less than satisfactory during hospitalization [27]. Patients also are exposed to colonization by resistant hospital bacterial organisms, which may increase their risk of infection. Patients who are admitted with new congestive heart failure or exacerbations of previous congestive heart failure frequently have had recent acute deterioration in their cardiac function. With optimal medical therapy for congestive heart failure, even in the most severe cases, cardiac function can be expected to improve and to reduce the risk of operation [28]. This also is true of many elderly patients who present with acute onset of unstable

Box 1. Conditions that create prohibitive risk Multisystem organ failure Chronic liver failure Severe pulmonary disease Severe malnutrition

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angina or myocardial infarction. Myocardial function in such patients and in patients who have myocardial stunning from transient severe ischemia may improve substantially if permitted a period of recovery similar to that seen in the recently reported entity of ‘‘stress cardiomyopathy’’ [29,30]. There are other specific causes of congestive heart failure that are of particular importance when deciding on timing of operation. Patients presenting with rapid tachycardia, such as those who have atrial fibrillation with rapid ventricular response, may have tachycardia-induced cardiomyopathy that improves substantially with a period of rate control [31–34]. Similarly, patients who have alcoholic cardiomyopathy together with other cardiac conditions amenable to surgical therapy likely have major improvement in left ventricular function after a period of abstinence or controlled drinking [35]. Correction of these causes of cardiac dysfunction is more important in the elderly, because the senescent ischemic left ventricle seems to have less mechanical efficiency [36] and be more susceptible to postoperative dysfunction leading to low cardiac output [37]. Preventing renal dysfunction Of all the potential causes of renal dysfunction after cardiac operation, probably the most common avoidable cause is operation done early after exposure to contrast agents for cardiac catheterization and angiography [38]. Dye-induced nephropathy is manifested most frequently 1 to 5 days after cardiac catheterization. If this complication is developing and patients are subjected to operation, in particular those requiring cardiopulmonary bypass (CPB), a transient reversible renal injury may be augmented and require temporary or permanent dialysis after operation. Acute renal failure after cardiac surgery is associated with a marked increase in perioperative mortality. Because diabetes, previous renal dysfunction, and advanced age are strong predictors of this entity [39–42], it frequently is wise to defer operation until dye-induced nephropathy is not present, which means delaying operation for 2 or more days. These factors must be considered carefully when deciding whether or not to perform an operation on the same admission or whether or not the relative risks favor optimizing medical therapy, permitting stabilized patients to go home under a carefully supervised regimen, with plans to readmit patients in 1 to 3 weeks for elective operation after the condition has improved. In appropriately chosen patients, the risk of such a delay is small [43] and should be expected to be more than offset by the benefits of a period of recovery.

Stroke and neurocognitive decline in elderly patients who have cardiac surgery The risk of perioperative stroke increases with age, and the frequency of this complication increases further in the presence of other risk factors. This

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was shown by a multicenter research group that identified six risk factors increasing the stroke risk for each age group (Fig. 2) [44]. This increased risk is noted particularly in patients operated on in their eighth decade and is confirmed by the analysis of the Society of Thoracic Surgeons database showing a 3% to 4.8% risk of stroke in this age group in the various reported cardiac surgical procedures [17]. Besides increasing perioperative mortality [45], stroke is likely to greatly compromise the quality of life of elderly patients and must be weighed carefully with overall operative mortality when advising operation in the absence of disabling symptoms from the cardiac lesion. As discussed later, elderly patients who have ascending aortic disease may benefit especially from CABG using techniques to avoid or minimize aortic manipulation and decrease the risk of embolic stroke. Preoperative cognitive dysfunction is one of the significant predictors of further postoperative deterioration [21]. The potential for this complication must be of particular concern in the elderly. The effect of cardiac surgery, however, and in particular, CPB, on neurocognitive function in most patients is not clear. The potential for this complication compromising the quality of life in elderly patients received considerable attention after the study by Newman and colleagues [46] showing a relatively high 42% incidence in cognitive dysfunction late after coronary artery bypass surgery.

0.50

Points: Unstable Angina Prior Neurological Disease Prior CABG History of Vascular Disease Diabetes Pulmonary Disorders

Predicted CNS injury rate

0.45 0.40 0.35 0.30

6

0.25 5

0.20 4

0.15

3

0.10

2

0.05

1 0

0.00 40

45

50

55

60

65

70

75

80

Age Fig. 2. Demonstration of the increase in probability of major central nervous system events versus age and additional patient risk factors from the stroke risk index (unstable angina, history of symptomatic neurologic disease, prior CABG, history of vascular disease, diabetes, and history of pulmonary disease). Note that on this scale, the plot is not linear but has the characteristic shape of an early sigmoid curve for logistic models. (From Newman MF, Wolman R, Kanchuger M, et al. Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia [McSPI] Research Group. Circulation 1996;94[Suppl II]:II78; with permission.)

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This same group of researchers had studied patients after randomization to coronary angioplasty and coronary bypass surgery and found no difference in cognitive decline in their earlier study [47]. In fact, a more recent study from the same institution looking at neurocognitive function in elderly patients after major noncardiac surgery, most of which were major orthopedic procedures, showed an incidence of early and late decline nearly identical to that seen in their earlier study after coronary bypass surgery (Table 1) [48]. Although there are differences in these two studies, in particular average age and when late cognitive function was measured, the major conclusion from both studies, namely that cognitive decline was frequent and those patients who manifested cognitive decline early after operation were more likely to show long-term decline, was the same. Although there are some studies that suggest that coronary bypass grafts done without CPB, particularly in the elderly, may decrease the risk of stroke and of cognitive decline, the conclusions of various studies are not consistent [49]. From these studies, it is reasonable to conclude that cognitive decline may be a risk of any major surgical procedure but is not specific to cardiac surgery and is not necessarily related to the effects of CPB. Furthermore, when patients who have CABG are compared with proper controls of patients who have coronary artery disease, it is not evident that the CABG operation is independently associated with late cognitive decline [50]. Surgical techniques designed to decrease morbidity and speed recovery Coronary artery bypass operations traditionally have been performed using a median sternotomy incision and CPB. Although recovery after median sternotomy incision in most patients is rapid and complete, the elderly proportionally tend to have more difficulties and recover more slowly. CPB also may have more risk in the elderly who are at higher risk of neurologic complications. Prominent efforts to perform coronary bypass grafts limited to

Table 1 Longitudinal assessment of neurocognitive function

Age Deficit Discharge 6–12 weeks Latea,c a

Coronary artery bypass grafteda n ¼ 261

Major noncardiac surgeryb n ¼ 351

61

69.5

53% 36% 42%

59% 34% 42%

Data from Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med 2001;344:395–402. b Data from Monk TG, Phillips-Bute BG. Longitudinal assessment of neurocognitive function in elderly patients after major, noncardiac surgery. Anesthesiology 2004;101:A62. c Late indicates 5 years in CABG study and 2 years in noncardiac surgery study.

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the front of the heart through a small anterolateral thoracotomy incision did not seem to improve outcomes and, in some studies, actually was associated with more early postoperative pain than full median sternotomy [51,52]. As a result, most surgeons in this country prefer median sternotomy as a standard approach for CABG. There is considerably more variability in the use of CPB with some surgical groups performing the vast majority of their coronary artery bypass (CAB) procedures off pump (OP-CAB) [53]. The elderly especially might be expected to benefit from this approach, particularly in regards to neurologic outcomes [54–57]. Prospective randomized studies that have directly compared CABG done with and without CPB, however, show little difference in average outcomes between these two approaches [58]. One reason for this may be the use of an aortic clamp to perform proximal anastomoses in patients who have OP-CAB that may increase the incidence of aortic embolic events. The elderly have a higher incidence of ascending aortic atherosclerosis and an approach that completely avoids any aortic manipulations in these high-risk patients seems to improve neurologic outcomes substantially [59]. These techniques, however, currently are not widely used. Valve replacement and repair have been done through smaller incisions, such as partial sternotomy, particularly for aortic valve replacement [60–63], right parasternal incisions for mitral valve procedures [64,65], and robotic techniques using minimal incisions for mitral valve repair or replacement [66]. The use of partial sternotomy and other smaller incisions has decreased postoperative morbidity in some studies [61,62], but clear benefit has not consistently been evident [60,63]. Larger randomized trials are needed to show that the compromise in exposure yields a clear net clinical benefit with these techniques. Robotic techniques for mitral valve surgery, although holding more promise, require expensive technology and will take considerably more time and experience for most surgeons to master. Another class of emerging technologies involves transcatheter heart valve interventions and replacement, which must undergo considerable development and testing before widespread clinical application [67].

Specific operations Coronary artery bypass graft There are few randomized trials that have focused on elderly patients to help determine specific indications for CABG and define which subgroups of these patients benefit from surgical coronary revascularization when disabling symptoms are not present. Most of the large randomized trials done early in the experience of CABG did not include older patients [68]. A more recent study from Europe looked at invasive versus optimal medical therapy in symptomatic elderly patients who had a mean age of 80 years who already were on antianginal therapy [69]. In this study of nearly 300 patients, mortality and new acute myocardial infarction were not different between the

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medical and the invasive assigned groups. In those treated with intervention of either percutaneous angioplasty or coronary bypass graft, however, the incidence of other cardiac events, in particular unstable angina and hospital readmission, was substantially lower, and the improvement in severity of angina and in quality of life were higher than in those treated medically. Consideration of these recent studies and earlier studies that have established the current indications for coronary bypass grafts are important so that this data can be applied to decision making in elderly patients. In properly selected symptomatic patients, CABG predictably improves their quality of life [70]. If the mortality early after operation is in the 5% to 10% range, as it is in some very elderly patients, this essentially eliminates any benefit regarding longevity except in coronary patients at much higher than average risk with continued medical therapy as indicated by these more current studies. It is, therefore, reasonable to consider symptoms of episodic or chronic cardiac ischemia in spite of optimal medical therapy as the major indication for operation in most patients over age 75 to 80. The exception is patients who, although asymptomatic or minimally symptomatic, have high-risk coronary characteristics but and otherwise are in good condition. This includes patients who have significant left main disease (in particular more than 70% stenosis), patients who have high-grade proximal 3 vessel disease with moderate left ventricular dysfunction, and patients who have severe threevessel disease and a high grade proximal left anterior descending lesion. Aortic valve replacement There are many studies that document the value of aortic valve replacement for symptomatic aortic stenosis in the elderly age group. Four of these recent studies are summarized in Table 2 [71–74]. The 30-day mortality varied from 6% to 13% with the 1- and 5-year survivals consistent at approximately 87% and 65%, respectively. These good long-term outcomes in the elderly have led to increased performance of aortic valve replacement, particularly in the age group 80 years and older [75]. Although there may be some valid predictors of early deterioration in patients who are asymptomatic and have aortic stenosis, the indication for operation for severe aortic stenosis is the presence of symptoms that can be attributed to the valve lesion [76]. The cardiac-related mortality in Table 2 Aortic valve replacement in elderly Survival Author/year

N/age (mean)

30 days

1 year

5 year

Chiappini, 2004 [71] Medalion, 1998 [73] Gehlot, 1996 [72] Tseng, 1997 [74]

115/82.3 248/82.6 322/82.7 247/76.2

91.5 91.1 86.3 93.9

86 85 d 89

69 60 60.2 69

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patients who are asymptomatic is low [76,77] and there are no individual adult subgroups that clearly are shown to benefit from operation while still asymptomatic. In sedentary elderly patients who have severe aortic stenosis and who do not describe symptoms, a carefully supervised exercise stress test offers assurance that they are without symptoms at moderate exercise levels. When assessing elderly patients, however, it also is important to be secure that symptoms are indeed caused by the effects of the stenotic valve and are not related to the patients’ general condition or other medical conditions. There are many patients who have the severity of aortic stenosis interpreted as severe or critical by echocardiogram who are entirely asymptomatic. Often, elderly patients have some mild compromise in exercise capacity that is entirely consistent with their age or general physical condition and which should be judged with caution as an indication for operation. Other potential symptoms of aortic stenosis, such as angina and syncope, must be differentiated from noncardiac chest pain and dizziness or vertigo from other causes. Coronary artery bypass graft in patients screened for cardiac disease before major noncardiac surgery The perceived need to screen for cardiac risk before elective noncardiac surgery increasingly is applied to older age groups. As stated in the American Heart Association (AHA)/American College of Cardiology (ACC) clinical guidelines, the same indications for surgical myocardial revascularization and percutaneous coronary intervention (PCI) apply in these patients as apply in all patient groups, regardless of an upcoming major noncardiac surgical procedure [78]. These guidelines state further that ‘‘the decision to perform revascularization on a patient to ‘get them through’ the non-cardiac procedure is appropriate only in a small subset of very high risk patients.’’ These AHA/ACC clinical guidelines regarding cardiac risk assessment for noncardiac surgery [78] probably are more restrictive in their indications for cardiac evaluation and preprocedure coronary revascularization than currently is practiced in most centers [79]. Even these guidelines may be more liberal regarding their indications for these procedures than is necessary, however, to minimize cardiac risk in these patients [80–82]. The recent Veterans Administration randomized study evaluating coronary artery revascularization before elective major vascular surgery further highlights the lack of benefit of coronary revascularization done on the basis of indicators of intermediate risk or a positive stress test when strong clear indications otherwise are not present [83]. With more than 500 patients of an average age of approximately 66 years randomized either to preoperative revascularization or no revascularization, no significant difference in either death or myocardial infarction perioperatively or up to 2.7 years after vascular surgery was identified. Certainly when addressing more elderly age groups, the indications for a preliminary

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operation on the basis of cardiac risk screening should be even more restrictive and the focus should be on the more important noncardiac disease requiring operation. With optimal perioperative management, particularly with b-blocker therapy and, particularly in vascular surgery patients, statin therapy, the relative risks do not favor a preliminary cardiac operation except when indicated otherwise [78].

Cardiac valve incompetence As with aortic and mitral stenosis, the major indications for operation in elderly patients who have mitral or aortic incompetence should be the presence of symptoms referable to the cardiac valve lesion. There are well-established indications for early operation in asymptomatic patients for both of these lesions that depend on left ventricular dimensions and ejection fraction [84,85]. In general, patients who have severe aortic incompetence with an ejection fraction of less than 55% or a left ventricular end systolic dimension of more than 55 mm are served best by early operation to prevent further cardiac deterioration. Likewise, patients who have severe nonischemic mitral incompetence and patients who have a left ventricular ejection fraction of less than 60% or a left ventricular end systolic dimension of more than 45 mm also are considered to have an indication for early operation. These indications continue to be valid in older asymptomatic patients only as long as patients have an expected longevity that warrants a preventive operation and the risk of perioperative death and other complications, such as stroke, are relatively low. These indications, therefore, apply to most otherwise healthy patients in their 70s but increasingly are not applicable as patients enter their ninth decade of life.

Acute aortic dissection Patients who have acute ascending (type A) aortic dissection or intramural hematoma involving the ascending aorta who are seen during the acute event should, in general, undergo urgent operation, whereas patients who have dissections involving only the descending aorta (type B) initially are managed medically. Some doubt has been raised as to the efficacy and risk of operation in older patients who have type A dissection, in particular those over age 80 [86]. In the international registry of aortic dissection, reported from 18 different sites, a larger proportion of patients over age 70 were treated medically (36%) versus patients under age 70 (14%) [87]. Operative risk increases with age in these patients and survival with medical therapy actually improved, likely because more patients are assigned medical therapy because of perceived increased operative risk and the absence of potentially life-threatening complications from the aortic dissection. Recent studies support an approach of offering immediate

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surgical therapy for most patients who have acute type A aortic dissection regardless of age [88,89]. Cardiac transplantation Heart transplantation occasionally is offered to patients over age 70 but rarely to those over age 75. Some have used only otherwise unacceptable or high-risk donors for recipients over age 70, with recipients understanding in advance that they expect a high perioperative risk but accept this risk in view of the alternatives [90]. It is known that recipient age incrementally and adversely effects 1-year survival after heart transplant, with an odds risk of 1 at age 55 and 1.3 at age 65 (P!.0001), but with no valid data beyond age 65 [91]. All solid-organ transplants require lifelong medications to suppress the immune systemdmedications that have predictable consequences, such as neuropathy, osteoporosis, hypertension, worsened diabetes, and renal dysfunction. As such, the potential recipient must not only be able to predictably survive the operation but also tolerate the consequences of the postoperative medications. An alternative in elderly patients who have severe congestive heart failure eventually may be destination therapy with a mechanical device to support left ventricular function. Summary Elderly patients increasingly have benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients, their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of lives and of optimal preoperative preparation of patients is emphasized. References [1] Duncan AK, Vittone J, Fleming KC, et al. Cardiovascular disease in elderly patients. Mayo Clin Proc 1996;71:184–96. [2] Rich MW. Heart failure in the oldest patients: the impact of comorbid conditions. Am J Geriatr Cardiol 2005;14:134–41. [3] Conaway DG, House J, Bandt K, et al. The elderly: health status benefits and recovery of function one year after coronary artery bypass surgery. J Am Coll Cardiol 2003;42:1421–6. [4] Heijmeriks JA, Pourrier S, Dassen P, et al. Comparison of quality of life after coronary and/ or valvular cardiac surgery in patients O or ¼ 75 years of age with younger patients. Am J Cardiol 1999;83:1129–32, A1129. [5] Sedrakyan A, Vaccarino V, Paltiel AD, et al. Age does not limit quality of life improvement in cardiac valve surgery. J Am Coll Cardiol 2003;42:1208–14. [6] Shapira OM, Kelleher RM, Zelingher J, et al. Prognosis and quality of life after valve surgery in patients older than 75 years. Chest 1997;112:885–94.

