South Florida Hospital News
Sunday August 25, 2019
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June 2008 - Volume 4 - Issue 12

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I was so much older then…*

A century ago, life expectancy in this country was approximately 60 years, and antibiotics, CT scans and heart surgery were dreams at best. As of 2004 the CDC reports life expectancy in America to be 77.8 ( 75.2 for men and 80.4 for women; http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf ) Mortality from heart disease, the nation’s leading killer of both men and women, has dropped nearly 40% in the past two decades, and octogenarians comprise one of the fastest growing segments of the population. In 1967, Rene Favalaro first popularized coronary artery bypass surgery. However, in those early years, patients over the age of 70 were considered elderly and were generally believed not to be candidates for the rigors of heart surgery. As surgical techniques and intensive care improved, heart surgeons gradually began to expand the age criteria and accept progressively older patients. A decade later, Andreas Gruntzig once again revolutionized the world of interventional therapeutics with the introduction of balloon catheter angioplasty for arterial obstructive lesions. Because these catheter-based techniques did not require open surgical exposure nor the challenges of the heart-lung bypass circuit, these procedures were generally less risky for the patient in the immediate periprocedural period, and clinicians were therefore more inclined to perform these procedures on increasingly elderly and high risk patients. Although with the tremendous advances of the ensuing years there has been and continues to be a lively debate regarding the most appropriate procedure—catheter-based intervention vs. surgical revascularization—for a given patient, the appropriate approach in those early years was to refer patients with single or even double vessel disease to angioplasty, while those with more extensive or complex disease required surgery.

The stage was now set for the old paradigm of not operating on the very elderly to change forever. When coronary artery catheterization (visualization of the coronary arteries through x-ray imaging of the injection of contrast dye) was conducted solely for the purpose of defining the anatomical roadmap for the surgeon, there was no reason to perform it on those who were not considered to be surgical candidates. However, with the advent of angioplasty, cardiologists became increasingly aggressive in the performance of diagnostic catheterization in the hopes of finding a lesion or two suitable for angioplasty. Because atherosclerotic coronary artery disease is a chronic and progressive inflammatory process which develops over years, what they tended to discover in the vast majority of these elderly patients was extensive coronary artery disease much more suitable for surgery than for angioplasty. Now surgeons were being increasingly challenged to operate on older and older and sicker and sicker patients.

Fortunately, over the years, mortality from cardiac surgery has continued to drop and surgeons were able to accept these patients with increasing technical success. However, just because one can do something, this does not mean that one must or should do it. Heart surgery in patients older than 80 raises two very serious questions. First, given the markedly diminished life expectancy of patients in these elder years, does patient longevity warrant such serious intervention? Secondly, although survival is an extremely important parameter of success, it is far from the only one—what sort of quality of life do patients enjoy after their surgery?

It is for this reason that the Florida Heart Research Institute has undertaken an extensive follow-up study on the survival and quality of life of patients aged 80 and older undergoing coronary artery bypass surgery. We have discovered two very important facts: first, despite the higher operative risk in this elderly and complex and somewhat fragile population, life expectancy approaches that of the general population of comparable age. Secondly, patients’ perception of their quality of life is indistinguishable from that of an age-matched group from the general population. It is therefore clear that for our elderly friends who suffer from severe and extensive coronary artery disease, therapeutic surgery remains a viable and promising option.

*songwriter Bob Dylan

Dr. Paul Kurlansky, board certified cardiothoracic surgeon, Director of Research at the Florida Heart Research Institute, can be reached at (305) 674-3154 or pak@floridaheart.org.
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