Abstract
Purpose: Cardiac surgery in octogenarians with severely deteriorated functional status is increasingly common, but outcome data are still limited. The aim of this study was to compare postoperative outcome, survival, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgery.
Methods: In all, 285 Czech octogenarians who underwent any cardiac surgical procedure between January 2011 and December 2012 were included in the study. Five out of all twelve national adult cardiac surgical centers participated in the study, representing almost half of all octogenarians operated in our country in that period. Patients’ perioperative data were analyzed retrospectively. Follow-up was performed by interviewing patients by telephone.
Results: There was higher 30-day mortality (20% vs. 6.4% vs. 5.2%, respectively, p <0.001), lower 2-year survival (60% vs. 84.0% vs. 85.4%, respectively, p <0.05), and lower Karnofsky score (44.4 vs. 70.1 vs. 70.6, respectively, p <0.001) in high-risk group compared with medium- and low-risk groups, respectively. Greater improvement in New York Heart Association (NYHA) status was noted in high- and medium-risk groups compared with low-risk group (51% vs. 45% vs. 24%, respectively, p <0.05).
Conclusion: High perioperative mortality, poor 2-year survival, and low postoperative quality of life have been observed in high-risk octogenarians undergoing cardiac surgery.
Keywords: cardiac surgery, octogenarians, mortality, postoperative outcome, quality of life
Introduction
The increase in life expectancy of western populations over the past decades has resulted in a significant increase in the number of octogenarians. Advances in cardiopulmonary bypass technique and improved perioperative care have allowed cardiac surgical procedures to be safely offered to octogenarians,1) with the improvement of overall outcome in comparison to sole medical therapy.2) Improved quality of life in octogenarians after open heart surgery has also been reported3) and is currently considered to be a key aspect of postoperative outcome. Functional results, independent living, and subjective outcome of surgery are important in risk benefit analysis for these patients.
Recently, many high-risk octogenarians with severely deteriorated functional status and multiple comorbidities have been increasingly referred for cardiac surgery. Despite numerous studies reporting improved outcome of mostly low-risk octogenarians undergoing cardiac surgery,4) outcome data especially including postoperative quality of life in high-risk octogenarians are still limited.5)
The aim of this study was to examine and compare early perioperative mortality, medium-term survival, early postoperative outcome, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgical procedures.
Materials and methods
This study was approved by the Institutional Review Boards of all university-affiliated, tertiary care medical centers involved (registration number 880/14S-IV).
Study population
All octogenarians undergoing any cardiac surgical procedure in five cardiosurgical centers in the Czech Republic from January 2011 through December 2012.
Data retrieval
Data from hospital records were reviewed retrospectively. Patient demographics, preoperative status, operative risk assessment calculated by EuroSCORE II (ES II) scoring system, and operative and postoperative data were retrieved and analyzed. The procedure was considered to be elective if the patient was admitted to the hospital 1 day prior to surgery excluding all the acute conditions as defined by ES II criteria. Perioperative mortality was considered as any death within 30 days of operation.
Follow-up
Follow-up was performed in May 2014 by interviewing the patients by telephone.
The questionnaire assessing the quality of life by objective and subjective means was administered to all patients. Objective measures included comparing New York Heart Association (NYHA) functional class preoperatively and postoperatively and Karnofsky dependency category postoperatively. Subjective indicators were obtained by asking clear bimodal question, which were designed to assess the satisfaction with different modalities including cognitive functions, physical well-being, independent living, and overall satisfaction with hospitalization. Survival data were retrieved from the Institute of Health Information and Statistics of the Czech Republic and analyzed up to December 2014.
Study design
All patients included in the study were divided into three groups according to the operative risk severity as calculated by ES II. The “low-risk group” included the patients in the first tertile of ES II values, the “medium-risk group” comprised of patients with ES II values in the second tertile, and finally the “high-risk group” represented the patients in the third tertile of the ES II values. All retrieved data including follow-up information were then compared among the three study groups. The primary outcome measures were early mortality (including intensive care unit and 30-day mortality) and medium-term 2-year survival. The secondary outcome measures included early postoperative outcome and quality of life parameters.
