|
| HOME | SUBSCRIPTIONS | CURRENT ISSUE | PAST ISSUES | CARDIOSOURCE | SEARCH | HELP | FEEDBACK |
|
|
|
|||||||||
|
|||||||||||
|
J Am Coll Cardiol, 2000; 35:731-738 © 2000 by the American College of Cardiology Foundation |
80 years: results from the National Cardiovascular Network
* Outcomes Research and Assessment Group, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina, USA
Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
|| National Healthcare Network, Atlanta, Georgia, USA
Manuscript received February 25, 1999; revised manuscript received October 22, 1999, accepted November 18, 1999.
Reprint requests and correspondence: Dr. Karen P. Alexander, Box 3411, Duke University Medical Center, Durham, North Carolina 27710
alexa019{at}mc.duke.edu
 |
Abstract |
|---|
 Top Abstract MethodsResultsDiscussionAppendixReferences |
|---|
The purpose of this study was to evaluate characteristics and outcomes of patients age 
80 undergoing cardiac surgery.
BACKGROUND
Prior single-institution series have found high mortality rates in octogenarians after cardiac surgery. However, the major preoperative risk factors in this age group have not been identified. In addition, the additive risks in the elderly of valve replacement surgery at the time of bypass are unknown.
METHODS
We report in-hospital morbidity and mortality in 67,764 patients (4,743 octogenarians) undergoing cardiac surgery at 22 centers in the National Cardiovascular Network. We examine the predictors of in-hospital mortality in octogenarians compared with those predictors in younger patients.
RESULTS
Octogenarians undergoing cardiac surgery had fewer comorbid illnesses but higher disease severity and surgical urgency than younger patients. Octogenarians had significantly higher in-hospital mortality after cardiac surgery than younger patients: coronary artery bypass grafting (CABG) only (8.1% vs. 3.0%), CABG/aortic valve (10.1% vs. 7.9%), CABG/mitral valve (19.6% vs. 12.2%). In addition, they had twice the incidence of postoperative stroke and renal failure. The preoperative clinical factors predicting CABG mortality in the very elderly were quite similar to those for younger patients with age, emergency surgery and prior CABG being the powerful predictors of outcome in both age categories. Of note, elderly patients without significant comorbidity had in-hospital mortality rates of 4.2% after CABG, 7% after CABG with aortic valve replacement (CABG/AVR), and 18.2% after CABG with mitral valve replacement (CABG/MVR).
CONCLUSIONS
Risks for octogenarians undergoing cardiac surgery are less than previously reported, especially for CABG only or CABG/AVR. In selected octogenarians without significant comorbidity, mortality approaches that seen in younger patients.
| ||||||||||||||||||||
Previous observational series of octogenarians undergoing bypass surgery have reported varied morbidity and mortality rates reflecting small sample sizes and divergent experiences at single institutions. For example, reported postoperative mortality ranges from 8% to 24%, postoperative stroke from 2% to 9%, and postoperative renal insufficiency from 2% to 13% (Table 1). Additionally, prior series were often underpowered to identify the major predictors of mortality after bypass surgery in the elderly and to determine the risk associated with concomitant valve replacement. Finally, as cardiac surgery is performed more often in elderly patients, we may see improved outcomes in current practice (4).
|
80 undergoing coronary artery bypass grafting (CABG) alone or with an associated valve surgery across 22 high volume centers between 1994 and 1998. We also identified the major clinical predictors of postbypass mortality and determined whether these risk factors varied with age. Finally, we described outcomes in those very elderly patients without comorbidity undergoing cardiac surgery. |
Methods |
|---|
|
TopAbstractMethodsResultsDiscussionAppendixReferences |
|---|
Data collection. The NCN database includes administrative data, demographics, risk factors, cardiac history, procedural data and outcome data. Designated personnel familiar with NCN clinical and outcome definitions were responsible for collecting data at each site. Each site then submitted their data semiannually to the NCN Data Coordinating Center at Duke University Medical Center. Personnel in the NCN Coordinating Center confirmed data integrity and variable consistency across sites.
Data definitions. Definitions specified in the NCN coding dictionary for postoperative outcomes refer to in-hospital adverse events. Postoperative neurologic complications included stroke, transient ischemic attacks or coma. Postoperative renal failure included acute renal failure (oliguria with a postoperative rise in blood urea nitrogen of >10 mg/dl and creatinine of >1 mg/dl) or the initiation of dialysis. Postoperative myocardial infarction (MI) was defined by new Q-waves in 2 or more precordial leads on the postoperative 12-lead electrocardiogram. Complete revascularization was identified if the number of distal anastomoses were equal to or greater than the number of diseased territories to a maximum of three.
Data analysis.
The primary analysis determined the relationship between patient age, surgical procedure and in-hospital outcomes. First, we divided our population into two age categories (age <80, age 80) and then into three surgical categories (CABG only, CABG/AVR, CABG/MVR). Baseline demographic, clinical and procedural characteristics are presented as means with standard deviations for continuous variables and percentages for dichotomous variables for each of these six groups. All statistical comparisons are made across age category (age <80 or age 80) using the chi-square test or t test where appropriate.
We present postoperative in-hospital outcomes (including mortality, all neurologic complications, stroke, renal failure, MI and postprocedural length of stay) in two ways. First, these outcomes were presented for patients undergoing CABG only and CABG with associated valve surgery separately by age category. Differences in outcomes across age category were tested for statistical significance. We also clarify the relationship between age and outcome (mortality, neurologic events and renal failure) by displaying outcome plotted by five-year age groups subsequently connected by trend lines for patients undergoing CABG only.
We examined the relationship between clinical risk factors, including age and in-hospital mortality for the CABG only population. Using multivariable logistic regression, we developed a model for the prediction of in-hospital mortality using the entire population undergoing CABG only. We excluded those patients with more than two missing variables leaving 88% of the CABG patients (n = 56,890) for our model development. For patients in the multivariable analysis missing one or two variables, categorical variables were assumed to be absent and continuous variables were imputed to the median. We included variables identified to be major clinical predictors in other models and variables identified as univariate predictors with significance levels of less than 0.01 in our population (3,7,10,12–14). Those variables included in the final model had significance at the level of 0.05. The c-index, or area under the receiver operator characteristic curve, is displayed for this model developed in the overall population and for the model when applied to both the young (age <80) and elderly (age 80) age groups. The odds ratios and 95% confidence intervals for the multivariable predictors are displayed by each age category. Finally, in order to determine whether variables in the model predicted differently by age group, we tested the significance of age-interaction terms for each variable. In addition, we tested the significance of a continuous variable for years of age 80 in the overall model.
Last, we displayed in-hospital mortality by age for each surgical type (CABG only, CABG/AVR, CABG/MVR) for patients without significant comorbidities. These comorbidities were those identified as independent risk factors for mortality from our model. These included: left ventricular ejection fraction (LVEF) of <35%, prior CABG, history of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), vascular disease, renal insufficiency, MI within 21 days and emergency surgery. By eliminating patients with these selected comorbidities, we provide actual mortality rates for the ‘best case scenario’ by age category and surgical type.
|
Results |
|---|
|
TopAbstractMethodsResultsDiscussionAppendixReferences |
|---|
80: n = 4,306), CABG/AVR (age <80: n = 1,690, age 80: n = 345) and CABG/MVR (age <80: n = 1,170, age 80: n = 92). The mean age of patients age 80 undergoing CABG only was 82.4 years, and the mean age for the younger patients was 63.7 years (Table 2). A large majority (89%) of our elderly population (age 80) were at or between the ages of 80 and 85 (n =4,227), 11% were at or between the ages of 86 and 89 (n = 501) and exactly 15 patients were 90 years old. There were no patients older than age 90 in our population.
|
As expected, there were also significant differences in procedural characteristics across age category (Table 3). Within our population, patients age 80 were twice as likely to have combined CABG/valve surgery compared with the younger patients in our population (9% combined CABG/valve vs. 4.5% combined CABG/valve, p = 0.001). They more frequently had preoperative shock, required preoperative left ventricular assist devices and had their surgery under emergency circumstances.
|
Operative mortality and morbidity.
After CABG, octogenarians had a significantly higher operative mortality than did younger patients did (8.1% vs. 3%, p < 0.001, Table 4). For descriptive purposes, we present mortality divided by categorical age (age <80 and age 80) although mortality after cardiac surgery rises in a linear fashion with advancing age as shown in Figure 1. Combined CABG/valve surgery is associated with higher mortality and complications than CABG only (Table 4), with octogenarians continuing to have a higher mortality rate than younger patients with either procedure: CABG/AVR (10.1% vs. 7.9%, p < 0.001), CABG/MVR (19.6% vs. 12.2%, p < 0.001). Although combining AVR with CABG surgery increased mortality by about 3% across all ages, combining MVR with CABG more significantly increases mortality compared with CABG alone, especially in octogenarians (Fig. 1).
|
|
Postoperative neurologic and renal complications occur twice as often in octogenarians as in younger patients, and elderly patients also have more postoperative MIs although these were infrequent (Table 4). As shown in Figure 2, postoperative neurologic events and postoperative renal failure both increase with advancing age in a similar fashion to in-hospital mortality, with the greatest rise occurring after age 75. The rate of postoperative stroke in octogenarians after CABG was 3.9%, after CABG/AVR was 4.9% but increased to 8.8% after CABG/MVR. Likewise, the rate of postoperative renal failure in octogenarians after CABG was 6.9% and increased to 12.1% after CABG/AVR and 25% after CABG/MVR.
|
Predictors of in-hospital mortality. We performed multivariate logistic regression to identify the major variables with independent prediction for in-hospital mortality. These variables are listed in Table 5 in order of descending chi-square (overall model c-index = 0.77). We found that young and old patients share many predictors of mortality following CABG. Variables that were similarly predictive in both age groups included gender, hypertension, emergency procedure, recent MI and ejection fraction. Although octogenarians with prior CABG and COPD less frequently undergo cardiac surgery, these variables carry higher odds of death in those who do. Younger patients had higher odds ratios for heart failure class and renal insufficiency. Although not in the final model, placement of an internal mammary artery graft was a univariate predictor for lower short-term mortality in both young and old (odds ratio 0.5 vs. 0.7). It is important to note, however, that the qualitative predictive importance of all variables was similar in both age groups.
|
80) to the model shown in Table 5 to determine whether the effect of age accelerated after 80 and found that it did not have independent predictive ability after accounting for the other variables (years of age 80; chi-square = 2.0, p = 0.16). Finally, we tested each variable in the model for interaction with age to determine whether these variables predicted differently across the range of age. We found no significant age interaction with the variables listed in Table 5. |
Discussion |
|---|
|
TopAbstractMethodsResultsDiscussionAppendixReferences |
|---|
Comparison with prior series. Mortality in octogenarians after CABG has been reported to range from 8% to 24%, but these reports were frequently limited to the experience of a small numbers of patients at a single institution. The largest prior series used Medicare data and reported a mortality of 11.5% for the years 1987 to 1990 for CABG only patients (4). Our population of octogenarians undergoing surgery from 1994 to 1997 had a lower mortality (8.1%) compared with this and most other series.
Combined CABG/valve surgery adds to mortality risk. One prior report of CABG/AVR in 149 octogenarians showed a mortality of 11.4% (16). The 345 octogenarians undergoing CABG/AVR in our study had a mortality of 10.1%, and those 100 without significant comorbidity had a mortality of 7%. Whereas AVR appears to increase mortality by the same amount across age category, MVR adds increasingly to operative mortality risk with advancing age. However, a relatively small number of octogenarians undergo CABG/MVR, so our conclusions about outcomes in this group must be considered preliminary. This worse outcome may reflect the fact that patients with mitral valve disease have depressed ventricular function that is an additive insult to the lower physiologic reserve of elderly patients. Thus, although bypass surgery in elderly patients is associated with favorable outcomes, combined CABG/valve surgery is associated with significantly higher risks.
