Cardiac surgery in octogenarians: have we gone too far or not far enough?

Yager, Jonathan E.E.; Peterson, Eric D.

doi:10.1016/j.ahj.2003.08.006

Cited by 6 publications

(5 citation statements)

References 9 publications

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“…Other major surgical procedures in the elderly, e.g. laparotomy and cardiac surgery, showed a severely reduced outcome and increased mortality in elder patients [22,23,24]. Rady et al [23] were able to show in their trial on patients undergoing cardiac surgery that in the elderly patient such reduced outcome was accompanied by a higher preoperative incidence of pulmonary hypertension, previous malignancy, cerebral vascular disease, valvular heart disease, and congestive heart failure.…”

Section: Discussionmentioning

confidence: 90%

Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Sandow¹,

Weitzel-Mudersbach

Rosenbaum

et al. 2013

Cerebrovasc Dis

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Background: Patients with chronic atherosclerotic vessel occlusion and cerebrovascular hemodynamic insufficiency may benefit from extra-intracranial (EC-IC) bypass surgery. Due to demographic changes, an increasing number of elderly patients presents with cerebrovascular hemodynamic insufficiency. So far, little data for EC-IC bypass surgery in elderly patients suffering occlusive cerebrovascular disease are available. We therefore designed a retrospective study to address the question whether EC-IC bypass is a safe and efficient treatment in a patient cohort ≥70 years. Methods: 50 patients underwent EC-IC standard bypass surgery with translocation of the superficial temporal artery to an M2 segment of the medial cerebral artery. Criteria for bypass surgery were presence of symptomatic occlusive cerebrovascular disease of the anterior circulation and proof of a severely restricted or abrogated reserve capacity (detected by H₂O-photon emission tomography or single photon emission computer tomography - before and after forced vessel dilatation by diamox). The incidence of perioperative neurological and surgical complications, bypass patency, bypass function and short-term outcome were retrospectively analyzed. Results: The study cohort consisted of 16 patients ≥70 years (mean = 74.3 years, SE 1.3). It was compared to a cohort of 34 patients <70 years (mean = 61.2 years, SE 1.0). Both groups underwent EC-IC bypass surgery after careful preoperative work-up. Both patient groups did not differ significantly in gender, vascular pathology, previous history of diseases/comorbidity or clinical symptoms. The number of patients which underwent stenting or other endovascular treatments of the internal or common carotid artery prior to EC-IC bypass surgery was significantly higher in the group of patients ≥70 years (37.5 vs. 0%, p < 0.001). Perioperative stroke rate was 0% in both groups and mild morbidity occurred in 18.8 and 14.7%, respectively (p = 0.699). One 84-year-old female patient died due to perioperative endocarditis. Initial bypass patency was 93.8% in patients above the age of 70 years and 97.1% in the younger group (p = 0.542). Secondary occlusion rate was low in both groups (≥70 years: 0% vs. <70 years 3.7%). No new neurologic deficit occurred in patients with a patent bypass during the follow-up period (median 18 ± 13.1 months). Two patients with an initially occluded bypass and one with a secondary bypass occlusion suffered from new neurological symptoms. Conclusions: Our data show comparable safety and efficiency of EC-IC bypass surgery in patients under and above the age of 70 years due to a careful preoperative work-up and a strict indication for bypass surgery.

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Section: Discussionmentioning

confidence: 90%

Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Sandow¹,

Weitzel-Mudersbach

Rosenbaum

et al. 2013

Cerebrovasc Dis

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“…[8][9][10][11][12][13][14] Consequently, the appropriateness of invasive and intensive interventions in patients with a limited life expectancy has been questioned. 6,[15][16][17] While sensitive to socio-economic arguments, cardiac surgical care providers must always act in the best interest of their patients. When caring for a high-risk patient, they must decide on the potential futility of surgery for that person.…”

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confidence: 99%

Clinical Predictions and Decisions to Perform Cardiac Surgery on High-Risk Patients

Dupuis

2005

Semin Cardiothorac Vasc Anesth

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The proportion of high-risk patients undergoing cardiac surgery has increased steadily over the last two decades. Many of those patients have a catastrophic postoperative course and use hospital resources in a proportion that largely outweighs their number. Consequently, the appropriateness of invasive and intensive interventions in those patients has been questioned. If futility of care were predictable preoperatively, cardiac surgery would probably be denied to many high-risk patients. Logistic regression has been used to develop many complex predictive models to identify high-risk patients and predict their outcome; however, those models do not provide much more discrimination than clinical judgment alone. Moreover, with continuous improvement in medical care all risk models lose their calibration over time. As a result, they often overestimate the probabilities of poor outcome in the individual patients. Many high-risk cardiac surgical patients require a prolonged stay in the intensive care unit (ICU). The analysis of small cohorts of patients who had a prolonged postoperative stay in the ICU shows that 50% and 40% of them are still alive at 1- and 2-year follow-up, respectively; and most survivors report a good quality of life. Considering the limitations of predictive risk models and the satisfaction of cardiac surgical patients who survive after a prolonged ICU stay, it is reasonable to recognize that cardiac surgery should rarely be denied to high-risk patients unless technically unfeasible, and clinical predictions should have only a marginal role in the decision to operate on those patients.

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“…B. fçr aortokoronaren Bypass oder Klappenersatz. Diese Frage allein auf der Grundlage medizinischer Ergebnisse zu beantworten, erweist sich als schwierig [20,31]. So ist nach wie vor nicht klar, ob es tatsåchlich ein bestimmtes Alter gibt, in dem akute oder långerfristige Risiken den erwarteten Nutzen eines operativen Eingriffs aufwiegen [31].…”

Section: Ethische Fragen Im Klinischen Alltagunclassified

“…Diese Frage allein auf der Grundlage medizinischer Ergebnisse zu beantworten, erweist sich als schwierig [20,31]. So ist nach wie vor nicht klar, ob es tatsåchlich ein bestimmtes Alter gibt, in dem akute oder långerfristige Risiken den erwarteten Nutzen eines operativen Eingriffs aufwiegen [31]. Selbst wenn herzchirurgische Patienten çber 80 Jahre signifikant schlechtere Ergebnisse fçr Parameter wie postoperative Komplikationen und Krankenhausmortalitåt aufweisen als jçngere Patienten, stellt sich auf der anderen Seite die Frage, ob sich eine vertretbare therapeutische Alternative anbietet: ¹old age .…”

Section: Ethische Fragen Im Klinischen Alltagunclassified

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Herzchirurgie und Ethik

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Risiko Und Qualität in Der Herzchirurgie

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Wie jedes Fachgebiet der Medizin muss sich auch die Herzchirurgie immer wieder mit ethischen Fragestellungen auseinandersetzen. Manche Probleme sind dabei spezifisch, z. B. wenn es um Forschungsansåtze geht, mit denen die experimentelle Herzchirurgie in ethische Randgebiete vordringt ± andere, wie die Auseinandersetzung mit aekonomischen Zwången im klinischen Alltag oder der Umgang mit dem Lebensende, betreffen die årztliche Tåtigkeit als solche und sind damit fachçbergreifend bedeutsam. Die Sterbehilfe oder auch die Debatten um die Transplantationsmedizin als traditionelle medizinethische Themen des ausgehenden 20. Jahrhunderts werden zunehmend durch die Probleme, die sich aus den finanziellen Rahmenbedingungen ergeben, ergånzt und durch aktuelle gesetzliche Entscheidungen, wie die Zulassung der aktiven Sterbehilfe in europåischen Nachbarlåndern, neu belebt. Gerade in den letzten Jahren hat sich auch zunehmend die Frage dessen, was die genetische und biomedizinische Grundlagenforschung darf und was nicht, am Beispiel der embryonalen Stammzellforschung entzçndet. Der vorliegende Artikel kann vor diesem Hintergund nur beispielhaft ethische Fragen aufzeigen, die fçr den Herzchirurgen/die Herzchirurgin relevant sein kaennen.

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Cardiac surgery in octogenarians: have we gone too far or not far enough?

Cited by 6 publications

References 9 publications

Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Extra-Intracranial Standard Bypass in the Elderly: Perioperative Risk, Bypass Patency and Outcome

Clinical Predictions and Decisions to Perform Cardiac Surgery on High-Risk Patients

Herzchirurgie und Ethik

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