Cardiac surgery for octogenarians: is it an informed decision?

BACKGROUND: Cardiac surgery is frequently performed to palliate cardiovascular symptoms in patients who are octogenarians, without controlled clinical trials to support its benefits. We hypothesized that death or discharge to a nursing care facility after cardiac surgery is similar in patients who are octogenarians and younger patients.
METHODS: We conducted an inception cohort study in a tertiary care teaching hospital in patients who had undergone coronary grafting, valve surgery, or both over 36 months before. We collected data on preoperative disease, operation characteristics, postoperative complications, and outcome at hospital discharge.
RESULTS: Of 783 patients who had cardiac surgery, 96 were octogenarians. Female sex, pulmonary hypertension, previous malignancy, cerebral vascular disease, valvular heart disease, and congestive heart failure were more frequent in patients who were octogenarians than in younger patients. Operative characteristics were similar in both age groups, except there were more frequent valve or combined with coronary grafts surgery and surgical re-exploration in octogenarians. The rate of postoperative complications including cardiovascular, neurological, renal, and nosocomial infections were higher in patients who were octogenarians than younger patients. Death or discharge to a nursing care facility was more frequent in patients who were octogenarians than younger patients (53% vs 14%, P <.002). Age > or =80 years, female sex, congestive heart failure, and surgical re-exploration were independent predictors for death or discharge to a nursing care facility after cardiac surgery.
CONCLUSIONS: The rate of death or discharge to nursing care facility after cardiac surgery was high among patients who were octogenarians. Current operative outcome end points do not reflect such important differences between patients who are octogenarians and younger patients. Informed discussion of treatment options, potential for discharge to a nursing care facility, and quality of life expectations should precede a decision to undergo cardiac surgery in patients who are octogenarians. Randomized clinical trials of medical versus surgical palliation of cardiovascular symptoms in patients who are octogenarians are needed to justify cost-effectiveness and guide better use of relatively scarce Medicare resources.