Data analysis
All data are expressed as mean ± standard deviation (SD). SPSS 13.0 software was used for statistical analysis. Chi-square test was used for comparisons of qualitative parameters. Shapiro—Wilk test was used to test normal distribution for all quantitative parameters. Kruskal—Wallis test was used to assess the differences of quantitative parameters among the study groups. Survival was compared using the Kaplan—Meier method and Mantel—Cox test was used to test survival difference among the study groups. Performance of ES II to predict hospital mortality was assessed by comparing the observed and predicted mortality. ES II discrimination and calibration were analyzed by determining the area under the receiver operating characteristic (ROC) curve and Hosmer—Lemeshow goodness-of-fit statistic, respectively. Statistical significance was assigned to differences with p <0.05.
Results
Study population characteristics
There were 285 patients included in the study. The ES II range for the low-risk group was 1.17–3.2, for the medium-risk group was 3.21–6.51, and 6.51–53.78 for the high-risk group. There was no difference in the demographic, preoperative, and perioperative data across all study groups, except for the higher incidence of stroke, renal dysfunction, and left/right ventricular dysfunction in the high-risk group (Table 1). There were also significantly more patients in NYHA III/IV category in medium- and the high-risk groups compared to the low-risk group.
Table 1. Preoperative data.
| Total, n = 285 | Low risk, n = 96 | Medium risk, n = 94 | High risk, n = 95 | p value | |
|---|---|---|---|---|---|
| EUROSCORE II range‡ | 1.17–53.78 | 1.17–3.2 | 3.21–6.51 | 6.51–53.78 | |
| EUROSCORE II average‡ | 6.87 ± 7.73 | 2.36 ± 0.52 | 4.54 ± 0.85 | 13.7 ± 10.3 | |
| Age (years)‡ | 82.2 ± 2.2 | 81.9 ± 2.1 | 82.5 ± 2 | 82.3 ± 2.4 | 0.097 |
| Male (female)† | 182 (103) | 68 (28) | 62 (32) | 52 (43) | 0.060 |
| CAD† | 206 (72.3%) | 68 (70.8%) | 67 (71.3%) | 71 (74.7%) | 0.805 |
| Arterial hypertension† | 255 (89.5%) | 87 (90.6%) | 85 (90.4%) | 83/95 (87.4%) | 0.714 |
| LV EF <35%‡ | 39 (13.7%) | 5 (5.2%) | 10 (10.6%) | 24 (25.3%) | 0.001* |
| RV dysfunction† | 21 (7.4%) | 3 (3.1%) | 5 (5.3%) | 13 (13.7%) | 0.013* |
| Pulmonary hypertension† | 55 (19.3%) | 14 (14.6%) | 19 (20.2%) | 22 (23.2%) | 0.312 |
| COPD† | 41 (14.4%) | 11 (11.5%) | 17 (18.1%) | 13 (13.7%) | 0.417 |
| Diabetes mellitus† | 107 (37.5%) | 34 (35.4%) | 35 (37.2%) | 38 (40%) | 0.805 |
| Stroke/TIA† | 42 (14.7%) | 8 (8.3%) | 11 (11.7%) | 23 (24.2%) | 0.005* |
| NYHA I† | 83 (29%) | 41 (43%) | 19 (20%) | 23 (24%) | 0.001* |
| II | 88 (31%) | 36 (37%) | 32 (34%) | 22 (23%) | |
| III | 94 (33%) | 17 (18%) | 33 (35%) | 44 (46.3%) | |
| IV | 20 (7%) | 2 (2%) | 9 (10%) | 9 (9%) | |
| Serum creatinine (µmol/L)‡ | 105.6 ± 30.7 | 95.8 ± 20.4 | 108 ± 29.4 | 114 ± 36.7 | 0.002* |
EUROSCORE II: European System for Cardiac Operative Risk Evaluation II; CAD: coronary artery disease; LV EF: left ventricular ejection fraction; RV: right ventricle; COPD: chronic obstructive pulmonary disease; TIA: transitory ischemic attack; NYHA: New York Heart Association heart failure classification; †c2 test; ‡Kruskal–Wallis test; *Values in bold represent statistical significance of p <0.05
Operative data
There were more acute, combined, mitral, and tricuspid valve surgical procedures performed in the high-risk group compared to the other two groups (Table 2). Also significantly longer aortic cross clamp and cardiopulmonary bypass times were noted in the high-risk group (Table 2).
