title: Cardiac surgery in select nonagenarians: should we or shouldn't we?
abstract: BACKGROUND
  Patients aged 90 years and older represent a rapidly growing subset of the population, many of whom are functionally limited by cardiovascular disease. Clinical decision making about cardiac surgical intervention in nonagenarians is hindered by a paucity of data examining survival outcomes in this population.
  
  
  METHODS
  A consecutive series of nonagenarians who underwent cardiac operations between 1995 and 2004 were retrospectively reviewed. Data collection included baseline preoperative clinical status, intraoperative characteristics, and perioperative course. Area under the Kaplan-Meier survival estimate method was used to calculate mean survival.
  
  
  RESULTS
  Cardiac surgical procedures were done in 49 patients (51% male); their mean age was 91.9 years (range, 90 to 97 years). Operative mortality was 8% (n = 4). Multivariate Cox proportional hazards models found preoperative chronic renal insufficiency (hazard ratio [HR], 4.88; 95% confidence interval [CI], 1.53 to 15.55; p = 0.007) and ejection fraction (HR, 0.96; 95% CI, 0.93 to 1.00; p = 0.033) were independently associated with death. Overall mean survival was 5.1 +/- 0.5 years (median, 5.2 years). Quality of life outcomes were similar to that of two related norm-based populations based on age and disease process.
  
  
  CONCLUSIONS
  Cardiac surgical procedures can be performed safely and with therapeutic benefit in carefully selected nonagenarians. We consider physiologic indicators, social factors, and patient preferences to be the main determinants in the patient selection process. Our results support the need for more proactive intervention in symptomatic nonagenarian patients as it relates to earlier consideration of elective, rather than emergency cardiac operations.
authors.affiliation: Department of Cardiothoracic Surgery, Center for Complementary and Integrative Medicine, Weill Cornell Medical College, New York, New York 10021, USA.
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.forename: Janey C
authors.initials: JC
authors.lastname: Peterson
authors.forename: Federico
authors.initials: F
authors.lastname: Milla
authors.forename: Martin T
authors.initials: MT
authors.lastname: Wells
authors.forename: William
authors.initials: W
authors.lastname: Briggs
authors.forename: Leonard N
authors.initials: LN
authors.lastname: Girardi
authors.forename: Wilson
authors.initials: W
authors.lastname: Ko
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Tortolani
authors.forename: O Wayne
authors.initials: OW
authors.lastname: Isom
authors.forename: Karl H
authors.initials: KH
authors.lastname: Krieger
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome