Geriatric Cardiac Surgery: Chronology vs. Biology

Geriatric Cardiac Surgery: Chronology vs.Biology

Michael Seco, BMedSc a,b,c, J. James B. Edelman, MBBS(Hons), PhD b,c,Paul Forrest, MBChB, FANZCA a,d, Martin Ng, MBBS, PhD, FRACP a,e,Michael K. Wilson, MBBS, FRACS b,c,f, John Fraser, MBBS, PhD, FRCA, FCICM g,Paul G. Bannon, MBBS, PhD, FRACS a,b,c,Michael P. Vallely, MBBS, PhD, FRACS a,b,c,f*

aSydney Medical School, The University of Sydney, Sydney, AustraliabThe Baird Institute of Applied Heart & Lung Surgical Research, Sydney, AustraliacCardiothoracic Surgery Unit, Royal Prince Alfred Hospital, Sydney, AustraliadDepartment of Anaesthetics, Royal Prince Alfred Hospital, Sydney, AustraliaeCardiology Unit, Royal Prince Alfred Hospital, Sydney, AustraliafAustralian School of Advanced Medicine, Macquarie University, Sydney, AustraliagCritical Care Research Group, The Prince Charles Hospital, The University of Queensland

Received 15 February 2014; received in revised form 14 March 2014; accepted 4 April 2014; online published-ahead-of-print xxx

Cardiac surgery is increasingly performed in elderly patients, and whilst the incidence of common riskfactors associated with poorer outcome increases with age, recent studies suggest that outcomes in thispopulation may be better than is widely appreciated. As such, in this review we have examined the currentevidence for common cardiac surgical procedures in patients aged over 70 years.Coronary artery bypass grafting (CABG) in the elderly has similar early safety to percutaneous intervention,though repeat revascularisation is lower. Totally avoiding instrumentation of the ascending aorta with off-pump techniques may also reduce the incidence of neurological injury.Aortic valve replacement (AVR) significantly improves quality of life and provides excellent short- andlong-term outcomes. Combined AVR and CABG carries higher risk but late survival is still excellent. Mini-sternotomyAVR in the elderly can provide comparable survival to full-sternotomyAVR.More accurate riskstratification systems are needed to appropriately select patients for transcatheter aortic valve implantation.Mitral valve repair is superior to replacement in the elderly, although choosing themost effectivemethod isimportant for achieving maximal quality of life. Minimally-invasive mitral valve surgery in the elderly hassimilar postoperative outcomes to sternotomy-based surgery, but reduces hospital length of stay and returnto activity. In operative candidates, surgical repair is superior to percutaneous repair.Current evidence indicates that advanced age alone is not a predictor of mortality or morbidity in cardiacsurgery. Thus surgery should not be overlooked or denied to the elderly solely on the basis of their‘‘chronological age’’, without considering the patient’s true ‘‘biological age’’.

Keywords Elderly ! Septuagenarian ! Octogenarian ! Cardiac surgery ! Valvular disease ! Coronary arterydisease

© 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier

Inc. All rights reserved.

*Corresponding author at: PO Box M102 Missenden Road, Camperdown NSW 2050, Australia Tel.: +61294226090; fax: +61294226099,

Email: [email protected]

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Please cite this article in press as: SecoM, et al. Geriatric Cardiac Surgery: Chronology vs. Biology. Heart, Lung andCirculation(2014), http://dx.doi.org/10.1016/j.hlc.2014.04.008

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‘‘Age does not matter if the matter does not age.’’General Carlos P. Romulo

IntroductionThe United Nations predicts that the population aged"80 years in developed countries will increase from 54 mil-lion in 2011 to 122 million in 2050 due to increasing lifeexpectancy, improved health care, and low fertility rates[1]. As a result, the number of elderly patients requiringcardiovascular invention is increasing, and it has been esti-mated that the number of cardiac surgical patients >80 yearsold has increased up to 24-fold over the last two decades [2].It is important that the most beneficial treatment is selected,whethermedical, interventional or surgical, and thereforeweaim to review the modern outcomes of common cardiacoperations in this population. In earlier studies the definitionof ‘‘elderly’’ was usually those aged >70 years, however itnowmore commonly refers to >80 years old, due to the effectincreasing life-expectancy has on the discrepancy betweenone’s ‘‘chronological age’’ and ‘‘biological age’’.The risks of cardiac surgery in the ‘‘biological’’ elderly

are largely due to the adverse cardiovascular effects ofaging. Oxidative stress and inflammation increases andimpairs vascular function [3]. Large and medium sizedarteries become thickened due to calcium depositionand collagen build-up, increasing left ventricular afterloadand work. While cardiac systolic function may be rela-tively well preserved, concentric hypertrophy impairs dia-stolic function, which declines by up to 50% by the ninthdecade (3). Significantly reduced lung compliance, respi-ratory muscle strength, and hypoxic respiratory driveincrease the risk of postoperative ventilatory failure [4],while changes to kidney structure and function increasethe risk of acute renal failure [5]. Age-related central andperipheral nervous system impairment contribute to post-operative delirium, delayed recovery and rehabilitation.Poor nutritional status and anaemia are common [6]. Phar-macokinetic and dynamic impairment increases the risk ofadverse drug reactions and reduce the effectiveness ofcardiovascular drugs [7].

Coronary SurgeryCoronary artery bypass grafting (CABG) may not be consid-ered in elderly patients because of the perceived riskinvolved and because of their limited life expectancy. Thisgroup of patients is thus frequently excluded from trialscomparing PCI and CABG. However, CABG is increasinglyperformed in the elderly [8], and they may benefit from thisintervention over PCI because they are more likely to presentwith complex multi-vessel disease [9,10] and because therisks of long term anti-platelet therapy are avoided. A recentmeta-analysis compared PCI (n=909) to CABG (n=1,477) inpatients aged >70 years [11]. There was no significant differ-ence in all cause-mortality at 30 days (3.9% vs. 5.7%, OR 0.72,

95% CI: 0.41 to 1.26), 12 months (6.0% vs. 7.8%, OR 0.80, 95%CI: 0.53 to 1.22) and 22months (10.6% vs. 13.0%, OR 1.00, 95%CI: 0.73 to 1.38). There was also no significant difference inMACCE (composite endpoint of death, nonfatal myocardialinfarction, stroke, and repeat revascularisation) at 30 days(11.0% vs. 18.3%, OR 0.60, 95% CI: 0.34 to 1.05), 12 months(16.6% vs. 20.3%, OR 0.82, 95% CI: 0.47 to 1.41), and22 months (26.2% vs. 21.9%, OR 1.27, 95% CI 0.81 to 1.98).However, stroke was more common in the CABG patients at30 days (0.7% vs. 6.6%, OR 0.14, 95% CI: 0.02 to 0.76) and12 months (0.52% vs. 5.95%, OR 0.14, 95% CI 0.03 to 0.60), butrepeat revascularisation was higher in the PCI at 22 months(15.5% vs. 3.5%, OR 4.34, 95% CI 2.69 to 7.01). They foundsimilar results in a subgroup analysis of an older cohort ofpatients aged " 75.Off-pump CABG (OPCABG) offers two main potential

advantages: it can avoid complications associated with car-diopulmonary bypass (CPB), including the systemic inflam-matory response [12]. It also provides an opportunity toperform CABG without any manipulation or clamping ofthe ascending aorta (a ‘‘no touch’’ or ‘‘anaortic’’ technique),which may decrease the rate of neurological events by avoid-ing dislodgement and embolisation of atherosclerotic plaque.Puskas and colleagues compared predicted mortality (usingthe STS Score) vs. observed mortality in over 14,000 patientsundergoing OPCABG vs. on-pump CABG. The groupshowed no difference in mortality between the groups inlow risk patients, but a survival benefit for OPCABG patientswhen predicted risk exceeded 2.5-3% (3.2% vs. 6.7%, OR 0.45,95% CI: 0.33 to 0.63) [13].In the recent GOPCABE trial 2,539 patients aged"75 years

were randomised to OPCABG or on-pump CABG; the dif-ference in a composite endpoint of death, myocardial infarc-tion, stroke, new renal replacement therapy or repeatrevascularisation did not reach statistical significance (7.8%vs. 8.2%, p=0.74), though OPCABG patients had significantlyfewer red blood cell transfusions (2.0% vs. 2.4%, p<0.001)[14]. However, the rate of side-clamp use (for proximal anas-tomosis of the aorto-coronary graft) in the OPCABG groupwas not reported, hence the potential benefit of an anaorticOPCABG technique was not tested in this trial. In a meta-analysis of over 10,000 patients, anaortic OPCABG patientshad a significantly lower stroke rate than OPCABG patientswhere a side-clamp was used (0.29% vs. 1.34%, p=0.006).When anaortic OPCABG was compared with conventionalCABG the rate of stroke was 0.41% vs. 1.98%, respectively,p<0.001 [15]. Our group reported the largest case series ofelderly patients undergoing anaortic OPCABG. In 1,135patients aged >70 years, 30 day mortality was 2.1% andstroke rate was 0.4%. In 318 patients aged >80 years, mortal-ity was 2.8% and stroke 0.9% [16]. This compares favourablyto contemporary series of PCI in octogenarians, which reportmortality of 1.5-2.5% of those revascularised for stableangina, and 5.7-6.9% if revascularised for unstable anginaor non-ST elevation MI [17,18].Surgery is therefore a safe option for revascularisation of

elderly patients and should be considered for those with

2 M. Seco et al.




complex multi-vessel coronary artery disease. An anaortic,off-pump technique also reduces the morbidity associatedwith surgical revascularisation.

Aortic Valve ReplacementThe most common aortic valvular pathology in the elderlypopulation is aortic stenosis (AS) due to age-related calcificdegeneration. The prevalence of AS increases with age; withan incidence of 0.2% at age 50-59, 1.3% at age 60–69, 3.9% atage 70–79 year old cohort and 9.8% at age 80–89 years [19].The natural history of symptomatic AS is very poor, with anaverage survival of five years, three years and two years afterthe development of angina, syncope and heart failure,respectively [20]. While there has been some recent interestin lipid lowering drugs as treatment (because of histologicalfeatures that suggest a common aetiology with atherosclero-sis), there is currently no medical therapy that has beenproven to modify disease progression [21].There are currently three treatment options available for

AS; balloon aortic valvuloplasty (BAV), surgical aortic valvereplacement (SAVR), and transcatheter aortic valve implan-tation (TAVI). Because the rate of serious, acute complicationfrom BAV may be >10%, and because restenosis and clinicaldeterioration occurs within six to 12 months in most patients,BAV is mainly used as a bridge to definitive treatment inacutely deteriorating patients [22]. SAVR with CPB has longbeen the gold standard of treatment for AS, with extensiveevidence for its efficacy and improvement in quality of life(QoL). For patients deemed inoperable or very high surgicalrisk, TAVI has been rapidly adopted as the treatment ofchoice, which involves implantation of a bioprosthetic valvewithin the native diseased valve via a transfemoral, trans-apical or other (less common) transcatheter approaches.Recent SAVR studies in octogenarians have demonstrated

that excellent short- and long-term outcomes can beachieved. In a meta-analysis of isolated SAVR by Vasquesand colleagues of 13,216 patients"80 years old, the incidenceof early postoperative mortality was 5.8%, stroke 2.3%, post-operative dialysis 2.6%, pacemaker implantation 4.7%, meanlength of ICU stay 3.5 days and mean length of in-hospitalstay of 13.3 days [23]. Pooled survival rates at one, three, five,and 10 years were 87.6%, 78.7%, 65.4%, and 29.7%, respec-tively [23]. We recently reviewed 117 patient octogenariansreceiving SAVR within our service, and also found encour-aging results: 30 day mortality was 3.4% and survival atsix months, one, and three years was 95.6%, 87.6% and58.4%, respectively [24]. Univariate analysis of subgroupsaged 80-84 (the ‘elderly’) and 85-89 (the ‘very elderly’) dem-onstrated a higher incidence of cerebrovascular disease (9.8%vs. 25.7%, p=0.042) and 30 day mortality (0.0% vs. 11.4%,p=0.007) in the very elderly patients. This indicates that therewere few differences between the ‘elderly’ and ‘very elderly’,including their overall risk reflected by EuroSCORE. Overall,these results are part of larger finding from STS database: thatoutcomes have been improving despite gradual increases in

patient age and overall risk profile [25]. As these patients arenow living longer, surgeons may have to consider usingmore durable prostheses to avoid reoperation, or considera transcatheter valve-in-valve approach in the event of pros-thesis failure.The risks of SAVR combined with CABG in patients aged

" 80 years was also examined in a recent meta-analysis byVasques and colleagues, which included 8,975 patients [26].Early postoperative mortality was 8.2%, (compared with5.8% they reported for isolated SAVR [23]) and morbidityand hospital stay were also increased [26]. Despite this, latesurvival was excellent: 83.2%, 72.9%, 60.8%, and 25.7%, atone, three, five, and 10 years, respectively. Therefore theseauthors concluded that percutaneous intervention (TAVIand PCI) could not be recommended over surgery until theirlong-term durability has been proven. Additionally, twoother recent studies of combined SAVR and CABG in elderlypatients found that agewas not an independent risk factor forin-hospital mortality [27,28].Minimally invasive SAVR (MiniSAVR) is also possible

through a parasternal incision, transverse sternotomy, rightthoracotomy, or upper hemi-sternotomy. A recent study byEl Bardissi and colleagues of 249 octogenarians undergoingisolated MiniSAVR at an experienced centre found an oper-ative mortality rate of 3% and postoperative stroke rate of 4%[29]. Long term survival (n=238) at one, five, and 10 yearswas93%, 77%, and 56%, respectively; and there was no significantdifference between an age and gender matched US popula-tion [29]. A 2009 meta-analysis of mini-sternotomy vs. fullsternotomy SAVR, mostly in younger patients (mean agesranging from 50 – 70), found similar rates of postoperativeadverse events between groups despite longer cross-clamp(XC) and CPB times, and small decreases in ICU and hospitallength of stay, ventilation time, and blood loss [30]. Ifthese outcomes are achievable in older patients as suggestedby El Bardissi and colleagues results, then elderly patientsmay also benefit from a minimally invasive approach toSAVR.QoL is often argued to be a more relevant outcome than

survival or complication rates in elderly patients. Othershave also argued that short- and long-term morbidity ofSAVR offsets any improvement in QoL, and thus the onlybenefit is the prolongation of survival [31]. Shan and col-leagues’ systematic review of 19 studies of heart-related QoLafter SAVR in patients " 70 years old indicates that patientsbenefit from noticeable improvement in symptoms and func-tionality, and that QoL is equal to or better than both an age-matched population and younger patients undergoing SAVR[32]. These gains were reflected in that most or all of thepatients were happy with their decision to undergo thesurgery. Similar results have been found in other studies [33].Despite current recommendations that all elderly patients

with symptomatic AS be considered for SAVR, it is fre-quently denied them because of the perceived risks[34,35]. Iung and colleagues observed in a pan-Europeansurvey that one-third of the elderly were denied SAVR,and that age and left ventricular function had a greater

Geriatric Cardiac Surgery 3




influence on this decision than combinations of comorbidities[34]. The consequences of this are significant, as Pierard andcolleagues observed a two-fold increase in mortality [36].Although, Australian groups have identified and addressedthis issue before [37–39]. In 2003 Hewitt and colleaguesreported that in 64 octogenarians that underwent cardiacsurgery for severely disabling symptoms (28% valve surgery,72% isolated CABG), one in five were advised not to proceedwith surgery because of their age. However, they achieved amortality of 0% in elective and 10.5% in urgent cases, and at amean follow-up time of 2.8 years 95% remained free fromcardiovascular symptoms, 94% remained independent, theirquality of life was significantly better than preoperatively,and 98% of patients would recommend surgery [37].Surgical risk scoring systems such as the EuroSCORE and

Society of Thoracic Surgeons Predicted Risk of Mortality(STS-PROM) Score [40,41] have been used in both trialsand clinical practice to identify patients at excessive riskfrom surgery, and select them for TAVI. These scoring sys-tems were developed as a method of quantifying risk ofmortality for surgical patients of all ages based on preopera-tive independent risk factors; patients with a predicted mor-tality of "15% (equating to a EuroSCORE II of >10 and STSscore of >8) are generally considered to be TAVI candidates.However, increasing evidence suggests these scores over-predict risk in high-risk cases, which may bias patient selec-tion towards TAVI rather than SAVR [42,43]. Additionally, inEl Bardissi and colleagues’ previously mentioned study ofoctogenarian MiniSAVR they calculated a predicted 30 daymortality of 11% for the cohort using both the STS andmodified EuroSCORE scores, but observed only a 3% mor-tality, demonstrating a very large discrepancy with the mini-mally invasive approach [44]. Thus it is necessary that amultidisciplinary team assess high-risk patients, where thewhole patient comorbidity and risk profile is considered, andnot advanced age alone [45,46]. Studies are underway todevelop TAVI-specific scores that more accurately reflectreal world results [47].

Mitral Valve SurgeryMitral valve (MV) disease is the most common valvularpathology in the elderly, predominately resulting in mitralregurgitation (MR). Moderate-severe MR has been found in9.3% in those aged "75 years, with an odds ratio for devel-oping MR of 1.84 per decade [48]. However, up to 85% ofoctogenarians with symptomatic or severe MR (Class I indi-cation for surgery [49]) are denied surgery, and thus there islimited data on outcomes in this population [50]. There arethree options for surgical correction of MR: 1) MV repair; 2)MV replacement with preservation of part or all of the mitralapparatus; and 3)MV replacement with removal of themitralapparatus [49].In the largest and most comprehensive study of mitral

surgery in the elderly to date, Chikwe and colleagues retro-spectively reviewed 322 octogenarians at two hospitals with

significant MV surgical experience [51]. Compared to MVrepair, MV replacement resulted in significantly higher30 day mortality (18.9% vs. 11.0%, adjusted OR 3.4,p=0.028), and gastrointestinal complications (14.7% vs.4.0%, adjusted OR 6.2, p=0.004). Other non-significantly dif-ferent (p>0.05) results for repair vs. replacement included: 90day mortality of 18.% vs. 31.6%, stroke of 3.1% vs. 1.1%,respiratory failure of 21.1% vs. 26.3%, and any major mor-bidity or mortality of 32.9% vs. 42.5%, respectively. Nlogaand colleagues similarly found replacement resulted in sig-nificantly higher 30 day mortality (18.5% vs. 2.5%, p=0.004)[52]. Replacement was also the only predictive factor ofoperative mortality in multivariate analysis (OR 6.7,p=0.04). The results of other large studies in octogenarianssince 2000 are reported in Table 1.There are a number of well-established advantages of

repair over replacement that may explain the survival advan-tage, especially in the elderly. These include: decreasedthromboembolism and endocarditis [56], avoidance of therisks of chronic anticoagulation and prosthetic failure. MVrepair also preserves left ventricular function better thanMVR due to the preservation of the mitral apparatus, whichhas an integral role in maintaining left ventricular shape,volume and function. This may be evenmore important in anelderly population with pre-existing ventricular dysfunction[57]. Although it is also possible that patients with unrepair-able valves have more advanced heart disease, which con-tributes to their poorer outcomes [53]. Work by Carpentier,Alfieri and others have improved repair techniques andtechnology to a point where it may be feasible in nearly90% of degenerative valves [58]. Despite this, a 2003 analysisof the STS database showed that about 75% of isolated mitralvalve surgery in the United States was replacement [59].Commonly reported reasons for not attempting repair inolder patients include concerns about the risks of prolongedCPB in the event of unsuccessful repair, unclear benefit ofrepair in elderly patients, and the concerns about theincreased technical difficulty of MV repair [53].The aetiology of MR in elderly patients also has a signifi-