Postoperative morbidity such as renal failure and neurologic complications were somewhat lower in our series than reported earlier. For example, we found a 6.9% incidence of renal failure in octogenarians after bypass surgery compared with previously reported rates of 2% to 13% (17). Prior reports indicated that the rate of postoperative stroke in patients of all ages is 3.1% and in octogenarians ranged from 2% to 9% (18). Our 3.9% incidence of stroke in octogenarians is comparable with previous studies.
The overall improvement in outcomes may be due to better selection of very elderly patients undergoing surgery or to the increased experience and skill acquired by operating on more octogenarians over time. In terms of patient selection, consistent with prior series, the octogenarians in our study had less diabetes, COPD and prior revascularization but higher disease acuteness and severity than younger patients (19). This selection appears to be evidence-based, given the higher risk of mortality associated with COPD and prior CABG in octogenarians. However, in general, our octogenarians appear to be at least as sick as those in earlier series. For example, compared with other series, our population had more diabetes, hypertension, three-vessel disease and left main disease, renal failure and prior bypass surgery (13,20). Therefore, although octogenarians undergoing cardiac surgery continue to be a carefully selected group, it seems unlikely that the lower mortality seen in our population is explained solely by improved selection.
In terms of process of care, our octogenarians received more internal mammary artery grafts than in prior reports (58.7% vs. 33%), which may be evidence of a trend towards more aggressive operative strategies in older patients (21). The use of IMA grafts was associated with better short-term outcome in our series and others and may partly explain the improved outcomes seen (7). Octogenarians had a similar number of distal anastomoses and complete revascularization as younger patients.
Clinical predictors of mortality. For patients of any age, the variables that were independent predictors of mortality in patients following CABG were age, gender, prior CABG, vascular disease, COPD, history of CHF, shock or emergency procedure, ejection fraction, renal insufficiency or dialysis and preoperative MI. We compared the predictors of in-hospital mortality after CABG in the young and old. We found some variability in the odds ratios associated with these variables but no differences in their overall prognostic significance. Consistent with prior series, major risk factors that were predictive across age were measures of disease acuity and left ventricular function (recent MI, shock, NYHA class III to IV, LVEF, prior CABG). However, unlike other series, measures of coronary disease severity (three-vessel disease, left main disease), and comorbid illness (diabetes, hypertension, vascular disease) were less predictive of mortality in our octogenarians (8,9,12,18,22). Finally, age was among the most powerful predictors of outcome in both young and old after adjusting for other known risk factors. Overall, the model was less able to distinguish which elderly patients were likely to die after surgery, perhaps because there are other factors besides those included in our model that explain this outcome in octogenarians.
Study limitations. While the NCN data have the advantage of having a significant amount of detail, data are submitted voluntarily. The outcomes were limited to in-hospital events and do not reflect the morbidity or mortality after hospital discharge. In addition, the explanatory power of risk factors may be affected by treatment selection bias that is inherent in any observational study. For example, older patients with severe comorbidity may not undergo bypass surgery. This may diminish the power of risk factors in the elderly. The categorical nature of the variables does not take into account variation in disease severity that may vary by age. Also, although the variables in our model are similar to those in other CABG mortality models, there may be other variables that explain some of the additional variation in elderly mortality. Although every clinician realizes the important contribution of "physiologic age" to patient outcome, this can not be quantified or included in a model. Finally, since the NCN data represent the experience in 22 high volume medical centers, the extrapolation of these outcomes to those at lower volume centers must be done with caution.
Conclusions. This large clinical series provides a profile of octogenarians currently undergoing cardiac surgery and their associated outcomes. We found that the major clinical predictors of mortality were largely the same in octogenarians as in younger patients. In addition, while the relationship between age and in-hospital mortality appears to be nearly linear, the gap between mortality in the young and old after CABG is smaller than previously thought, especially for CABG and CABG/AVR. Because these data are observational, we cannot answer the question of which elderly patients have the most to gain and should be referred for bypass surgery. The physician and the octogenarian patient must continue to answer this question on an individual basis.
|
Appendix |
|---|
|
TopAbstractMethodsResultsDiscussionAppendixReferences |
|---|
|
Footnotes |
|---|
|
References |
|---|
|
TopAbstractMethodsResultsDiscussionAppendixReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  G. Ailawadi, B. R. Swenson, M. E. Girotti, L. M. Gazoni, B. B. Peeler, J. A. Kern, L. M. Fedoruk, and I. L. Kron Is mitral valve repair superior to replacement in elderly patients? Ann. Thorac. Surg., July 1, 2008; 86(1): 77 - 86. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. L. Ngaage, M. E. Cowen, S. Griffin, L. Guvendik, and A. R. Cale Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians Eur. J. Cardiothorac. Surg., April 1, 2008; 33(4): 653 - 659. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. W. Ullery, J. C. Peterson, F. Milla, M. T. Wells, W. Briggs, L. N. Girardi, W. Ko, A. J. Tortolani, O. W. Isom, and K. H. Krieger Cardiac Surgery in Select Nonagenarians: Should We or Shouldn't We? Ann. Thorac. Surg., March 1, 2008; 85(3): 854 - 860. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Silvay, J. G. Castillo, J. Chikwe, B. Flynn, and F. Filsoufi Cardiac Anesthesia and Surgery in Geriatric Patients Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2008; 12(1): 18 - 28. [Abstract] [PDF]
|
|
|
|
 |
|
 M. A. Albert, N. Halevy, and E. M. Antman Preoperative Evaluation for Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 261 - 280. [Full Text]
|
|
|
|
 |
|
 J. G. Webb, S. Pasupati, K. Humphries, C. Thompson, L. Altwegg, R. Moss, A. Sinhal, R. G. Carere, B. Munt, D. Ricci, et al. Percutaneous Transarterial Aortic Valve Replacement in Selected High-Risk Patients With Aortic Stenosis Circulation, August 14, 2007; 116(7): 755 - 763. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Grube, G. Schuler, L. Buellesfeld, U. Gerckens, A. Linke, P. Wenaweser, B. Sauren, F.-W. Mohr, T. Walther, B. Zickmann, et al. Percutaneous Aortic Valve Replacement for Severe Aortic Stenosis in High-Risk Patients Using the Second- and Current Third-Generation Self-Expanding CoreValve Prosthesis: Device Success and 30-Day Clinical Outcome J. Am. Coll. Cardiol., July 3, 2007; 50(1): 69 - 76. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. H. Huber, V. Goeber, P. Berdat, T. Carrel, and F. Eckstein Benefits of cardiac surgery in octogenarians -- a postoperative quality of life assessment Eur. J. Cardiothorac. Surg., June 1, 2007; 31(6): 1099 - 1105. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. G. Cerillo, A. Assal Al Kodami, M. Solinas, P. Andrea Farneti, S. Bevilacqua, S. Maffei, A. Mazzone, and M. Glauber Aortic valve surgery in the elderly patient: a retrospective review Interactive CardioVascular and Thoracic Surgery, June 1, 2007; 6(3): 308 - 313. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. J. Melby, A. Zierer, S. P. Kaiser, T. J. Guthrie, J. D. Keune, R. B. Schuessler, M. K. Pasque, J. S. Lawton, N. Moazami, M. R. Moon, et al. Aortic Valve Replacement in Octogenarians: Risk Factors for Early and Late Mortality Ann. Thorac. Surg., May 1, 2007; 83(5): 1651 - 1657. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Bardakci, F. H. Cheema, V. K. Topkara, N. C. Dang, T. P. Martens, M. L. Mercando, C. S. Forster, A. A. Benson, I. George, M. J. Russo, et al. Discharge to Home Rates Are Significantly Lower for Octogenarians Undergoing Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., February 1, 2007; 83(2): 483 - 489. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. di Marco and G. Gerosa Percutaneous aortic valve replacement: Which patients are suitable for it? A quest for a controlled use J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 294 - 298. [Full Text] [PDF]
|
|
|
|
|
|
