Twenty Years of Cardiac Surgery in Patients Aged 80 Years and Older: Risks and Benefits

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1 Twenty Years of Cardiac Surgery in Patients Aged 80 Years and Older: Risks and Benefits Markus Krane, MD,* Bernhard Voss, MD,* Andreas Hiebinger, MD, Marcus Andre Deutsch, MD, Michael Wottke, MD, MPH, Alexander Hapfelmeier, Dipl. Bioinf., Catalin C. Badiu, MD, Robert Bauernschmitt, MD, PhD, and Rüdiger Lange, MD, PhD Department of Cardiovascular Surgery, German Heart Center Munich, and Institute for Medical Statistic and Epidemiology, Clinic Rechts der Isar of the Technische Universität München, Munich, Germany Background. Patients aged 80 years and older who require cardiac surgical procedures are an increasing population and usually present with considerable comorbidity. Detailed operative risk stratification versus longterm survival and quality of life after surgery is mandatory. Methods. A retrospective analysis was performed on 1,003 patients aged 82.3 years (range, 80 to 94 years) who underwent aortic valve replacement (n 303), coronary artery bypass grafting (n 403), or aortic valve replacement with coronary artery bypass grafting (n 297) between 1987 and Preoperative data, operative outcome, long-term survival, and predictors for early and late mortality were analyzed. Furthermore, the Short Form 36 Health Status questionnaire was used to evaluate the quality of life. Results. Overall in-hospital mortality was 7.1%. Overall actuarial survival at 1, 5, and 10 years was 81.6% 1.2%, 60.4% 1.9%, and 23.3% 2.6% (mean survival time, years) and showed no significant difference compared with an age- and sex-matched general population. Multivariate analysis showed that preoperative creatinine concentration greater than 1.3 mg/dl (p < 0.001), preoperative atrial fibrillation (p < 0.005), and postoperative prolonged ventilation (p < 0.001) were independent predictors for poor long-term survival. The physical health summarized score of the Short Form 36 Health Status questionnaire was significantly increased in the study population compared with a German standard population aged 80 years and older (p < 0.05). Conclusions. Despite an increased operative mortality, octogenarians showed a considerable quality of life and an excellent long-term survival. To further improve surgical outcome in octogenarians, patient selection should be done with consideration of the identified independent preoperative risk factors. (Ann Thorac Surg 2011;91:506 13) 2011 by The Society of Thoracic Surgeons Accepted for publication Oct 19, *These authors contributed equally to this manuscript. Address correspondence to Dr Krane, Department of Cardiovascular Surgery, German Heart Center Munich, Lazarettstr 36, Munich, Germany; krane@dhm.mhn.de. People aged 80 years and older account for a rapidly increasing percentage of the European population. In 2005, 5.2% of the German population was 80 years and older, and by 2050, this subpopulation will have increased to 14.8% [1]. Accordingly, more octogenarians may require cardiac surgical procedures in the future [2]. Recent studies investigated the outcomes of octogenarians undergoing cardiac surgery by analyzing operative mortality, incidences of postoperative complications, and long-term survival. However, to evaluate the success of surgery, investigating the quality of life (QoL) after operation is also a key aspect. Quality of life reflects not only the physical functional status but also the emotional and mental well-being and the social functioning of patients. In previous studies, only New York Heart Association classification was used to describe functional capacities after cardiac surgery, which does not necessarily reflect postoperative QoL [3 5]. Although a few studies attempted to analyze postoperative QoL using nonstandardized questionnaires [6] or the standardized Short Form 36 Health Survey questionnaire (SF-36) [7], these were limited by small patient numbers and the analysis of mixed collectives of surgical procedures. The aim of this study was to analyze the operative and long-term mortality of patients aged 80 years and older undergoing aortic valve replacement (AVR), coronary artery bypass grafting (CABG), or both (AVR CABG). Furthermore, risk factors for early and late outcomes were investigated, and QoL was assessed using the SF-36 questionnaire. These data are the basis for a risk-benefit analysis in octogenarians undergoing cardiac surgery. Patients and Methods Patients Data were selected from the electronic