cant impact on outcomes of surgery. Chikwe and colleaguesfound that octogenarian patients with MR due to ischaemiccardiomyopathy had significantly poorer outcomes thanpatients with degenerativeMR [51]. Less than half of patientswith ischaemic MR and poor LV function survived to oneyear. Patients with degenerative MV disease undergoingconcomitant CABG also had better outcomes than patientswith ischaemic MR. These authors suggested that medicalmanagement to improve QoL and symptoms may be themost appropriate action in octogenarians with ischaemicMR and poor LV function. Other authors have reportedsimilar findings [60].Maisano and colleagues assessed QoL in 225 patients aged

71-79 and >80 years undergoing surgical treatment for MR,using the Minnesota Living with Heart Failure questionnaire[61]. At a mean follow-up of 2.8# 1.2 years (up to five years),they found that 66% of patients had a score >30 (representingsub-optimal QoL). There was no difference between repair or

4 M. Seco et al.




replacement (p=0.36), however recurrent MR after repairresulted in significantly poorer scores than both durablerepair or replacement (p=0.0013). Multivariate analysis iden-tified preoperative AF, diabetes, higher creatinine level,higher EuroSCORE, MR grade at follow-up, systolic pulmo-nary artery pressure at follow-up, and ejection fraction atfollow-up as factors that predicted poorer QoL. This suggeststhat extra-cardiac factors have a significant role in determin-ing QoL.Minimally invasive mitral surgery (MIMVS) can be per-

formed though a right-lateral minithoracotomy using aorticor femoral cannulation for CPB, with or without roboticassistance. Whilst MIMVS in the general population under-going mitral valve surgery has been proven to be effectiveand safe [62,63], there is limited evidence on its use in theelderly. A propensity analysis by the Leipzig group of 143MIMVS patients >70 years old vs. 143 conventional casesfound no differences in 30 day mortality (7.7% vs. 6.3%,p=0.82), major adverse cardiac and cerebral events (11.2%vs. 12.6%, p = 0.86); but a lower rate of postoperative arrhyth-mias (50.3% vs. 65.7%, p=0.023) and pacemaker implants(10.5% vs. 18.9%, p=0.059); and similar long-term survivalrates at five years (66% # 5.6% vs. 56 # 5.5%) and eight years(35% # 12% vs. 40% # 7.9%) [64]. The same group recentlypresented the results of 191 octogenarian cases, finding simi-lar results; including a 30 day mortality of 3.1% [65]. In a US

study, when 70 MIMVS patients >75 years old were com-pared with 105 sternotomy patients, the rates of major post-operative complications and long term survival were similar,although MIMVS decreased the duration of hospitalisation(8.7 # 0.7 vs. 11.7 # 1.1, p=0.033), overall median cost($37,069 vs. $43,790, p=0.007), and shorter rehabilitation [66].Recently, a percutaneous mitral valve repair technique has

been developed. The MitraClip device (Abbott Vascular) isdeployed via an atrial transseptal approach and clips theregurgitant portion of the mitral leaflets together, creating adouble orifice. This is similar in concept to an Alfieri edge-to-edge surgical repair, howevermitral annuloplasty (an impor-tant component of the Alfieri repair) is not possible with theendovascular device. The EVEREST II randomised con-trolled trial compared the MitraClip (n=184) vs. surgery(n=95) in patients with moderate or severe MR (3+ to 4+).Surgery was significantly more efficacious according to acomposite endpoint (defined as freedom from death, free-dom from surgery for valve dysfunction, and freedom from3+ or 4+ MR at 12 months) than the device (73% vs. 55%,p=0.007), but had a higher rate of major adverse events at30 days (48% vs. 15%, p<0.001) [67]. This latter difference wasalmost entirely due to the inclusion of "2 red cell units as anadverse event, which some surgeons argue should not be amajor event, and when excluded the difference was notsignificant (10% for surgery vs. 5% for device, p=0.23). The

Table 1 Modern outcomes of mitral valve replacement or repair in studies with >100 elderly patients.

Paper n Age group Procedure (% of patients) Hospital/30d mortality Conclusions

Chikwe 2011 [51] 322 "80 Replacement 30%,

repair 70%

18.9% replacement vs.

11.0% repair (p=0.028)

Favours repair. Surgery for

ischaemic MR has poorer

outcomes than degenerative MR.

Nloga 2011 [52] 129 "80 Replacement 42%,

repair 58%


2.5% repair (p=0.004)

Replacement is an independent

predictor of higher operative

mortality in octogenarians.

Ailawadi 2011 [53] 117 "75 Replacement 40%,

repair 60%


7.1% repair (p=0.01)

Repair was associated with a

lower risk of mortality,

postoperative stroke, and

longer survival compared to

replacement.

Detaint 2006 [54] 284 "75 Replacement 29%,

repair 71%

27% in earliest cohort

(1980-83) vs. 5%

in latter cohort (1992-95)

(p<0.001)

Life expectancy (ratio of observed

to expected survival) after surgery

was similar in elderly and younger

patients. Operative mortality in

elderly significantly decreased

over 15 years.

Gogbashian 2006 [55] 292 "70 Replacement 25%,

repair 75%


0.7% repair (p=0.002)

Repair was associated with reduced

in-hospital mortality and length of

stay and increased long-term

survival compared to replacement.

With concomitant CABG, survival

was similar to replacement.

NS = non-significant; MR = Mitral regurgitation.





composite endpoint definition also meant that postoperative2+ MR was also considered successful. Hence surgery cur-rently remains the standard of care forMR, and theMitraClipshould be reserved for inoperable patients [68].

Atrial FibrillationPreventing cardioembolic stroke in elderly patients with AFis particularly important as neurological function reserve isalready low and adverse events can have a significant impacton quality of life. Avoiding warfarin whenever possible isalso important in elderly people predisposed to falls and riskof bleeding. Haıssaguerre and colleagues demonstrated thataround 94% of the ectopic foci that give rise to spontaneousAF are located in the pulmonary veins [69], and thus suc-cessful ablation of these foci using radiofrequency energy orcryoablation can abolish AF. During open cardiac surgery itis possible to ablate these foci from both an epicardial andintracardical approach (e.g. duringMV surgery when the leftatrium is accessed). The most recent meta-analysis in 2010found that in patients with persistent or permanent AF whohad surgical ablation added to their cardiac operation had ahigher rate of sinus rhythm at discharge, and this effect lastedduring one to five year follow-up (OR 6.7, 95% CI 2.8–15.7for RCTs) [70]. In meta-regression analysis the risk ofstroke decreased significantly with longer follow-up time.Although the ablative procedure increased operating time, itdid not have a significant effect on peri-operative all-causemortality or hospital length of stay [70].Since around 90% of the thrombi that cause stroke in AF

form in the left atrial appendage (LAA) [71], successfulclosure of the appendage may also reduce the risk of neu-rological injury. LAA exclusion can be performed duringopen cardiac surgery using a number of techniques includ-ing stapling, ligation, and amputation. However a 2010 bestevidence review found that most studies only achievedsuccessful LAA exclusion in 55–66% of patients and con-cluded there was insufficient evidence to support its use[72]. Despite this, amore recent study of 2,067 patients foundthat cerebrovascular accidents were significantly reduced(0.0% vs. 6.1%, p=.003) [73]. New devices aim to achievehigher and more reliable exclusion success rates, for exam-ple the Atriclip (AtriCure, Ohio, USA) which achieved anexclusion rate of 100% at a mean follow-up time of 3.5 # 0.5years (n=36) [74].

ConclusionCurrent evidence indicates that advanced age alone is not apredictor of mortality or morbidity in cardiac surgery, andsurgical groups in Australia and worldwide have achievedexcellent outcomes in this population formore than a decade.Thus surgery should not be overlooked or denied to theelderly solely on the basis of their ‘‘chronological age’’, with-out considering the patient’s true ‘‘biological age’’.

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