{

AGE IS NOT A CONTRAINDICATION

FOR CARDIAC SURGERY

(Pre 23rd kongres ’Ceske spolecnosti aneteziologie,

resuscitace a intenzivni medicini’ – 6 to 8/10/2016

Prague, Czech Republic)

)

George Silvay, M.D. Ph.D. Professor Division of Cardiac Anesthesiology Department of AnesthesiologyIcahn School of Medicine at Mount SinaiNew York, NY

Icahn School of Medicine at Mount Sinai, New York, NY

DISCLOSURE – Nothing at present

...but I am hoping …..

Karlova Univerzita & internat 5, maja – Praha, 1952

Hotel a restauracia “U troch pstrosov” Praha.

Hotel and restaurant “ At the three ostriches” at the foot of Charles Bridge.

Hans G. Borst, M.D.

With his assitance, I received a Alexander Humboldt

Scholarship in Munchen, Germany (1965)

Borst et al, Arteriovenous fistula of the Aortic

Arch: Repair during DHCA

J Thorac Cardiovasc Surg 1964;3:443-447

Robert S. Litwak, M.D

He invited me to Mount Sinai for a 3-year

fellowship in Cardiothoracic Surgery (1967–1970)

Litwak RS, Lev R, Baron M, Silvay G, Gadboys H:

The surgical treatment of aortic aneurysm.

Geriatrics 1967;21:105-125.

August 21, 1968 Soviet Union and Warsaw Pact the

Invasion of Czechoslovakia

My dream ends after surgical training in CSR and a fellowship in

Germany and USA. Since 1970 I am cardiac anesthesiologist in Mount Sinai .

Who Is Old?

What is more important?

Physiological age or chronological age?

There is NO exact definition of “aged”,

“geriatric”, “elderly”, “advance age”

“senior” or “older” patients

Sieber et al Geriatric Anesthesia McGraw-Hill 2007

Chronological and biological age may differ

considerably

Chronological age is most commonly accepted

and is widely used in clinical practice

Medicare proposed to categorized

geriatric patients:

Young old (aged 65 to 74 years)

Mid-old (aged 75 to 84 years)

Oldest-old (aged 85 years and above)

Recent publications divided patients to two

groups: 1. 79 years and younger;

2. 80 years and older

An important and unresolved question is:

“What does age mean”?

Age does not provide and objective criterion of any

Individual’s health condition.!

It seems that other criteria for selection should be used.

In this regard, an addition to the usual surgical scores,

the indices of frailty developed mostly by geriatricians

could be of some interest and could better define those

individuals actually at major risk.

Unfortunately, those indices and frailty scores have not

been widely adopted by the cardiovascular surgical

community!

Bachet J Thor Cardiovasc Surg 2016:152: 447

Presidential terms: 1981 - 1989 1911 - 2004

The mean life expectancy of the USA is projected to

increase from 78.3 years at present to over 81 years

in 2025, with concomitant increase in the percentage

of the population over the age of 75 years. The

number of people older than 65 years is projected to

grow 50% from 35 to 71 million, representing 19.6%

of the overall population

Several reports have documented, that more as a

25% octogenarians are functionally limited by

cardiovascular disease, cerebrovascular accidents,

respiratory disease and diabetes.

Spencer G et al US Bureau of the Census 1988-2080

C. Barnard M. DeBakey A. Kantrowitz

Face the Nation, 1967

American College of Cardiology National Database 2011.

Nilsson et al European Heart Journal (2006) 27, 867–874

Nilsson et al European Heart Journal (2006) 27, 867–874

Ranucci et al Eur J Cardiothorac Surg. 2010;37:724-29

Ranucci et al Eur J Cardiothorac Surg. 2010;37:724-29

Age

Left Ventricular EF

Serum creatinine

Filsoufi et al J Cardiothorac Vasc Anesth. 2007 Dec;21(6):784-92

Filsoufi et al J Cardiothorac Vasc Anesth. 2007 Dec;21(6):784-92

Title: Cardiac surgery in 260 octogenarians: a case

series.

Material : 260 (3.5%0 out of 7,357 scheduled patients for

OHS were aged 80y and older. 85% had elective

surgery.

Hospital mortality in octogenarians was 3.9% compared

to the 2.2% mortality rate in 7,357 patients.

Conclusion: Clinicians should be strongly aware that

cardiac surgery can be safely performed at all ages:

meticulous preoperative evaluation is the key element

which may help to stratify patients. Hemodynamic

treatment should be optimized in order to prevent major

complications.

Scandroglio AM, et al. Brit Med Anesth 2015; 15; 412 - 420

Title: Mortality, outcomes good in aortic aneurysms repair

in octogenarians. Age alone should not bar treatment.