Table 2. Operative data.
| Total, n = 285 | Low risk, n = 96 | Medium risk, n = 94 | High risk, n = 95 | p value | |
|---|---|---|---|---|---|
| Elective procedure† | 191 (67%) | 67 (69.8%) | 70 (74.5%) | 41 (56.8%) | 0.021* |
| Re-operation† | 8 (2.8%) | 2 (2.1%) | 1 (1.1%) | 5 (5.3%) | 0.189 |
| Type of surgery: | |||||
| CABG on pump† | 56 (19.6%) | 23 (24%) | 15 (16%) | 18 (18.9%) | 0.373 |
| CABG off pump† | 73 (25.6%) | 23 (24%) | 26 (27.7%) | 24 (25.3%) | 0.861 |
| AVR† | 63 (22.1%) | 22 (22.9%) | 22 (23.4%) | 19 (20%) | 0.828 |
| MVR† | 6 (2.1%) | 1 (1%) | 0 | 5 (5.3%) | 0.028* |
| MV repair† | 13 (4.6%) | 0 | 9 (9.6%) | 4 (4.2%) | 0.007* |
| TV repair† | 11 (3.9%) | 0 | 4 (4.3%) | 7 (7.4%) | 0.026* |
| Aortic surgery† | 3 (1.1%) | 1 (1%) | 0 | 2 (2.1%) | 0.363 |
| Combined procedure† | 77 (27%) | 17 (17.7%) | 22 (23.4%) | 38 (40%) | 0.002* |
| Aortic cross clamp time (min)‡ | 56.4 ± 27.1 | 46.8 ± 24.4 | 55.3 ± 22.7 | 67.7 ± 29.5 | 0.001* |
| CPB time (min)‡ | 85.1 ± 38.2 | 73.4 ± 37.7 | 79.3 ± 33.4 | 103.1 ± 37.7 | 0.001* |
AVR: aortic valve replacement; CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; MVR: mitral valve replacement; MV: mitral valve; TV: tricuspid valve; †c2 test; ‡Kruskal–Wallis test; *Values in bold represent statistical significance of p <0.05
Early mortality
ICU mortality was significantly higher in the high-risk group compared to medium- and low-risk groups (12.6% vs. 4.6% vs. 4.2%, respectively, p <0.05). Also higher 30-day mortality was noted in the high-risk group compared to medium- and low-risk groups (20.0% vs. 6.4% vs. 5.2%, respectively, p <0.05). There was a trend toward higher observed 30-day mortality in comparison to predicted mortality according to ES II with the observed/ expected mortality ratios of 2.2, 1.4, and 1.5 for the low-, medium-, and high-risk groups, respectively. For the whole population of octogenarians, the observed/expected ratio was 1.5; however, all these findings did not reach statistical significance (Hosmer–Lemeshow, p = 0.44). In ROC analysis, area under the curve (AUC) was 0.705 with 95% confidence interval (0.596–0.813), identifying ES II as a fair predictor of perioperative mortality.
Heart failure represented the most common cause of perioperative death and was significantly higher in the high-risk group compared to the medium- and low-risk groups (15.8% vs. 4.3% vs. 4.2%, respectively, p <0.05).
Medium-term survival
Two-year survival rate was significantly lower in the high-risk group compared to the medium- and low-risk groups (60.0% vs. 84.0% vs. 85.4%, respectively, p <0.05). Kaplan–Meier analysis showed a marked decrease in overall survival in the high-risk group compared to the medium- and low-risk groups, particularly during the first postoperative year (p <0.001) (Fig. 1).
Fig. 1. Actuarial survival of octogenarians undergoing cardiac surgery: comparison among the study groups. Cross bars depict censored patients.
The most common cause of late (>30 days) death in all study groups was also represented by heart failure and was significantly higher in the high-risk group compared with the medium- and low-risk groups (14.7% vs. 5.3% vs. 6.3%, respectively, p <0.05).
Early postoperative outcome
There was no difference in early postoperative outcome data except for the higher incidence of low cardiac output syndrome (LCOS) in the high-risk group (Table 3). The intensive care unit (ICU) stay was significantly longer in the high-risk group in comparison to low- and medium-risk groups (Table 3); however, no difference in hospital length of stay was found among the study groups.
Table 3. Postoperative outcome.
| Total, n = 285 | Low risk, n = 96 | Medium risk, n = 94 | High risk, n = 95 | p value | |
|---|---|---|---|---|---|
| Myocardial infarction† | 9 (3.2%) | 2 (2.1%) | 1 (1.1%) | 6 (6.3%) | 0.09 |
| Low cardiac output† | 21 (7.4%) | 4 (4.2%) | 1 (1.1%) | 16 (16.8%) | 0.001* |
| Atrial fibrillation† | 154 (54%) | 44 (45.8%) | 57 (60.6%) | 53 (55.8%) | 0.113 |
| Stroke/TIA† | 11 (3.9%) | 2 (2.1%) | 6 (6.4%) | 3 (3.2%) | 0.279 |
| ICU delirium† | 46 (16.1%) | 19 (19.8%) | 15 (16%) | 12 (12.6%) | 0.404 |
| AKI (RIFLE criteria)† | 0.074 | ||||
| Risk | 27 (9.5%) | 6 (6.3%) | 9 (9.6%) | 12 (12.6%) | |
| Injury | 8 (2.8%) | 3 (3.1%) | 2 (2.1%) | 3 (3.2%) | |
| Failure | 22 (7.7%) | 5 (5.2%) | 3 (3.2%) | 14 (14.7%) | |
| Loss of function | 7/285 (2.5%) | 3 (3.1%) | 3 (3.2%) | 1 (1.1%) | |
| Infection† | 42 (14.7%) | 12 (12.5%) | 10 (10.6%) | 20 (21.1%) | 0.098 |
| Length of ICU stay (days)‡ | 4.1 ± 4.6 | 3.8 ± 4.9 | 3.6 ± 3 | 5 ± 5.3 | 0.028* |
| Length of hospital stay (days)‡ | 12.8 ± 10.7 | 12.2 ± 7.8 | 12.9 ± 11.4 | 13.4 ± 12.3 | 0.654 |
TIA: transitory ischemic attack; ICU: intensive care unit; AKI: acute kidney injury; RIFLE: RIFLE classification system for acute kidney injury; †c2 test; ‡Kruskal–Wallis test; *Values in bold represent statistical significance of p <0.05
Quality of life
In all, 161 patients were reached and interviewed by telephone after a mean of 27.5 months (range: 17–43 months) after surgery. The success rate was 71.6% from the total number of 225 surviving patients. There was significantly lower Karnofsky dependency score in the high-risk group compared to low- and medium-risk groups (Table 4). No differences in the spectrum of answers on quality of life subjective questions were found among the study groups (Table 4). There was also greater improvement in NYHA category in the high- and medium-risk groups compared to low-risk group (Table 4).
Table 4. Postoperative functional status.
| Total, n = 161 | Low risk, n = 64 | Medium risk, n = 58 | High risk, n = 39 | p value | |
|---|---|---|---|---|---|
| Karnofsky score‡ | 61.7 ± 38.7 | 70.7 ± 32.8 | 70.1 ± 33.5 | 44.4 ± 42.9 | 0.001* |
| NYHA I† | 39 (24%) | 20 (31%) | 9 (15%) | 11 (28%) | 0.270 |
| II | 93 (58%) | 34 (54%) | 36 (62%) | 22 (56%) | |
| III | 29 (18%) | 10 (15%) | 13 (23%) | 6 (16%) | |
| IV | 0 | 0 | 0 | 0 | |
| NYHA | |||||
| Improvement† | 64 (38%) | 16 (24%) | 27 (45%) | 21 (51%) | 0.027* |
| No change | 63 (38%) | 29 (44%) | 23 (38%) | 11 (27%) | |
| Worsening | 40 (24%) | 21 (32%) | 10 (17%) | 9 (22%) | |
| Subjective questions† | |||||
| Incidence of positive answers | |||||
| 1 | 36 (22.4%) | 16 (25%) | 9 (15.5%) | 11 (28.2%) | 0.274 |
| 2 | 80 (49.7%) | 31 (48.4%) | 29 (50%) | 20 (51.3%) | 0.990 |
| 3 | 20 (12.4%) | 10 (15.6%) | 7 (12.1%) | 3 (7.7%) | 0.475 |
| 4 | 135 (83.9%) | 52 (81.3%) | 48 (82.8%) | 35 (89.7%) | 0.569 |
| 5 | 142 (88.2%) | 56 (87.5%) | 49 (84.5%) | 37 (94.9%) | 0.417 |
| 6 | 145 (90.1%) | 56 (87.5%) | 51 (87.9%) | 38 (97.4%) | 0.383 |
NYHA: New York Heart Association heart failure classification; †c2 test; ‡Kruskal–Wallis test; *Values in bold represent statistical significance of p <0.05
Subjective questions are as follows:
1. Have you noticed any memory loss or mental disability after surgery?
2. Has your physical status improved?
3. Have you noticed any sleep disorders after surgery?
4. Do you feel independent from help and support of the others?
5. Would you undergo the same operation again?
6. Were you satisfied with the hospital services?
Discussion
Our study shows that cardiac surgery performed in high-risk octogenarians is associated with increased incidence of postoperative complications, high 30-day mortality, and poor medium-term survival. Functional postoperative status of all surviving patients is generally improved; however, overall quality of life as expressed by Karnofsky score is low, especially in the high-risk patients. Also a significant number of subjective complaints regarding postoperative cognitive dysfunction, memory loss, and sleep disorders have been noted across all study groups. Despite these limitations, most of the surviving patients felt subjectively independent in daily living activities, which is in contrast with the poor results in objective measures of quality of life, specifically in the high-risk octogenarians.
Cardiac surgical procedures have been performed safely in octogenarians, however, with increased perioperative morbidity and mortality in comparison to younger patients.6) Excellent results in terms of perioperative and late outcome measures have been reported in octogenarians undergoing low-risk cardiac procedures. On the contrary, higher morbidity and mortality has been observed in high-risk combined procedures,7) reoperations,8) and acute aortic surgery.9) Most of these studies examined postoperative outcome of distinct surgical procedures without special attention to overall perioperative risk. However, in our routine practice, we often assess octogenarians with many comorbidities, in whom the type of surgery constitutes only a part of the overall risk. Thus, risk scoring systems in adult cardiac surgery are becoming increasingly important as they reliably estimate the risks associated with surgery.10) The most popular scoring system for the estimation of perioperative mortality after cardiac surgery in Europe is ES II. It was launched in 2011 to update the older additive and logistic ESs.11) ES II was validated in large populations of patients and it was shown that it is particularly accurate in predicting perioperative mortality of high-risk patients and even a good predictor of late postoperative outcome.12) In our study, there was a trend toward increased observed hospital mortality in comparison to expected mortality with the observed/expected mortality ratio up to 2.2 in the low-risk group (Fig. 1). However, according to Hosmer–Lemeshow, statistical significance was not reached; thus, ES II seems to be sufficiently calibrated in our study population. In addition, ROC analysis with AUC of 0.705 also identified ES II as a fair predictor of perioperative mortality. That is in contrast to other studies, which reported a lack of discriminatory ability of ES II to predict mortality in the elderly undergoing cardiac surgery.13,14) These contradictory results could be caused by a relatively small number of patients enrolled in our study. A larger sample would generate a larger number of events and would provide more solid results as the Hosmer–Lemeshow test is based on contrasting predicted events with observed events.
A possible explanation for the reported findings of increased observed perioperative mortality compared to the predicted one could be a high proportion of so-called “frail” patients in octogenarians. Syndrome of frailty is an emerging concept in clinical medicine and has been reported to be a key factor with the potential of increasing mortality in the elderly surgical patients.15) It is defined as a reduced resistance to external stressors with the predisposition to falls, prolonged hospitalization, and mortality.15) Furthermore, it was also identified as an independent predictor of increased morbidity and mortality after elective cardiac surgery.16) Minimally invasive methods including transcatheter aortic valve replacement have been proposed to decrease postoperative mortality in these high risk and frail patients17) by limiting the surgical stress of the operation. However, as recent meta-analyses show, controversy still remains, whether these techniques can really improve survival.18) Thus, commonly used ES II risk assessment may underestimate the true risk of perioperative mortality in the frail elderly patients. Further studies are warranted to elucidate discriminatory power of ES II to accurately predict perioperative mortality in octogenarians undergoing cardiac surgery.
The 2-year survival rate in the low- and medium-risk groups is comparable with other studies19) and shows good medium-term survival despite advanced age. In contrast, the 2-year survival in the high-risk group was significantly lower, reaching 60% with the highest mortality in the first 12 months (Fig. 1). After a year, slopes of Kaplan–Meier curves were similar in all study groups. Heart failure represented the most common cause of perioperative and late death in all study groups.
The most serious postoperative complication is LCOS, which is associated with high morbidity and mortality rate reaching up to 38%.20) In our study, there was a significantly increased incidence of LCOS in the high-risk group compared to the other groups. As our data show, it is most likely a consequence of a higher complexity of surgical procedures with longer duration of cardiopulmonary bypass, increased incidence of preoperative myocardial dysfunction, and higher percentage of acute procedures in the high-risk group, as these conditions were previously identified as predictors of LCOS and perioperative mortality.20) This assumption is supported by the high incidence of heart failure (15.8%) as a cause of perioperative death in the high-risk group, which clearly dominated over other causes of death (78.9% of all deaths).
