title: Cardiac surgery in nonagenarians: not only feasible, but also reasonable?
abstract: OBJECTIVE
  Changes in the age profile of the population in the western world and improvement in surgical techniques and postoperative care have contributed to a growing number of cardiosurgical patients aged over 90. In periods when transapical and transfemoral aortic valve replacement were done, we aimed at evaluating the outcome of nonagenarians after conventional aortic valve replacement and cardiac surgery in general, and determining perioperative parameters to predict a complicated postoperative course.
  
  
  METHODS
  Between 1995 and 2011, 49 nonagenarians (aged 91.2±3.1 years) underwent cardiac surgery. A subgroup of 30 patients received aortic valve replacement alone (63%; n=19), in combination with coronary artery bypass grafting (27%; n=8) or other surgical procedures (10%; n=3). Most of the patients suffered from combined aortic valve disease with a mean valve orifice area of 0.6±0.3 cm2 and a mean antegrade pressure gradient of 86±22 mmHg.
  
  
  RESULTS
  Cardiac surgery in nonagenarians resulted in remarkable postoperative morbidity and an overall in-hospital mortality of 10% (n=5). In the AVR subgroup, biological valve prostheses were implanted in 29 patients. In this subgroup, the length of stay was 2.9±0.9 days in the intensive care unit and 17.0±5.5 days in the hospital. The in-hospital mortality amounted to 13% (n=4). Although several general preoperative risk factors of postoperative complications such as renal failure, low cardiac output syndrome and New York Heart Association Class IV were remarkably more frequent among the patients who died after the operation, the small cohort of non-surviving nonagenarians did not allow for significant differences.
  
  
  CONCLUSIONS
  Cardiac surgery in the very elderly, particularly with regard to aortic valve replacement, carries a high risk of early morbidity and mortality. However, in selected nonagenarians, surgery can be performed with an acceptable outcome. The risk may even be reduced by an individual approach to the procedure. With regard to potential risk factors, the selection of these patients should be carried out very carefully.
authors.affiliation: Department of Cardiovascular Surgery, Heinrich Heine University, Medical Faculty, Duesseldorf, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Assmann
authors.forename: Jan-Philipp
authors.initials: JP
authors.lastname: Minol
authors.forename: Arash
authors.initials: A
authors.lastname: Mehdiani
authors.forename: Payam
authors.initials: P
authors.lastname: Akhyari
authors.forename: Udo
authors.initials: U
authors.lastname: Boeken
authors.forename: Artur
authors.initials: A
authors.lastname: Lichtenberg
mesh_terms: D000367:Age Factors; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D001026:Coronary Artery Bypass; D005240:Feasibility Studies; D005260:Female; D006331:Heart Diseases / Q000401:mortality / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008297:Male; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic valve replacement; Cardiac surgery; Nonagenarians; Operative mortality; Outcome