The increase in life span of the American population over

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1 Ten-Year Experience f Cardiac Surgery in Patients Aged 80 Years and Over Tsung-P Tsai, MD, Aureli Chaux, MD, Jack M. Matlff, MD, Rbert M. Kass, MD, Richard J. Gray, MD, Michele A. DeRbertis, RN, and Steven S. Khan, MD Department f Cardithracic Surgery, Cedars-Sinai Medical Center, Ls Angeles, Califrnia Five hundred twenty-eight cnsecutive patients aged 80 years and ver (mean age, 8.1 ±.7 years) underwent cardiac peratins with hypthermia (mean, 1.9 ±. C), hyperkalemic cardiplegia, and cardipulmnary bypass in a -year perid. Fifty-six percent f the patients were male. Preperatively, 68% f the patients were in New Yrk Heart Assciatin functinal class IV, and 1% were in class III. Amng them, 0 patients had islated crnary artery bypass grafting (CABG) (grup I), 1 had artic valve replacement nly r cmbined with CABG (grup 11), 4 had mitral valve replacement nly r cmbined with CABG (grup 111), 1 had mitral valve repair and CABG (grup IV), and 0 had dublevalve prcedure nly r cmbined with CABG (grup V). The 0-day r in-hspital mrtality was 8.% in grup I, 4.% in grup II, 9% in grup III, % in grup IV, and 0% in grup V. Ttal0-day r in-hspital mrtality was.6%. One-year and -year actuarial survival rates were as fllws: grup I, 8% and 6%; grup II, 8% and 8%; grup III, 61% and 7%; grup IV, 6% and 19%; and grup V, 6% and 1%. Ttall-year and -year actuarial survival were 79% and 4%. At fllw-up (mean, years), 70% f verall survivrs reprted that their general health had imprved. Our experience demnstrates that fr select patients aged 80 years and ver with unmanageable cardiac symptms, CABG and artic valve replacement grups had better results in imprving quality f life as cmpared with patients having mitral r cmbined prcedures. (Ann Thme Surg 1994;8:44-1) The increase in life span f the American ppulatin ver the past decade has resulted in a significant increase in the number f peple aged mre than 80 years. Based n statistical data derived frm ppulatin studies, life expectancy varies frm an average f apprximately 8.1 years at the age f 80 years t 6.0 years at the age f 89 years [1]. In 1990, 7.4 millin Americans, representing % f the ppulatin, were mre than 80 years f age. Of these ctgenarians, % have serius symptmatic heart disease, including 18% with ischemic heart disease []. Octgenarians with significant symptms f cardivascular disease frequently are referred fr peratin t try t imprve their quality f life. Recent reprts reveal that cardiac peratins fr selected elderly individuals wh have therwise gd physical and mental health can imprve mrtality, mrbidity, and even quality f life [-9]. Hwever, the utcmes remain prly defined, especially fr valve and cmbined prcedures. This reprt describes the results f mycardial revascularizatin and valve prcedures in patients aged 80 years and lder by examining ur -year experience. Material and Methds There were 8 patients lder than 80 years wh underwent cardiac peratins with hypthermic cardipulmnary bypass between June 198 and Octber 199. Age Accepted fr publicatin Nv 9, 199. Address reprint rel..luests t Dr Tsai, Department fcardithracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Rm 61, Ls Angeles, CA by The Sciety f Thracic Surgens ranged frm 80 t 94 years, with a mean f 8.1 ::':::.7 years. Fifty-six percent f the patients were male. Preperatively, 68% f the patients were in New Yrk Heart Assciatin functinal class IV and 1% were in class III. Frty-six percent f the patients had severe triple-vessel crnary artery disease and 6% had left main stensis. Mst patients presented with acute cardivascular symptms: 70% had unstable prgressive angina pectris, 69% f the patients experienced dyspnea, 4% had a histry f chrnic angina pectris, % had abnrmal exercise test, and % experienced syncpe. Sixty percent f the patients had a histry f mycardial infarctin. Risk factrs included hypertensin in %, histry f diabetes mellitus in 19%, a family histry f heart disease in 7%, and a histry f cigarette smking in % (Table 1). Systemic hypthermia t a mean f 1.9 ::':::. C and hypthermic hyperkalemic cardiplegia (either antegrade r cmbined with retrgrade) was used in each patient (1% f patients with bld cardiplegia and 79% f patients with crystallid cardiplegia). The mean ttal bypass time and ttal ischemic time were.4 and 1.7 hurs, respectively. Frty-nine patients (.9%) needed intraartic balln cunterpulsatin either preperatively r pstperatively. Reperatin fr bleeding was required in 8.7% f the patients (46 patients). In this elderly grup, 7.8% f patients were underging secnd peratins and 4.4% f patients had a histry f a prir failed percutaneus transluminal crnary angiplasty. Three hundred three patients underwent islated crnary artery bypass grafting (CABG). The average number /94/$7.00

2 446 TSAI ET AL Ann Thrac Surg 1994;8:44-1 Table 1. Preperative Characteristics in Octgenarians Characteristic CABG (n = 0) AVR (n = 1) MVR (n = 4) MVRP (n = 1) DVR" (n = 0) Ttal (n = 8) Mean age (y) Sex (% male) NYHA (%) Class I & II Class III Class IV CAD extent (%) Symptms (%) CHF & dyspnea Unstable angina Histry f angina Abn exercise test Palpitatins Syncpe Cardiac arrest Histry f MI Risk factrs (%) Hypertensin Diabetes mellitus Family histry f heart disease < Smking Previus Current Abn ~abnrmal; AVR ~artic valve replacement with r withut CABG; CABG = crnary artery bypass grafting; CAD = crnary artery disease; CHF = cngestive heart failure; DVR+ = duble valve r cmbined prcedure with r withut CABG; MI = mycardial infarctin; MVR = mitral valve replacement with r withut CABG; MVRP ~mitral valve repair with CABG; NYHA = New Yrk Heart Assciatin. f grafts per patient was. ± 0.8, and % f the patients had received internal thracic artery grafts. A small number f patients had saphenus vein, arm vein, r crypreserved hmgraft vein (4 patients) as their bypass cnduit (Table ). Tw hundred twenty-five patients underwent valvular prcedures. The causes f valvular heart disease were as fllws: 4% were degenerative, 1.% had prlapse, % had papillary muscle infarctin r rupture, % had prsthetic dysfunctin, % were rheumatic, and.% had cngenital abnrmalities (Table ). A ttal f patients had valvular prcedures: 1 Table. Operative Prfiles in Octgenarians CABG AVR MVR MVRP DVR' Ttal Variable (n = 0) (n = 1) (n = 4) (n = 1) (n = 0) (n = 8) Hypthermia (mean C) Pump time (h) Ischemic time (h) IABP (n.) Rep fr bleeding (%) Red (%) Pst-PTCA (%) Cartid endarterectmy (%) Hspital stay (mean days) Years f fllw-up Number f grafts (mean) ITA (%) Prsthetic dysfunctin (n.) IABP ~intraartic balln pump; ITA ~internal thracic artery; PTCA ~percutaneus transluminal crnary angiplasty; Red ~reperatin; ther abbreviatins are as in Table 1.

3 Ann Thrac Surg 1994;8:44-1 TSAIET AL HEARTSURGERY IN ELDERLY 447 Table. Cause f Valvular Disease in Octgenarians (%) AVR MVR MVRP DVR+ All Cause (n = 1) (n = 4) (n = 1) (n = ) (n = 8) Degenerative Rheumatic 19 0 Papillary muscle MI r rupture Prsthetic dysfunctin Prlapse Cngenital All abbreviatins are as in Table 1. patients (8%) had tissue valves and 74 patients (%) had St. Jude prstheses. Furteen patients underwent Carpentier-Edwards mitral ring annulplasty and 17 patients had mitral suture annulplasty. Tricuspid annulplasty was perfrmed in 7 patients (6 with Carpentier-Edwards ring). Results Mrtality Thirty-day and in-hspital mrtality was 8.% fr the islated CABG grup (grup I), 4.% fr the artic valve replacement with/withut CABG grup (grup II), 9% fr the mitral valve replacement with/withut CABG grup (grup III), % fr the mitral valve repair with CABG grup (grup IV), and 0% fr the duble-valve r cmbined prcedure with/withut CABG grup (grup V). Ttal D-day r in-hspital mrtality was.6%. In refutatin f the ften-stated dictum that mrtality at this age is related t multisystem failure, 8 f the ttal 179 deaths, r 46%, were cardiac in nature. Estimatin f the causes f death revealed that 7 patients died f arrhythmia, f pump failure r cngestive heart failure, 14 f cerebrvascular accident, 1 f renal failure, 1 f pulmnary insufficiency, 1 f cancer, 6 f unknwn causes, f hemrrhage, and 4 f sudden death (Table 4). Surgical Cmplicatins Frty-ne percent f the patients had atrial fibrillatin and 19% had atrial flutter. Third degree heart blck requiring pacemaker implantatin develped in % (6 patients). Seven percent f the patients had pstperative mycardial infarctin (new Q waves n serial electrcardigrams). Furteen percent f the patients had pstperative cnfusin r disrientatin, and % f the patients had cerebrvascular accidents. Thirteen percent f the patients had pulmnary insufficiency. Leg infectin ccurred in 6%, and sternal wund infectin in %. Transient renal insufficiency (creatinine level greater than mg/dl) develped in 11% f the patients. Five patients required hemdialysis and patients died during their hspitalizatin. Six percent f the patients had sepsis and 4% had pericarditis. Survival One-year and -year pstperative actuarial survival rates were 8% and 6% fr the CABG, 86% and 8% fr the Table 4. Causes f Death in Octgenarians Wh Underwent Cardiac Operatin Cause (n.) Early Late Ttal Arrhythmia r presumed 1 7 Pump failure r CHF 8 4 Nncardiac Hemrrhage Pulmnary insufficiency 1 Sepsis 0 Cerebrvascular accident Mycardial infarctin 8 Pulmnary emblism 1 Renal failure Cardiac-nnvalvular 1 Cardiac rupture Cancer Endcarditis 0 Suicide 0 Trauma Sudden death Unknwn Ttal CHF = cngestive heart failure. artic valve replacement with/withut CABG grup, 61% and 7% fr the mitral valve replacement with/withut CABG grup, 6% and 19% fr the mitral valve repair with CABG grup, and 6% and 1% fr the duble-valve r cmbined prcedure with/withut CABG grup. Ttal I-year, -year and -year pstperative actuarial survival rates were 79%, 67%, and 4%, respectively (Table ). Table. Results f Cardiac Operatins in Octgenarians 0-Day & In-Hspital Actuarial Survival (%) Mrtality Prcedure (N.) (%) I-Year -Year -Year Grup I CABG (0) Grup II AVR (6) AVR + CABG (76) Sum (1) Grup III MVR (1) MVR + CABG (7) Sum (4) Grup IV MVRP + CABG (1) Grup V DVR' (7) DVR+ + CABG (1) Sum (0) Ttal (8) Abbreviatins are as in Table 1.

4 448 TSAI ET AL Ann Thrac Surg 1994;8:44-1 Percentage 80 Number f Cases CABG AVA MVA Fig 1. Quality f life in ctgenarian survivrs. (AVR = artic valve replacement; CABG = crnarv artery bypass grafting; MVR = mitral valve rcplaccmcnt.) Year Fig. Annual activity f cardiac peratins in ctgenarians. Quality f Life The fllw-up evaluatins included assessment f survival status, an evaluatin f general health as cmpared with that befre peratin (imprved, the same, r wrse) and an assessment f current level f activity (active, sedentary, r restricted). Seventy percent f the patients were shwn t be imprved, 18% remained unchanged and 1% deterirated (Fig 1). Thirty-eight percent f the patients led active lives, 6% f the patients were sedentary, and % were restricted in their daily activities-accrding t their respnses n a 6-mnth fllw-up questinnaire-fr a ttal mean f years' fllw-up. Cmment Mycardial Revascularizatin in Octgenarians The number f patients ver age 80 underging cardiac surgery is increasing yearly (Figs, ). As has been generally bserved in prir reprts f CABG in ctgenarians, mst patients in this age grup present with New Yrk Heart Assciatin functinal class III r IV symptms that are always refractry t mre cnservative Number f Patients _ c:::::::::j Number f Patients Earlymrtality (n) Percent Mrtality 0 Fig. Annual activity f crnary artery bypass peratins in ctgenarians thrugh a lo-year perid. 1 management [6-11]. In ur patient chrt, 6% f the patients were in class III and 7% were in class IV. In an therwise "healthy and viable" ctgenarian, the urgency f presentatin with unstable angina r lifethreatening symptms further cmpels perative interventin and has a significant impact n the perative mrtality rate. In the series reprted by Freeman and assciates [], the verall periperative mrtality rate was. times greater in patients having urgent versus elective prcedures. Emergency cardiac peratin in ctgenarians als has been shwn t be independently predictive f an increased periperative mrtality rate [7]. Khan and clleagues [1] stated that elderly patients perated n within 4 hurs after admissin had a mrtality rate equivalent t that f yunger patients and suggested that delays in treatment f elderly patients may adversely affect the utcme f peratin in the elderly. Clinical variables such as left ventricular ejectin fractin less than 0., New Yrk Heart Assciatin class IV, lw cardiac utput, r lw cardiac index preperatively were assciated with periperative mrtality [6]. Multiple studies have shwn that CABG in wmen clearly has a higher risk than in men [1]. Late referral fr bypass peratin has been suggested t be a significant cmpnent. In ur wn series we fund that patient sex (66% male) did nt influence early pstperative survival (male, 7.8%, versus female, 7.0%). Left main crnary disease was relatively cmmn (%) in this study grup; hwever, it was less frequently assciated with perative mrtality than in larger series f yung patients underging CABG []. Nearly all patients in this series had significant preperative symptmatic limitatin. Hwever, there was significant imprvement in general cnditin at fllw-up evaluatin. The actuarial survival rate f all patients in the current study discharged frm the hspital after cardiac peratin was significantly better than that f age and sex-matched cntrl ctgenarians []. Pstperative cmplicatins have been shwn t have independent variables influencing lng-term survival after CABG, especially arrhythmia [14] and cerebrvascular accident []. There was a substantial percentage (4%) in ~ t,.. J L..... & = -.. I L a. ~ l =... a L J L. - J L L J -. u.... a L.. L.. - L J 1 ~ 1 ~ 1 ~ 1 ~ 1 ~ l m 1 ~ 1 ~ 1 ~ l m 1 m Year

5 Ann Thrae Surg 1994;8:44-1 TSA1 ET AL 449 whm majr cmplicatins develped during the early pstperative perid. In ur 61 late nnsurvivrs, causes f death were cngestive heart failure in 16, arrhythmia r presumed arrhythmia in 14, renal failure in 14, pulmnary insufficiency in 9, cancer in 9, and cerebrvascular accident in 7. Valve Repair r Replacement and Cmbined Prcedures in Octgenarians Fr elective valvular peratins, the type f cardiac surgical prcedure clearly influences periperative mrtality [7, 11, 1]. Islated artic valve replacement had the lwest mrtality rate (1.8%), which increased with cncmitant CABG (6.6%). The ttal perative mrtality rate was 4.% in the artic valve replacement with r withut CABG grup. The periperative mrtality rate was clearly higher in patients underging mitral valve peratins: 0% fr islated mitral valve replacement, % fr mitral valve repair with CABG, and % fr mitral valve replacement with CABG. The ttal perative mrtality was 9% fr the mitral valve replacement with r withut CABG grup. Hwever, the mst cmmn cause fund in ur 7 patients with mitral valvular disease was degenerative (9%). Operatin was recmmended in patients with severe mitral valvular symptms; if minimal symptms were evident, it was recmmended nly in the case f deteriratin f ventricular functin r cardiac enlargement [16]. If repair was nt technically feasible, replacement was perfrmed with preservatin f the mitral valve apparatus [17]. In ur series, 1 patients underwent mitral valve repair with CABG, either using suture annulplasty (Kay Zubiate type) (17 patients) r Carpentier-Edwards ring annulplasty (14 patients), with a periperative mrtality rate f %. There were 4 patients wh underwent mitral valve replacement, mst f them with the subvalvular apparatus preserved, with a periperative mrtality rate f 9%. N statistical difference between these tw prcedures in mrtality and mrbidity was nted. The durability f mitral repair exceeds the expected life span f the ctgenarian. This fact, cupled with the avidance f anticagulatin, made mitral valve recnstructin an ideal prcedure in this age grup [18, 19]. Fr mre than tw valve prcedures, the perative mrtality rate was 14% fr duble-valve prcedures and 9% fr duble-valve prcedures cmbined with CABG bypass; the ttal mrtality rate was 0%. Of all prcedures, nly mitral valve peratin (especially fr severe ischemic mitral regurgitatin) was significantly assciated with an increased perative mrtality rate [0]. Mitral valve peratin als has been identified previusly as an independent risk factr fr perative mrtality in elderly patients [1, ]. The hemdynamics f the St. Jude mechanical valves in use (74 patients), favred their use in the small artic rt, as hydraulic functin was significantly imprved cmpared with the prcine biprsthesis []. The newly apprved Carpentier-Edwards pericardial valve als prvided excellent hydraulic functin, and experience t date suggests it is durable and als suitable in the smaller artic rt [4]. Brkn and assciates [] reprted a threefld increase in anticagulant-related bleeding in patients mre than 70 years ld with implantatin f mechanical valves. Frtunately, the increased incidence f bleeding was nt assciated with an increased incidence f mrtality. The plicy f using bilgic valves in ctgenarians, if pssible (68% in ur series), wuld seem beneficial because it bviates life-lng anticagulatin with warfarin. The ttal fllw-up mrtality rate (early and late) was 7.% in the mechanical valve replacement grup versus 0.% in tissue valve replacement grup. Biprsthetic valves may be much mre durable in the elderly than in yunger ppulatins. In the ctgenarian, the durability f the biprsthetic valve clearly exceeds expected survival. When valve replacement is indicated and anticagulatin can be avided, a biprsthetic valve appears t be the best chice, prvided a suitable size can be implanted [, 6]. Mst deaths were f cardiac rigin (48%), with the majrity due t lw cardiac utput state, pstperative mycardial infarctin, and arrhythmia. Hwever, nncardiac event, cancer, pulmnary insufficiency, cerebrvascular accident, and chrnic renal failure were respnsible fr a significant percentage f the late deaths (46%) [7, 1]. Frm 4% t 8% f the survivrs were fund t be imprved as cmpared with their preperative status at the time f fllw-up. It is significant that nearly all f the patients were gravely decmpensated and in New Yrk Heart Assciatin class III r IV befre peratin (98% were in New Yrk Heart Assciatin class III and IV). Table 6. Survival Cmparisn Acrss Age Grups Survivrs Age Mre Than Age Years 80 Years p Grup Number Percent Number Percent Value CABG year 1, year AVR year year AVR + CABG year year MVR; MVR CABG 1 year year 1 7 MVRP;MVRP CABG 1 year year DVR;DVR CABG 1 year year All patients year 1, year Abbreviatins are as in Table 1.

6 TSAI ET AL Ann Thrac Surg 1994;8:44-1 Cnclusins Elective cardiac peratins can be perfrmed in selected patients aged mre than 80 years with acceptable periperative mrtality 00.6%) r mrbidity and with anticipatin f significantly imprved symptmatic status (70%) and pssibly increased lngevity. In cmparing the survival prbability acrss the septuagenarian age grup (70 t 79 years), there is a statistically significant difference in septuagenarians wh underwent islated CABG (p = ) and mitral valvular peratins (p = 0.07) (Table 6). Early mrtality is least with elective islated artic valve replacement (1.8%) and islated CABG (8.%) but is greatest in peratins fr mitral regurgitatin. Clinical evidence f preperative left ventricular failure, functinal class IV symptms, and urgent surgical prcedures are assciated with increased periperative mrtality. The decisin regarding whether r nt an ctgenarian shuld underg a cardiac peratin shuld be made with an pen discussin by the treating physician, the cardilgist, the cardiac anesthesilgist, the cardiac surgen, the patient, and the patient's family. Whenever feasible, these patients shuld be in stable cnditin befre underging peratin. Severely symptmatic ctgenarians shuld nt be denied the benefit f a cardiac peratin if they are reasnably gd surgical candidates with gd physical and mental health. We thank Kathleen Farringtn fr her secretarial assistance in the preparatin f the manuscript, and Phyllis Crise, Varujan Kash, Rmmel