Quality of life is another major parameter in assessing the outcome of cardiac operations, especially in patients with limited expected life expectancy. Information on the expected postoperative quality of life allows the patient to form realistic expectations regarding morbidity and mortality, as well as physical, functional, emotional, and mental welfare. For medical practitioners, it is often difficult to correlate patient’s postoperative outcome including quality of life parameters to a specific risk score value. Therefore, we stratified our study population and created three risk categories as a function of the distribution of ES II to elucidate a relationship between specific risk score range and postoperative outcome measures. We chose NYHA cardiac failure functional class and Karnofsky dependency category as objective indicators of quality of life.
Symptom relief with remarkable improvement in NYHA functional category in octogenarians has been previously reported in the literature3) and our study results also support these findings. Significant improvements were noted in NYHA across all study groups (Table 4) and, interestingly, this improvement was greater in the medium- and high-risk groups compared to the low-risk group. Taking into account very high incidence of postoperative complications and excessive perioperative mortality in high-risk octogenarians, we assume that such a significant improvement in cardiac failure symptoms outweighs these operational risks and in addition to survival it represents another major and vital benefit of cardiac surgery in these patients.
Another objective measure of quality of life, Karnofsky dependency category, reflects the degree of help needed by these elderly patients. This scale was originally designed to assess overall performance status in cancer patients, but it has since been used by many authors in cardiac surgical patients.21) In our study, the average postoperative Karnofsky scores in the low- and medium- risk groups were 70.7 and 70.1, respectively, representing patients able to care for themselves at home, nonetheless unable to work and requiring various degree of assistance. Such a relatively favorable finding in octogenarians was also reported in previous studies.21,22) Contrary wise, the high-risk group had average Karnofsky score of 44.4, which represents disabled patients with the requirement of special assistance and frequent medical care. It is likely that such poor functional outcome especially in high-risk octogenarians might be caused by the natural progression of the underlying cardiac disease and associated multiple comorbidities related to advanced age.
The subjective indicators of quality of life are more problematic and involve a number of modalities relating to various domains of life. In the follow-up, we asked clear bimodal questions regarding postoperative memory problems, sleep disorders, physical functioning, and satisfaction with operation and hospital services (Table 4). Approximately, half of the interviewed patients confirmed improved physical functioning postoperatively, which is in agreement with significant improvement in NYHA category in all study groups. Subjective feeling of independence from the help of the others experienced 81.3%, 82.8%, and even 89.7% in the low-, medium-, and high-risk groups, respectively. That is in contradiction with the findings of semiautonomous and dependent functional status, when objectively measured by Karnofsky score, especially in the high-risk group.
Also, a significant number of patients experienced some degree of permanent, subjectively sensed mental or memory impairment with the highest incidence of 28.2% in the high-risk group. In addition, long-term postoperative sleep disorders were also noted in all of the study groups, with the highest incidence of 15.6% in the low-risk group. Postoperative neuropsychological and cognitive dysfunction is recognized as a significant issue facing the elderly patient. Cognitive dysfunction following cardiac surgery is the most common neurological complication, affecting up 20%–40% of patients.23) Although the pathophysiology of postoperative cognitive dysfunction is still controversial, the long-term consequences include decreased quality of life and increased dependency on society. It definitely represents a significant problem for patients, families, and health systems escalating care needs and costs, especially in these elderly patients.24) However, despite all these above-mentioned limitations including postoperative neuro-psychological impairment and loss of independence in routine daily activities, almost all the patients across the study groups were satisfied with the operation and hospital services and would undergo the same surgery again. Based on these findings, we conclude that overall subjective perception of the symptomatic benefit of cardiac surgery is of paramount importance for majority of patients and influences their decision-making further on.
Our study has some limitations. A retrospective design and small number of patients represent major limitations of our study, especially in interpreting mortality data. Another limitation is only 71.6% success rate of the telephone follow-up.
Conclusion
Considering significant improvement in cardiac failure symptoms and subjective outcome data, we believe, that despite high mortality and low postoperative quality of life, high-risk octogenarians should not be denied the benefits of cardiac surgery. However, before referring for an operation, the potential for a higher than expected mortality rate and decreased functional status should be taken into account. Indicating cardiologists as well as surgeons and anesthesiologists, who participate in perioperative care, should openly speak to the patients and their relatives giving them enough relevant information to decide whether to undergo cardiac surgical procedure or not.
Disclosure Statement
All authors have no conflicts of interest.
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