Cardiac Surgery in the Elderly Patient: In reply

by PD Dr. med. Ivar Friedrich, PD Dr. med. Andreas Simm, Joachim Kötting, Dr. med. Frank Thölen, Burkhard Fischer, Prof. Dr. med. Rolf-Edgar Silber in volume 25/2009

Thus far, the classic scoring systems have used postoperative mortality as their target parameter for a successful intervention. Thus far, scoring systems for assessing postoperative mortality have not focused primarily on the risk of morbidity and reduction in quality of life after cardiac surgery in very old patients. The postoperative result depends crucially on a patient’s biological age. The extent of frailty comprises various areas, such as, among others, muscular weakness, cognition or depression, which may be present in individually varying degrees (1). For this reason, the postoperative risk assessment needs to be extended because specifically geriatric risk factors seem to have a substantial influence on postoperative morbidity after cardiac surgery. Frilling et al showed this very convincingly, reporting the uncomplicated assessment of risk constellations by measuring muscular reserve (manual strength) and by testing patients’ mental and cognitive status. A scoring system especially for elderly patients would be highly desirable, to quantify the known, specifically geriatric, factors that influence operative risk and thus enable a more precise assessment of the surgical risk. The parameters should be able to be captured by simple methods in the context of routine clinical examinations. Further to a thorough risk assessment, this would enable individually tailored advice on suitable therapeutic options. Additionally, targeted preoperative conditioning may potentially reduce the operative risk (2).

In addition to postoperative mortality, surgical procedures in elderly patients should be approached with a view to the patients’ quality of life. Even if a patient’s physical integrity is fully restored and cardiac output is notably improved by the procedure, his or her quality of life may be impaired for the long term. This is due to cognitive impairments, as justifiably introduced into the discussion by Heusinger von Waldegg and Klement. The statement “Since his cardiac surgery, Father has not been who he used to be” is well known to many general practitioners/family physicians. Pre-existing impairments that were mostly asymptomatic before the procedure may deteriorate as a result of the surgery (3). If the risk constellation is high then less invasive procedures should be considered in order to achieve a good functional outcome, such as off-pump coronary artery bypass grafting (OPCAB surgery), -minimally invasive aortic valve implantation, or a hybrid intervention. In defining an indication for cardiac surgery in very elderly patients, it is crucial to give greater weight to the patient’s postoperative quality of life. This can be achieved only by conducting research in collaboration with geriatric specialists.
DOI: 10.3238/arztebl.2009.0694

PD Dr. med. Ivar Friedrich
Klinik für Herz- und Thoraxchirurgie
Universitätsklinikum Halle
Ernst-Grube-Str. 40
06108 Halle, Germany
[e-mail]

Conflict of interest statement
The authors of all contributions declare that no conflict of interest exists according to the guidelines of the International Committee of Medical Journal Editors.

References

1. Afilalo J, Karunananthan S, Eisenberg MJ, Alexander KP, Bergmann H: Role of frailty in patients with cardiovascular disease. Am J Cardiol 2009; 103: 1616–21.

2. Daniels R, van Rossum E, de Witte L, Kempen GI, van den Heuvel W: Interventions to prevent disability in frail community-dwelling elderly: a systematic review. BMC Health Serv Res 2008; 8: 278.

3. Stroobant N, Vingerhoets G: Pre-existing cognitive impairment in candidates for cardiac surgery: an overview. Heart 2009; (Epub ahead of print).

4. Friedrich I, Simm A, Kötting J, Thölen F, Fischer B, Silber RE: Cardiac surgery in the elderly patient [Der alte Patient in der Herzchirurgie]. Dtsch Arztebl Int 2009; 106(25): 416–22.