Del Rsari, Michele DeRbertis, and Thmas Salciccia fr their technical assistance. References 1. Statistical abstract f the United States: 1991 (Ll lth ed). Washingtn, DC: US Bureau f the Census, 1991:81.. Natinal Center fr Health Statistics. United States life tables: US decennial life tables fr , vl 1, n 1. Washingtn, DC: Gvernment Printing Office, 198 (DHHS publicatin (PHS) 8-1-1).. Freeman WK, Schaff HV, O'Brien PC, et al. Cardiac surgery in the ctgenarian: periperative utcme and clinical fllwup. J Am Cll Cardil 1991;18: K W, Krieger KH, Lazenby WD, et al. Islated crnary artery bypass grafting in ne hundred cnsecutive ctgenarian patients. J Thrac Cardivasc Surg 1991;:-8.. Weintraum WS, Craver JM, Chen CL, et al. Influence f age n results f crnary artery surgery. Circulatin 1991; 84(Suppl ): Tsai TP, Nessim, Chaux A, et al. Mrbidity and mrtality after crnary artery bypass in ctgenarians. Ann Thrac Surg 1991;1: Cullifrd AF, Gallway AC, Clvin SB, et al. Artic valve replacement fr artic stensis in persns aged 80 years and ver. Am J Cardil 1991;67: Tsai TP, Chaux A, Kass R, et al. Cardiac valvular surgery in 1 ctgenarians. Chest 1991;0:1. 9. Kleikamp G, Minami K, Breymann T, et al. Artic valve replacement in ctgenarians. J Heart Valve Dis 199;1: Khan, Kupfer JM, Matlff JM, et al. Interactin f age and preperative risk factrs in predicting perative mrtality fr crnary bypass surgery. Circulatin 199;86(SuppI): Tsai TP, Matlff JM, Gray RJ, et al. Cardiac surgery in the ctgenarian. J Thrac Cardivasc Surg 1986;91: Khan, Kupfer JM, Matlff JM, et al. Hetergeneus mrtality rates f elderly patients underging crnary bypass surgery. Circulatin 199;86(Suppl 1): Glin A, Panza A, Vigrit C, et al. Mycardial revascularizatin in wmen. Tex Heart Inst J 1991;18: Lp FD, Lytle BW, Csgrve DM, et al. Crnary artery bypass graft surgery in the elderly: indicatins and utcme. Cleve Clin J Med 1988;: Fire AC, Naunheim KS, Barner HB, et al. Valve replacement in the ctgenarian. Ann Thrac Surg 1989;48: Assey ME. Indicatins fr heart valve replacement. Clin Cardil 1990;1: Miki, Kusuhara K, Ueda Y, et al. Mitral valve replacement with preservatin f chrdae tendineae and papillary muscles. Ann Thrac Surg 1988;4: Csgrve DM, Chavez AM, Lytle BW, et al. Results f mitral valve recnstructin. Circulatin 1986;74(Suppl 1): Gallway AC, Clvin SB, Baumann FG, et al. Lng-term results f mitral valve recnstructin with Carpentier techniques in 148 patients with mitral insufficiency. Circulatin 1988;78(Suppl 1): Czer LSC, Gray RJ, DeRbertis MA, et al. Mitral valve replacement: impact f crnary artery disease and determinants f prgnsis after revascularizatin. Circulatin 1984;70(Suppl 1): Fremes SE, Gldman BS, Ivanv J, et al. Valvular surgery in the elderly. Circulatin 1989;80(Suppl 1): Tsai TP, Matlff JM, Chaux A, et al. Cmbined valve and crnary artery bypass prcedures in septuagenarians and ctgenarians: results in 10 patients. Ann Thrac Surg 1986; 4: Czer LSC, Matlff JM, Chaux A, et al. Cmparative clinical experience with prcine biprsthetic and St. Jude valve replacement. Chest 1987;91: Bessne LN, Pupell DF, Hir SP, et al. Surgical management f artic valve disease in the elderly: a lngitudinal analysis. Ann Thrac Surg 1988;46: Brkn AM, Sule LM, Baughman KL, et al. Artic valve selectin in the elderly patient. Ann Thrac Surg 1988;46: Jamiesn WRE, Burr LH, Munr AI, et al. Cardiac valve perfrmance in the elderly: clinical perfrmance f bilgic prstheses. Ann Thrac Surg 1989;48:17-8. INVITED COMMENTARY This reprt accurately dcuments the fact that elderly patients, especially thse 80 years ld and lder, are being referred fr pen heart peratins mre frequently, reflecting the increase in the very elderly prtin f the ppulatin as well as the excellent utcme seen with heart peratins in yunger patients. Many peple, bth medical prfessinals and the lay public, hwever, are questining the apprpriateness f such majr surgical prcedures in individuals with limited life expectancies. In the cntext f such skepticism abut peratins in elderly individuals,