database of the Department of Cardiovascular Surgery of the German Heart Center Munich. During the study period 1,201 octogenarians underwent a cardiac surgery procedure in our hospital. The distribution of different procedures was 2011 by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 Ann Thorac Surg KRANE ET AL 2011;91: AVR, CABG, AND AVR CABG IN OCTOGENARIANS 507 Table 1. Preoperative Variables Variable Overall (n 1,003) AVR (n 303) CABG (n 403) AVR CABG (n 297) p Value Age (y, median) Male (%) NYHA class III and IV (%) Serum creatinine 1.3 mg/dl (%) Diabetes mellitus (%) Hypertension (%) BMI (kg/m 2, mean) Hypercholesteremia (%) Stroke (%) Myocardial infarction (%) EF Atrial fibrillation (%) Urgent/emergent operation (%) Reoperation (%) AVR aortic valve replacement; BMI body mass index; CABG coronary artery bypass grafting; EF ejection fraction; NYHA New York Heart Association. as follows: AVR (n 303), CABG (n 403), AVR CABG (n 297), isolated mitral valve surgery (n 47), mitral valve surgery CABG (n 30), mitral valve surgery AVR (n 23), and 98 complex procedures including multiple valve surgery with and without CABG and aortic surgery. We have chosen the three largest standard cardiac surgery procedures to achieve a reasonable number of patients for a meaningful statistical analysis. Smaller procedure groups were excluded to avoid a mixed collective. Preoperative demographic profiles and operative and postoperative data were obtained from medical records. Follow-up was obtained from questionnaires and the German registration office. The periodic life table from 2000 to 2002 of the Federal Statistical Office was used to compare long-term survival. For each patient of the study group, one simulated patient was matched according to sex and age. The study was approved by the ethics committee of the Technical University Munich, medical faculty; file number 2284/08. Short Form 36 Health Survey Questionnaire The SF-36 was used to assess QoL as described previously [8]. The study group was compared with a German standard population obtained from the database of the SF-36, which documented 2,908 subjects in every age class, of which we selected all 104 subjects aged 80 and older. Statistical Analysis Results are presented as median or mean 1 standard deviation or 95% confidence intervals. For comparisons between dichotomous variables, Fisher s exact test was used. For comparisons of continuous variables by means the Student s t test was used. Actuarial survival was calculated with the Kaplan-Meier method, reported 1 standard error. Comparisons among groups were made by a test based on a Poisson distribution that compared expected and observed events and by using the log-rank test. A univariate analysis of potential risk factors for early mortality was performed. Factors showing a trend to significance (p 0.1) were entered into a stepwise multivariate regression model to determine independent risk factors for early mortality (p 0.05). The odds ratios and 95% confidence intervals for the multivariate predictors are displayed. A univariate analysis of potential risk factors for late mortality ( 3 months) was performed. Predictors showing a trend to significance (p 0.1) were entered into a Cox proportional hazard model to determine independent risk factors for late mortality (p 0.05). The hazard ratios and 95% confidence intervals for multivariate predictors are displayed. The following variables were included in the risk factor analysis for the short- and long-term survival: preoperative variables (age, atrial fibrillation, body mass index, serum creatinine level 1.3 mg/dl, diabetes mellitus, left ventricular ejection fraction 0.35, urgency of procedure, hypercholesteremia, hypertension, previously myocardial infarction, NYHA class, stroke, reoperation and sex); operative variables (cardiopulmonary bypass time, operative time and crossclamp time); postoperative variables (cerebrovascular accident, dialysis, episode of atrial fibrillation, duration of hospital stay, use of an intraaortic balloon pump, intensive care unit stay, persistent atrial fibrillation at discharge, renal failure, rethoracotomy and ventilation 24 h). To evaluate results of the SF-36, the Student s t test was used for comparisons by means. Results of the SF-36 were presented as mean 1 standard error. Results Preoperative Characteristics During the study period, (48.1% male) patients underwent AVR (n 303), CABG (n 403), or AVR CABG (n 297). The median age of the study group was 82.3 years (range, 80 to 94 years; Table 1).

3 508 KRANE ET AL Ann Thorac Surg AVR, CABG, AND AVR CABG IN OCTOGENARIANS 2011;91: Table 2. Operative Variables Variable Overall (n 1,003) AVR (n 303) CABG (n 403) AVR CABG (n 297) p Value Type of valve Biological Stented Stentless CABG Total no. of peripheral anastomosis 1,731 1, ITA LAD SVG LAD Operative time (min, mean) CPB time (min, mean) Cross-clamp time (min, mean) AVR aortic valve replacement; CABG coronary artery bypass grafting; CPB cardiopulmonary bypass; ITA internal thoracic artery; LAD left anterior descending artery; SVG saphenous vein graft. Operative Characteristics All patients who underwent AVR received biologic prostheses. In 290 of 403 patients of the CABG group, the internal thoracic artery was used as graft for the left anterior descending coronary artery, and in 88 patients a saphenous vein graft was used for the left anterior descending coronary artery. In 25 patients the left anterior descending coronary artery was not anastomosed. In 2006, 96% (43 of 45) of octogenarians undergoing CABG received the internal thoracic artery as a graft for the left anterior descending coronary artery (Table 2). Postoperative Morbidity Of study group patients, 25.3% exhibited temporary atrial fibrillation and 12.8%, renal disturbance. Temporary hemodialysis was required in 8.3%, prolonged ( 24 hours) ventilator support in 11.2%, and intraaortic balloon pump support in 3.8%. Cerebrovascular accidents were found in 2.2%. Rethoracotomy was necessary in 4.1% owing to increased bleeding. The median intensive care unit stay was 4 days, and the median length of hospital stay was 10 days (Table 3). Early Mortality and Long-Term Survival Follow-up was completed for 979 of 1,003 patients (97.6%). Twenty-four patients were lost to follow-up. At follow-up 514 patients were alive. Mean follow-up time was years, and the cumulative follow-up for the study group was 3,496 patient-years. Overall 30-day mortality rate was 8.4%, ie, 7.9% for AVR, 7.4% for CABG, and 10.1% for AVR CABG, differences not being statistically significant. The overall in-hospital mortality rate was 7.1% and was significantly higher in patients undergoing AVR CABG (10.1%) compared with the isolated procedures (6.6% for AVR and 5.2% for CABG; p 0.041). Multivariate logistic regression analysis revealed the following variables as independent preoperative predictors for 30-day mortality: serum creatinine concentration greater than 1.3 mg/dl (p 0.02; 30-day mortality, 12.3%; 32 of 261), preoperative stroke (p 0.01; 30-day mortality rate, 20%; 8 of 40), and urgent or emergent operation (p 0.01; 30-day mortality rate, 12%; 33 of 275; Table 4). Overall actuarial survival at 1, 5, and 10 years was Table 3. Postoperative Variables Variable Overall (n 1,003) AVR (n 303) CABG (n 403) AVR CABG (n 297) p Value Renal disturbance (%) a Hemodialysis (%) Need for ventilation 24 h (%) IABP (%) Length of hospital stay (days, median) Length of stay on ICU (days, median) Postoperative atrial fibrillation (%) Rethoracotomy (%) CVA (%) day mortality (%) a Renal disturbance is defined as maximal postoperative creatinine concentration minus preoperative creatinine concentration that is at least 1 mg/dl. AVR aortic valve replacement; CABG coronary artery bypass grafting; CVA cerebrovascular accident; IABP intraaortic balloon pump; ICU intensive care unit.

4 Ann Thorac Surg KRANE ET AL 2011;91: AVR, CABG, AND AVR CABG IN OCTOGENARIANS 509 Table 4. Predictors for 30-Day Mortality by Univariate and Multivariate Analysis Variable p Value Univariate Analysis p Value Multivariate Analysis Odds Ratio 95% CI Preoperative Serum creatinine 1.3 mg/dl Hypercholesteremia Stroke Atrial fibrillation Urgent/emergent operation Postoperative Renal insufficiency a Hemodialysis Need for ventilation 24 h IABP Length of ICU stay ( 4 days) Atrial fibrillation Rethoracotomy CVA a Renal disturbance is defined as maximal postoperative creatinine concentration minus preoperative creatinine concentration that is at least 1 mg/dl. CI confidence interval; CVA cerebrovascular accident; IABP intraaortic balloon pump; ICU intensive care unit. 81.6% 1.2%, 60.4% 1.9%, and 23.3% 2.6%. Survival between the entire study group and the sexand age-adjusted general population showed no significant difference (p 0.35; Fig 1A). The number of expected deaths in the study group was 472 compared with 453 in the general population. The median survival time was 6.1 years (95% confidence interval, 5.7 to 6.6) for the study population and 5.8 years for the general population. Comparing the survival of patients who survived the first 90 days after surgery, the study group had a significantly better survival with 347 deaths compared with the general population, which had 421 estimated deaths (p 0,001; Fig 1B). Actuarial survival at 1, 5, and 10 years was significantly decreased in patients who underwent AVR CABG (76.9% 2.5%, 54.3% 3.5%, and 18.2% 4.7%, respectively) compared with AVR (84% 2.1%, 64.5% 3.4%, and 21.6% 5%, respectively; p 0,02) or CABG (83% 1.9%, 61.6% 2.9%, and 27.9% 4.2%, respectively; p 0.02; Fig 2). Actuarial survival at 1, 5, and 10 years was not significantly different for patients who underwent cardiac surgery in the first 10 years (1987 to 1996) of the study period (80.8% 3.5%, 65.5% 4.3%, and 25.9% 3.9%, respectively), compared with the last 10 years (1997 to 2006) (81.6% 1.3%, 58.6% 2.1%, and 24.6% 3.7%, respectively; p 0.27; Fig 3). A Cox proportional hazard model was used to calculate independent predictors for a decreased long-term survival. Preoperative creatinine concentration greater than 1.3 mg/dl (p 0.001) and preoperative atrial fibrillation (p 0.005) were independent predictors for decreased long-term survival (Table 5). Figure 4 shows the actuarial survival of octogenarians with the preoperative risk factors atrial fibrillation or creatinine concentration greater than 1.3 mg/dl compared with octogenarians without these risk factors. Quality of Life Three hundred eighty-six of 514 (75.1%) living patients completed the SF-36. Twenty-three patients (4.5%) declined participation. The mean scores of the study population for the eight categories were as follows: physical functioning, ; role-emotional, ; social functioning, ; mental health, ; bodily pain, ; vitality, ; role-physical, ; and general health, , respectively. Compared with a standard population of subjects aged 80 years and older, scores for bodily pain and general health were significantly increased (p 0.01) whereas scores for role-physical and role-emotional were significantly decreased (p 0.02) in the study group (Fig 5A). The summarized score for physical health ( versus ) was significantly increased (p 0.05) compared with the general population. The mental health summarized scores ( versus ) showed no differences between populations (p 0.1; Fig 5B). Comparing the summarized scores of patients undergoing the three different surgical procedures revealed no significant differences. Comment 30-Day Mortality In 2006, 11,557 patients in Germany underwent isolated AVR with an in-hospital mortality rate of 3.9% [9]. In octogenarians the mortality is higher. In our study, the 30-day mortality rate of 7.9% for isolated AVR is similar to previously reported perioperative mortality rates of 5.7% to 8.5% [2, 4, 10]. For the CABG group, the 30-day

5 510 KRANE ET AL Ann Thorac Surg AVR, CABG, AND AVR CABG IN OCTOGENARIANS 2011;91: Fig 2. Actuarial survival of patients undergoing aortic valve replacement (AVR; dashed line), coronary artery bypass grafting (CABG; dotted line), or both procedures (AVR CABG; solid line). The survival in patients undergoing both procedures was significantly decreased compared with those undergoing only aortic valve replacement or coronary artery bypass grafting (p 0.02). patients and higher for combined procedures than isolated procedures. This increased mortality rate in octogenarians suggests that the decision to perform cardiac surgery for these patients needs to be carefully considered. Long-Term Survival We were able to show a benefit of cardiac surgery procedures for those patients who survive the early Fig 1. (A) Actuarial survival of the study group compared with a sex- and age-matched general population of subjects aged 80 years and older. (B) Actuarial survival of patients of the study group who have survived the first 90 postoperative days compared with a sexand age-adjusted general population of subjects aged 80 years and older. The solid heavy line represents the study population, with 95% confidence intervals represented by the dashed lines. The lighter solid line represents an age- and sex-matched general population. mortality rate of 7.4% is also comparable to the perioperative mortality of 5.1% to 8.1% reported by different investigators [3, 11 13]. AstoAVR CABG, patients in our study group showed a 30-day mortality rate of 10.1%, supporting studies by Alexander and colleagues [11], who found a perioperative mortality of 10.1% in 345 octogenarians. Hence, the mortality after AVR, CABG, and AVR CABG is higher in octogenarians compared with younger Fig 3. Actuarial survival of patients undergoing cardiac surgery between the first 10 years (1987 to 1996; solid line) of the study period and the last 10 years (1997 to 2006; dashed line) of the study period.

6 Ann Thorac Surg KRANE ET AL 2011;91: AVR, CABG, AND AVR CABG IN OCTOGENARIANS 511 Table 5. Predictors for Late Mortality ( 3 Months) by Univariate and Multivariate Analysis Variable p Value Univariate Analysis p Value Multivariate Analysis Hazard Ratio 95% CI Preoperative Age ( 82.3 y) Sex Serum creatinine 1.3 mg/dl Hypertension Hypercholesteremia EF Atrial fibrillation Reoperation Postoperative Hemodialysis Need for ventilation 24 h IABP Length of ICU stay ( 4 days) CVA CI confidence interval; CVA cerebrovascular accident; EF ejection fraction; IABP intraaortic balloon pump; ICU intensive care unit. postoperative phase but not for the overall study group. Previous studies reported no differences for actuarial survival between their study groups and a general population [5, 14]. Adkins and associates [15] found in 42 patients, who underwent valve surgery with or without additional CABG, a 40-month actuarial survival of 51.9%, which was not significantly different (p 0.3) from the survival of an age-, sex-, and race-matched general population. Cane and coworkers [16] reported a comparable 80-month actuarial survival rate in 121 octogenarians (32.8%), who underwent CABG with or without additional valve procedures, and a respectively matched population (37.6%). In contrast to our results, Chiappini and colleagues [17] were not able to find a significant difference for longterm survival between 44 octogenarians who underwent AVR CABG and 71 octogenarians who underwent isolated AVR (p 0.7). However, the number of patients investigated in their study was small. Huber and associates [18] reported a lower actuarial survival at 5 years in 41 octogenarians undergoing AVR CABG (survival, 65%) compared with isolated CABG (n 61; survival, 70%) or isolated AVR (n 34; survival, 75%), but they did not report statistical significance. Craver and associates [10] showed significantly decreased survival in 73 octogenarians undergoing AVR CABG and 71 octogenarians after isolated AVR compared with younger patients ages 60 to 69 undergoing the respective procedures (p and p ). No differences for long-term survival were found between octogenarians and patients ages 70 to 79 for the respective procedures (p 0.25 and 0.467). Similar to the trend for early postoperative mortality, long-term survival in octogenarians is also lower than that of younger patients (particularly in patients younger than 70 years of age). However, octogenarians who undergo cardiac surgical procedures exhibit at least the same long-term survival as a matching group of the general population. It might be speculated that once their cardiac disease is cured, they are no longer vulnerable to die as a result of their specific cardiac disease. To address the relatively high operative mortality and the restricted long-term survival in this age group, improvements in patient selection and procedural performance could eventually lead to reductions in mortality in the future. Patient Selection To improve perioperative mortality, special emphasis should be placed on independent preoperative predictors of 30-day mortality. In the present study, renal insufficiency, preoperative stroke, and urgent or emergent surgery were identified as independent preoperative predictors for 30-day mortality. The highly increased 30-day mortality rate in octogenarians with these risk factors was 12% to 20%. Further predictors of early mortality like recent ( 24 hours) preoperative myocardial infarction, chronic obstructive pulmonary disease, and low ejection fraction were reported by other investigators [2, 11, 12]. As a result of our study, we are currently more likely to consider patients exhibiting renal insufficiency or preoperative stroke for less invasive transfemoral or transapical valve implantation procedures. We also identified renal insufficiency and atrial fibrillation as independent preoperative risk factors for late postoperative mortality ( 3 months). The combination of both risk factors further decreased long-term survival rates within the first year after operation (59% 6.7% versus 82.8% 1.3%). In addition, other investigators have found chronic obstructive pulmonary disease, previous myocardial infarctions, and urgent procedure to be independent risk factors for late mortality [7, 19, 20].

7 512 KRANE ET AL Ann Thorac Surg AVR, CABG, AND AVR CABG IN OCTOGENARIANS 2011;91: Fig 5. (A) Results of the Short Form 36 Health Status questionnaire of the study group (black bars) compared with the standard population (gray bars) of people aged 80 years and older for the following categories: physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), and mental health (MH). *p 0.05; **p (B) Results of the summarized scores for physical health and mental health of the study population (black bars) and the standard population (gray bars). *p Fig 4. (A) Actuarial survival of octogenarians with preoperative atrial fibrillation (Afib; dotted line) was significantly decreased compared with patients without preoperative atrial fibrillation (solid line; p 0.001). (B) Actuarial survival of octogenarians with a preoperative creatinine concentration greater than 1.3 mg/dl (dotted line) was significantly decreased compared with patients with a creatinine concentration less than 1.3 mg/dl (solid line; p 0.001). (C) Actuarial survival of octogenarians with preoperative atrial fibrillation and a creatinine concentration greater than 1.3 mg/dl (dotted line) was significantly decreased compared with patients with only preoperative atrial fibrillation or a creatinine concentration of at least 1.3 mg/dl or without both (solid line; p 0.002). Hence, improved patient selection for cardiac surgery with attention to these independent preoperative predictors may improve surgical results. Quality of Life The SF-36 is one of the leading instruments for the evaluation of QoL and has often been used to measure QoL after cardiac operations [7, 19, 21 23]. Our retrospective study design did not allow the comparison of QoL between preoperative and postoperative status, and consequently, no improvement in QoL could be assessed. An additional limitation is the potential positive selection caused by the nonresponders, hypothesizing that nonresponders exhibit a lower QoL. Comparing the SF-36 results of study patients with those of an age-related general population, more than 75% of living patients reported a comparable or better QoL in six of eight assessed categories, after a mean follow-up time of years (cumulative follow-up, 1,409 patient-years). Sundt and coworkers [22] previously used the SF-36 to assess 65 participants of 82 living

8 Ann Thorac Surg KRANE ET AL 2011;91: AVR, CABG, AND AVR CABG IN OCTOGENARIANS 513 patients who underwent AVR CABG (their follow-up rate of 75.6% is similar to our rate of 75.1%). Likewise, their study population scored higher in five of eight categories including general health and bodily pain. Tseng and colleagues [19] studied 70 participants of 159 survivors of AVR ages 70 to 89 years (follow-up rate of 44%). Octogenarians exhibit a comparable or slightly better QoL after a mean follow-up time of 3.6 years compared with an age-related standard population. Therefore, the option to undergo cardiac surgical standard procedures should not be denied to older patients. For the evaluation of an improvement in QoL after cardiac surgery in octogenarians, further prospective trials with a preoperative and postoperative use of the SF-36 will be necessary. Conclusions In the present study, octogenarians showed excellent long-term survival. Overall long-term survival was equal to that of a sex- and age-related population, whereas the long-term survival was significantly increased in patients who survived the early phase after surgery. These results suggest that AVR, CABG, and AVR CABG may benefit long-term survival for octogenarians. The combined procedure AVR CABG showed an increased in-hospital mortality and a decreased long-term survival compared with that of isolated procedures such as AVR or CABG. The majority of postoperative octogenarians show a comparable or slightly better QoL compared with an agerelated standard population. To improve surgical outcomes in octogenarians, patient selection for surgery should be done with consideration of independent preoperative predictors for early and late mortality. References 1. Eisenmenger M, Pötsch O, Sommer B. 11. koordinierte Bevölkerungsvorausberechnung Deutschlands bis Wiesbaden: Statistisches Bundesamt; Akins CW, Daggett WM, Vlahakes GJ, et al. Cardiac operations in patients 80 years old and older. Ann Thorac Surg 1997;64: Ishikawa S, Buxton BF, Manson N, et al. Cardiac surgery in octogenarians. ANZ J Surg 2004;74: Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R. Cardiac surgery in octogenarians peri-operative outcome and long term-results. Eur Heart J 2001;22: Williams DB, Carrillo RG, Traad EA, et al. Determinants of operative mortality in octogenarians undergoing coronary bypass. Ann Thorac Surg 1995;60: Goyal S, Henry M, Mohajeri M. Outcome and quality of life after cardiac surgery in octogenarians. ANZ J Surg 2005;75: Fruitman DS, MacDougall CE, Ross DB. Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg 1999;68: Krane M, Bauernschmitt R, Hiebinger A, et al. Cardiac reoperation in patients aged 80 years and older. Ann Thorac Surg 2009;87: Gummert JF, Funkat A, Beckmann A, et al. Cardiac surgery in Germany during 2006: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiov Surg 2007;55: Craver JM, Puskas JD, Weintraub WW, et al. 601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg 1999;67: Alexander KP, Anstrom KJ, Muhlbaier LH, et al. Outcomes of cardiac surgery in patients or 80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 2000;35: Bardakci H, Cheema FH, Topkara VK, et al. Discharge to home rates are significantly lower for octogenarians undergoing coronary artery bypass graft surgery. Ann Thorac Surg 2007;83: Morris RJ, Strong MD, Grunewald KE, et al. Internal thoracic artery for coronary artery grafting in octogenarians. Ann Thorac Surg 1996;62: Collart F, Feier H, Kerbaul F, et al. Valvular surgery in octogenarians: operative risks factors, evaluation of Euroscore and long term results. Eur J Cardiothorac Surg 2005; 27: Adkins MS, Amalfitano D, Harnum NA, Laub GW, McGrath LB. Efficacy of combined coronary revascularization and valve procedures in octogenarians. Chest 1995;108: Cane ME, Chen C, Bailey BM, et al. CABG in octogenarians: early and late events and actuarial survival in comparison with a matched population. Ann Thorac Surg 1995;60: Chiappini B, Camurri N, Loforte A, Di Marco L, Di Bartolomeo R, Marinelli G. Outcome after aortic valve replacement in octogenarians. Ann Thorac Surg 2004;78: Huber CH, Goeber V, Berdat P, Carrel T, Eckstein F. Benefits of cardiac surgery in octogenarians a postoperative quality of life assessment. Eur J Cardiothorac Surg 2007;31: Tseng EE, Lee CA, Cameron DE, et al. Aortic valve replacement in the elderly. Risk factors and long-term results. Ann Surg 1997;225: Kohl P, Kerzmann A, Honore C, Comte L, Limet R. Aortic valve surgery in octogenarians: predictive factors for operative and long-term results. Eur J Cardiothorac Surg 2007;31: Falcoz PE, Chocron S, Mercier M, Puyraveau M, Etievent JP. Comparison of the Nottingham Health Profile and the 36- item health survey questionnaires in cardiac surgery. Ann Thorac Surg 2002;73: Sundt TM, Bailey MS, Moon MR, et al. Quality of life after aortic valve replacement at the age of 80 years. Circulation 2000;102(Suppl 3):III Velanovich V. Behavior and analysis of 36-item Short-Form Health Survey data for surgical quality-of-life research. Arch Surg 2007;142:473 7.