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[7] Fruitman DS, MacDougall CE, Ross DB. Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg 1999;68:2129–35. [8] Gatti G, Cardu G, Lusa AM, et al. Predictors of postoperative complications in high-risk octogenarians undergoing cardiac operations. Ann Thorac Surg 2002;74:671–7. [9] Graham MM, Ghali WA, Faris PD, et al. Survival after coronary revascularization in the elderly. Circulation 2002;105:2378–84. [10] Hirose H, Amano A, Yoshida S, et al. Coronary artery bypass grafting in the elderly. Chest 2000;117:1262–70. [11] Kirsch M, Guesnier L, LeBesnerais P, et al. Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy. Ann Thorac Surg 1998;66:60–7. [12] Maharajh GS, Masters RG, Keon WJ. Cardiac operations in the elderly: who is at risk? Ann Thorac Surg 1998;66:1670–3. [13] Olsson M, Granstrom L, Lindblom D, et al. Aortic valve replacement in octogenarians with aortic stenosis: a case-control study. J Am Coll Cardiol 1992;20:1512–6. [14] Schmitz C, Welz A, Reichart B. Is cardiac surgery justified in patients in the ninth decade of life? J Card Surg 1998;13:113–9. [15] Edwards MB, Taylor KM. Outcomes in nonagenarians after heart valve replacement operation. Ann Thorac Surg 2003;75:830–4. [16] Tu JV, Pashos CL, Naylor CD, et al. Use of cardiac procedures and outcomes in elderly patients with myocardial infarction in the United States and Canada. N Engl J Med 1997;336: 1500–5. [17] Bridges CR, Edwards FH, Peterson ED, et al. Cardiac surgery in nonagenarians and centenarians. J Am Coll Surg 2003;197:347–57. [18] Killip T, Passamani E, Davis K. Coronary artery surgery study (CASS): a randomized trial of coronary bypass surgery. Eight years follow-up and survival in patients with reduced ejection fraction. Circulation 1985;72(Suppl V):V102–9. [19] Peterson ED, Alexander KP, Malenka DJ, et al. Multicenter experience in revascularization of very elderly patients. Am Heart J 2004;148:486–92. [20] Manton KG, Vaupel JW. Survival after the age of 80 in the United States, Sweden, France, England, and Japan. N Engl J Med 1995;333:1232–5. [21] Millar K, Asbury AJ, Murray GD. Pre-existing cognitive impairment as a factor influencing outcome after cardiac surgery. Br J Anaesth 2001;86:63–7. [22] Samuels LE, Kaufman MS, Morris RJ, et al. Coronary artery bypass grafting in patients with COPD. Chest 1998;113:878–82. [23] Bizouarn P, Ausseur A, Desseigne P, et al. Early and late outcome after elective cardiac surgery in patients with cirrhosis. Ann Thorac Surg 1999;67:1334–8. [24] Hayashida N, Shoujima T, Teshima H, et al. Clinical outcome after cardiac operations in patients with cirrhosis. Ann Thorac Surg 2004;77:500–5. [25] Klemperer JD, Ko W, Krieger KH, et al. Cardiac operations in patients with cirrhosis. Ann Thorac Surg 1998;65:85–7. [26] Rich MW, Keller AJ, Schechtman KB, et al. Increased complications and prolonged hospital stay in elderly cardiac surgical patients with low serum albumin. Am J Cardiol 1989;63:714–8. [27] Sullivan DH, Sun S, Walls RC. Protein-energy undernutrition among elderly hospitalized patients: a prospective study. JAMA 1999;281:2013–9. [28] Kotlyar E, Macdonald PS, Keogh AM, et al. Optimization of left ventricular function with carvedilol before high-risk cardiac surgery. J Heart Lung Transplant 2001;20:1129–31. [29] Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472–9. [30] Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. [31] Grogan M, Smith HC, Gersh BJ, et al. Left ventricular dysfunction due to atrial fibrillation in patients initially believed to have idiopathic dilated cardiomyopathy. Am J Cardiol 1992; 69:1570–3.

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