B. G. Levy Praschker, P. Leprince, N. Bonnet, A. Rama, V. Bors, L. Lievre, A. Pavie, and I. Gandjbakhch Cardiac surgery in nonagenarians: hospital mortality and long-term follow-up Interactive CardioVascular and Thoracic Surgery, December 1, 2006; 5(6): 696 - 699. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. Rosborough Cardiac Surgery in Elderly Patients: Strategies to Optimize Outcomes Crit. Care Nurse, October 1, 2006; 26(5): 24 - 31. [Full Text] [PDF]
|
|
|
|
|
|
T. Eitz, D. Fritzsche, G. Kleikamp, A. Zittermann, D. Horstkotte, and R. Korfer Reoperation of the aortic valve in octogenarians. Ann. Thorac. Surg., October 1, 2006; 82(4): 1385 - 1390. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Kaehler, T. Meinertz, and C. W Hamm Coronary interventions in the elderly. Heart, August 1, 2006; 92(8): 1167 - 1171. [Full Text] [PDF]
|
|
|
|
|
|
M. G. St. John Sutton and R. C. Gorman Surgery for Asymptomatic Severe Mitral Regurgitation in the Elderly: Early Surgery or Wait and Watch? Circulation, July 25, 2006; 114(4): 258 - 260. [Full Text] [PDF]
|
|
|
|
|
|
D. Detaint, T. M. Sundt, V. T. Nkomo, C. G. Scott, A. J. Tajik, H. V. Schaff, and M. Enriquez-Sarano Surgical Correction of Mitral Regurgitation in the Elderly: Outcomes and Recent Improvements Circulation, July 25, 2006; 114(4): 265 - 272. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S.-E. Hassani, G. S. Mintz, H. S. Fong, S.-W. Kim, Z. Xue, A. D. Pichard, L. F. Satler, K. M. Kent, W. O. Suddath, R. Waksman, et al. Negative Remodeling and Calcified Plaque in Octogenarians With Acute Myocardial Infarction: An Intravascular Ultrasound Analysis J. Am. Coll. Cardiol., June 20, 2006; 47(12): 2413 - 2419. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Circulation, June 20, 2006; 113(24): e873 - e923. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. B. Goldstein, R. Adams, M. J. Alberts, L. J. Appel, L. M. Brass, C. D. Bushnell, A. Culebras, T. J. DeGraba, P. B. Gorelick, J. R. Guyton, et al. Primary Prevention of Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke, June 1, 2006; 37(6): 1583 - 1633. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. V. Lichtenstein Closed heart surgery: Back to the future J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 941 - 943. [Full Text] [PDF]
|
|
|
|
|
|
J. Ye, A. Cheung, S. V. Lichtenstein, R. G. Carere, C. R. Thompson, S. Pasupati, and J. G. Webb Transapical aortic valve implantation in humans J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 1194 - 1196. [Full Text] [PDF]
|
|
|
|
|
|
S C Stoica, F Cafferty, J Kitcat, R J F Baskett, M Goddard, L D Sharples, F C Wells, and S A M Nashef Octogenarians undergoing cardiac surgery outlive their peers: a case for early referral Heart, April 1, 2006; 92(4): 503 - 506. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Iung, A. Cachier, G. Baron, D. Messika-Zeitoun, F. Delahaye, P. Tornos, C. Gohlke-Barwolf, E. Boersma, P. Ravaud, and A. Vahanian Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery? Eur. Heart J., December 2, 2005; 26(24): 2714 - 2720. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. M. Johnson, J. M. Smith, S. E. Woods, M. P. Hendy, and L. F. Hiratzka Cardiac Surgery in Octogenarians: Does Age Alone Influence Outcomes? Arch Surg, November 1, 2005; 140(11): 1089 - 1093. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 F. Liistro, K. Ducci, G. Falsini, and L. Bolognese Early invasive strategy in elderly patients with non-ST-elevation acute coronary syndromes Eur. Heart J. Suppl., October 1, 2005; 7(suppl_K): K23 - K25. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F Liistro, P Angioli, G Falsini, K Ducci, S Baldassarre, A Burali, and L Bolognese Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome Heart, October 1, 2005; 91(10): 1284 - 1288. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Nagendran, C. Norris, A. Maitland, A. Koshal, and D. B. Ross Is mitral valve surgery safe in octogenarians? Eur. J. Cardiothorac. Surg., July 1, 2005; 28(1): 83 - 87. [Abstract] [Full Text] [PDF]
|
|
