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Geriatric Care

Heartening news about cardiac surgery in the elderly

From the February ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Marilyn Kochman

Sidebar: Keys to success

Not long ago, a patient’s advanced age was a serious, potentially prohibitive risk factor when considering surgery. But innovations in surgical techniques, better patient care, and improving attitudes towards aging have led to octogenarians routinely surviving surgery and often significantly benefiting from it, allowing them to enjoy an improved quality of life for a decade or more afterward.

“Twenty years ago, when I was in training, if you told someone you were going to operate on an 80-year-old person, they would have said, ‘You’re crazy,’” said John V. Conte, MD, professor of surgery and associate director of the division of cardiac surgery at Johns Hopkins Hospital in Baltimore. Today, he said, physiologic age plays a greater role than chronologic age in decisions about surgery for the elderly.

“I don’t care whether you’re 50, 60, 70 or 80. If you’re not in good shape, you’re going to be a high-risk candidate for surgery,” said Dr. Conte. “But if you take care of yourself and get sick in later life, you have a good chance of being successfully treated.”

Two recent studies reinforce Dr. Conte’s assertion. In one, published in the Oct. 28, 2008, Circulation, researchers analyzed data from 1,062 consecutive patients age 80 years or older who underwent coronary artery bypass graft (CABG) surgery between 1989 and 2001. Operative mortality dropped dramatically during those years, from 15% to 2.2%, and, notably, more than 97% of these patients reported an improved quality of life.

In a second study, more than half of the patients (8,796 in total) over age 80 who underwent aortic valve surgery between 1987 and 2006 were alive six years after the procedure, though concomitant CABG slightly diminished this survivorship. (“Long-term survival of the very elderly undergoing aortic valve surgery,” Circulation, Oct. 28, 2008).

“Patients who are undergoing aortic valve surgery, with or without a concomitant coronary artery bypass grafting procedure, have similar life expectancy as those of similar age in the general population,” said Donald S. Likosky, PhD, lead author of the second study conducted by the Northern New England Cardiovascular Disease Study Group. “What this suggests is that advanced age (80-plus years) may not be a reason in and of itself for disqualifying a patient for surgically treating their aortic valve symptoms.”

Making the call

Decisions about whether to perform cardiac surgery on the elderly are bound to become more frequent, with the rapid growth of the elderly population and life expectancy steadily rising. According to the U.S. Census Bureau, the “oldest old”—those 85 and over—are the most rapidly growing age group among the elderly. In 2050, they are projected to make up 24% of elderly Americans and 5% of all Americans.

While the increasing expertise of health care professionals such as surgeons, nurses, perfusionists, anesthesiologists and ICU specialists has improved elderly patients’ chances of benefiting from surgery, identifying appropriate candidates is still “a difficult call,” said Susan Zieman, MD, assistant professor of cardiology at Johns Hopkins.

“Studies have looked at trying to find markers for biologic age, versus chronologic age, but those have not shown a consistent pattern,” Dr. Zieman said. “However, certain conditions predict poor outcome, such as bad renal function, lung disease, prior history of strokes, and poor functional status [frailty].”

To justify surgery, there should be “good evidence that the patient has a condition that is surgically remediable, and has enough reserve to get through the operation,” said Paul Kurlansky, MD, research director of the Florida Heart Research Institute in Miami and lead author of the Circulation study.

Equally important is ensuring that the patient is psychologically prepared for the operation.

“For an octogenarian, it can be one or two months before they feel better. To put it simply, the patient has to want to live,” Dr. Kurlanksy said.

Having support at home and realistic goals is also key, said Dr. Zieman, who insists that her patients receive cardiac rehabilitation after their valve or bypass surgery.

“Most find rehab a great experience,” Dr. Zieman said. “Data show that it improves depression and functional status, and decreases blood pressure, cholesterol and weight.”

Getting patients out of bed and into physical and respiratory therapy as early as possible is crucial as well, and so is ensuring that patients’ nutritional needs are met, Dr. Kurlansky added.

More research needed

A limitation of the Circulation study is that it is retrospective, Dr. Kurlansky said.

“The cardiologist and surgeon had already selected patients for surgery. Exactly how the selection process was made was not accessible,” Dr. Kurlansky said.

The perfect study would have involved following patients between 1989 and 2001 who had coronary artery disease, and noting which ones had surgery, medical therapy or percutaneous intervention. From that, researchers could determine the best approach for different kinds of patients, Dr. Kurlansky said.

“We are nowhere near being able to predict the best approach for every patient,” Dr. Kurlansky said. “But our studies add useful information to the current decision-making process. Now, we know that when a person over 80 is considered for surgery, and if the surgeon feels the person is a reasonable candidate, we can expect an operative mortality to approach that of a younger person.”

Bruce Leavitt, MD, cardiothoracic surgeon at Fletcher Allen Health Care in Burlington, Vt. and co-author of the aortic valve surgery study, shares a similar sentiment regarding the implications of his work.

“We’re not telling doctors and surgeons how to do the operation better,” he said. “We’re just telling them that maybe they should consider surgery, because a group of elderly patients in our region did very well with it.”

Marilyn Kochman is a freelance writer in Princeton, N.J.

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Keys to success

Experts noted several key factors that have contributed to the increasingly positive outcomes of cardiac surgery in the elderly.

Improved surgical techniques. “Over the course of the study, there was increasing use of the left internal thoracic artery as a bypass graft,” said Paul Kurlansky, MD, research director of the Florida Heart Research Institute in Miami and lead author of an Oct. 28, 2008 Circulation study that looked at coronary artery bypass surgery in octogenarians. “It is an arterial graft, rather than a venous graft, and is less prone to acute perioperative thrombosis. Many elderly people don’t have great veins, which can make grafting difficult. With this artery, you don’t need to manipulate the aorta as much to create the bypass graft. We’ve known for years that the left internal thoracic artery leads to a better long-term prognosis, but now we know that it is also related to a better operative mortality as well.”

Better anesthesia. Propofol, for example, induces a deep sleep, but allows the patient to wake up promptly after surgery, which contributes to a healthier recovery, said Dr. Kurlansky.

Going “off-pump.” John V. Conte, MD, professor of surgery and associate director of the division of cardiac surgery at Johns Hopkins Hospital in Baltimore, prefers to perform surgery without using the heart-lung machine, when appropriate. “I do more and more bypass operations on the elderly ‘off pump,’” he said. “There may be less need for blood transfusions, and patients don’t retain as much fluid. There also appears to be a lower risk for stroke or neurologic complication, though this is controversial.”

Minimally invasive valve operations. “We don’t divide the entire breast bone to replace an aortic valve,” said Dr. Conte. “We make a small incision between the ribs to take care of mitral valves. The patient gets out of bed sooner, tends to have less discomfort, is usually less immobile and often avoids complications like pneumonia and blood clots in the vein.”

Limiting blood transfusions and aggressively managing blood glucose levels and blood pressure. Doing these three things leads to more successful outcomes in aortic valve surgery, noted Bruce Leavitt, MD, cardiothoracic surgeon at Fletcher Allen Health Care in Burlington, Vt. “This tends to reduce infections, pneumonia and mortality. Also, replacement heart valves are better than they used to be, and our repair techniques have improved, allowing us to fix far many more valves than we did 20 years ago. This increases longevity.”

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ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated