title: Cardiac surgery in nonagenarians: single-centre series and review.
abstract: BACKGROUND
  Cardiac surgery is widely believed to be an excessively high-risk intervention for very elderly patients with coronary artery or valvular disease. However, as life expectancy and the prospect of sustained quality of life into older age increase, this assumption should be challenged so that surgery is not denied to patients who may derive significant symptomatic benefit with acceptable levels of operative risk.
  
  
  OBJECTIVE
  To evaluate outcomes from cardiac surgery in nonagenarian patients.
  
  
  METHODS
  Analysis of prospectively collected single-centre data and review of outcomes reported in the literature.
  
  
  RESULTS
  Twenty-three patients (13 males) aged 90 years or more underwent open cardiac surgery between 1998 and 2007. Four patients died within 30 days of surgery (surgical mortality 17.4%) and all-cause in-hospital morbidity was 74%. Actuarial survival at 1 and 5 years was estimated at 72 and 54%, respectively. Comparison of patients' survival against age-matched life tables for the English population found a standardised mortality ratio of 0.57 (95% CI: 0.24-0.99; one-sample log-rank test chi(2) = 3.93; p < 0.05) representing a significant survival benefit associated with surgery. The majority of patients reported symptomatic improvement reflected by significant decreases in angina and dyspnoea scores. Six single-centre series of nonagenarians and 3 reviews from national databases in the US and UK were identified in the literature. Pooled surgical mortality was 12.7% (95% CI: 8.7-17.3%) with no significant heterogeneity (chi(2) = 4.12; p = 0.77; I(2) = 0).
  
  
  CONCLUSIONS
  Cardiac surgery in the elderly carries higher operative risk than in younger patients. However, in selected nonagenarians, surgery can be performed with acceptable morbidity and early mortality, and patients gain significant symptomatic relief and survival benefit.
authors.affiliation: Papworth Hospital, Cambridge, UK.
authors.forename: Mathew R
authors.initials: MR
authors.lastname: Guilfoyle
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Drain
authors.forename: Asmatullah
authors.initials: A
authors.lastname: Khan
authors.forename: Jonathan
authors.initials: J
authors.lastname: Ferguson
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Large
authors.forename: Samer A M
authors.initials: SA
authors.lastname: Nashef
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve; D006348:Cardiac Surgical Procedures / Q000401:mortality*; D001026:Coronary Artery Bypass / Q000401:mortality; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology