Cardiac surgery in the very elderly
January 12, 2010 2 Comments
Blog Post by Dr Alan D Ashworth MB BCh FRCA, Clinical Fellow in Cardiothoracic Anaesthesia, Papworth Hospital NHS Foundation Trust and Dr Stephen T Webb MB BCh BAO FRCA EDIC Consultant in Anaesthesia & Intensive Care Medicine, Papworth Hospital NHS Foundation Trust
As the average life expectancy of the general population increases, the age of patients requiring cardiac surgery is also increasing. In the 1970s patients over the age of 65 were regarded as too high risk and were denied cardiac surgery. In 1985 a series of 25 octogenarians undergoing cardiac surgery was reported with an operative mortality of 4% and a 92% postoperative complication rate.
Surgical techniques, perioperative management and postoperative critical care continue to improve, with ever reducing morbidity and mortality following cardiac surgery. There is however the undeniable risk of cardiac surgery in patients of advanced age. Observational studies of nonagenarians undergoing cardiac surgery have demonstrated an increased frequency of perioperative complications and mortality. Mortality rates for nonagenarians vary from 7 – 18%.
There have been a number of studies that report the long-term outcomes of nonagenarians following cardiac surgery. They conclude that cardiac surgery can be performed in carefully selected nonagenarians with acceptable perioperative morbidity and mortality. They also comment that these patients have reasonably good quality of life and late survival, when compared with medical management.
A variety of factors have been identified as having the potential to reduce postoperative morbidity and mortality; avoidance of patients with end-organ damage, maintaining high perfusion pressures (60 – 80 mmHg) on cardiopulmonary bypass (CPB), minimising CPB and aortic cross-clamp times and by maintaining the haematocrit greater than 30%.
At present cardiac surgery in nonagenarians accounts for a small percentage of the workload, but this is set to increase in the future. Although there are increased risks in this population, careful patient selection and meticulous perioperative management can improve outcomes.
For more information, please see Core Topics in Cardiac Anaesthesia, 2nd edition, edited by Joseph Arrowsmith and Jonathan Mackay, published by Cambridge University Press