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When You're ... Old ... at Heart?

December 6, 2007 By:
Frank Rosci, JE Feature
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People are living longer than ever these days -- some to 100 and beyond -- and they're having all sorts of medical procedures as they age, including heart surgery for patients 80 and older.

Yet inevitable questions follow suit: How does that operation fit into the picture of maintaining health and quality of life for the elderly, and is someone ever too old for this delicate type of surgery?

"A different perspective is needed when thinking about heart surgery for the elderly," stated V. Paul Addonizio, M.D., chief of cardiac surgery at Abington Memorial Hospital and surgical director of the hospital's Porter Institute of Valvular Heart Disease.

"First, we always assume the risk is high because the elderly don't have the same compensatory mechanisms in place as they did as young people, [that] those from 14 to 65 have; but we can still intervene in a team approach that strives to be as minimally invasive as possible to improve and extend the lives of the elderly. And we should -- just as we do for the young.

"Too many physicians consider operating on the elderly as a last resort, instead of as part of overall care. To operate on them or not is the essence of the ethical debate. My view is that the elderly have made great contributions to society and deserve treatment, just as young people do," he said.

Even though elderly patients have special needs -- they often don't regulate body temperature very well, and have more of a possibility of hemorrhaging if not kept warm -- Addonizio noted that surgery for them is even "more compelling" because of their needs.

But, the physician continued, someone who makes it to 80 has had to have had a "very strong constitution," so operating on someone who's that age can potentially be a lower risk than operating on someone who's 40 but has abused his or her health.

Explained Addonizio: "No one should assume that simply because someone is 80, that person shouldn't feel well or doesn't have the right to feel well. The elderly have heart conditions because, in living a long time, things have just worn out.

"Yes, in helping them to gain a better life, they're going to consume a fair amount of health-care resources, but that's okay, they deserve it, just as everyone else does," he maintained.

Among the many elderly patients Addonizio has treated is 87-year-old Sylvia Croll, who had her main aortic valve replaced on June 4, 2006.

"I was hopeful, though scared, before the surgery, but not surprised that it was needed, since my family, the Goldsteins, all had fatal heart disease," said Croll.

She added that she's happy Addonizio gave her more years.

Michael Acker, M.D., chief of the division of cardiovascular surgery and the William Maul Measey Professor of Surgery at the University of Pennsylvania Health System, talked about how heart surgery for the elderly has become mainstream.

"We perform this type of surgery all the time now, so that it has become routine in recent years. Of course, not everyone 80 and older is the same, so what we consider first is a person's physiologic age -- not simply that person's chronologic age -- and, obviously, we evaluate the person's mental health.

"Age itself should not be a deterrent to heart surgery," he continued, adding that "it's not unusual today for people 90 and older to have heart surgery. I did three or four last year, and will do several every year."

Acker said that a surgeon has to be very selective about which patients are chosen, and that there has to be a critical need for the surgery. "We're not trying to make people live longer, but are trying to return their quality of life to them. We want to do it, especially, if the person has a miserable quality of life, but patients have to have the capability to rehab and recover also."

Types of surgery performed include replacement of the mitral valve, the inflow valve to the heart's left ventricle; and coronary bypass, one of the most common heart surgeries.

Even though surgery is getting safer, he continued, risks are higher for the elderly -- for strokes around the time of surgery and, of course, for death.

Therefore, surgeons and cardiologists are always looking aggressively at seeking alternatives to surgery, Acker said, such as replacing the aortic valve without surgery by using a catheter endovascularly, and by using the same concept through the apex with a tiny incision.

A clinical trial in these areas will take place later this fall at Penn, and at several other national surgical heart centers.

At Jefferson University Hospital, Scott Silvestry, M.D., assistant professor of surgery and surgical director at the advanced heart-failure and cardiac-transplant center, said, "There is definitely a cultural bias in the U.S. against performing heart surgery for the elderly, as opposed to the U.K. and Canada, for example, where it's much easier for those 75 and older to obtain heart surgery."

Silvestry estimated more than 10 percent of his patients are elderly. In fact, he stressed, the elderly have the highest chance of survival statistically of anyone: "Someone who's 85 has a life expectancy beyond that of another 6.3 years."

That said, he advised that advanced years also mean a longer period of recovery.

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