We reviewed 847 consecutive patients aged 80

years or older (April 2005 to February 2014) for repair of

TAAA. In elective patients OHS and EVAR surgery the

results were same. In urgent and rupture the immediate

results. with lower mortality were in EVAR group. But the

median survival rates in patients who lived longer than

30 days was significantly higher in OHS patients (42.5

months versus 11 months).

QoL 6 months after hospitalization not reported.

In discussion: “At some point, the question

becomes” Can we afford to spend $ 100.000 to keep a

90 years old patient “alive” for 6 months?

McKnight W.: Vascular Specialist 2015; 11: April 2015 1&7.

Title: Contemporary outcomes of open thoraco-abdominal

aortic aneurysm (TAAA) repair in octogenarians.

We analyzed clinical data from 1267 enrolled patients

who underwent open TAAA repair between 2003 to 2013.

Eighty-eight patients (7%) were octogenarians.

Adverse postoperative outcomes was higher in

octogenarians 36% versus 15.3%, so as mortality 26% versus

6.9%.

Aneurysm rupture was more common in octogenarians

14% versus 4.7%.

Conclusion: Although TAAA repair should not be denied to

octogenarians based solely on age. Extensive TAAA repair

should be performed with caution.

Aftab M, et al. J Thor Cardiovasc Surg 2015; 149: 134 - 141

Title: Does quality of life improve in octogenarians

following cardiac surgery? A systematic review.

Material from 44 studies that reported the QoL (quality of

life) of 80y and older (mean age 81 – 86.5) following CS.

Two essential reasons to offer CS are: improve quality of

life and prognosis !

Study included 8456 patients. Follow-up from 6 months

to 11.8 years.

Conclusion: QoL following CS improves in majority of

patients. However 8 – 19% appear to experience a fall in

QoL. and regret to have CS.

Abah U, et al. Brit Med J 2015; 5 in press

AGE – dilemma for OHS ?

In Mount Sinai Medical Center in NY, 1,138 patients

had an elective open repairs of thoracic aortic

aneurysm,(1999 – 2010).

Stanford Type A : 792 pts ( 293 females)

Stanford Type B: 346 pts (130 females)

Silvay G,,,, Griepp R. : Thoracic aortic aneurysm: Anesthesiologist’s view 2011.

Revista Mex Anesth 32: 35-37; 2009

Type A: Summary of Surgical

Deaths by Age and Gender

Females Males

Age

Group

N Death

s

%

Died

N Death

s

%

Died

<65 61 4 6.6 206 7 3.4

66– 75 110 3 2.7 162 10 6.2

>76 122 8 6.6 131 6 4.6

Total 293 15 5.1 499 23 4.6

P=.76 P=.52

Changes during decades: Improvements in surgical

techniques, anesthetic management, monitoring,

postoperative cate. Influence on mortality.

Material: 110 patients for elective MV replacement

Mean age: 44.5 y. Mortality: 12.7%

Litwak RS, Silvay G, Gadboy HL, et al: Factor associated with operative risk in mitral

valve replacement. Amer J Cardiolog 1969;23:335-343.

Material: 1,308 patients for variety of thoracic aortic surgery

Mean age: 61.4 y. Mortality: 4.5% (N=1,077)

Mean age: 83.3 y. Mortality: 5.2% (N= 231)

Silvay G, Castillo JG, Chikwe J, et al: Cardiac anesthesia and surgery in geriatric

patients.Semin Cardiothor Vasc Anesthesia 2008;12:18-29.

Geriatric Patients - TAA

Early diagnosis !!

Select treatment: conservative

surgical repair

stent graft

Results depending: Type of the TAA, urgency, comorbidity but

also in experiences of the hospital and surgeon!

Long term survival and quality of life is largely determined by

concurrent medical condition. In our material survival rate in

patients age 80 y. and older is similar to the general population

with the same age.

One year survivals is 81-87%.

Most importantly, the data clearly indicate that no patient group

is “too old” for repair of TAA.

Chiesa R. et al:H.San Raffaele Proceeding 2009;1: 47-55

Silvay G, et al Aortic Symposium 2012 (April 26-27) POD #252

Silvay et al Semin Cardiothorac Vasc Anesth. 2008;12(1):18-28

THE BEST CASE TO DOCUMENT

“Age is not a contraindication for

open heart surgery” is

Dr Michael DeBakey !

Silvay G, Castillo J.: History of anesthesia for aortic surgery. In: Chiesa R, et al::

History of aortic surgery in the world. Edizione Minerva Medica, Turin, Italy 2015.

He diagnosed himself with an aortic dissection at the age 97, and he

refused to have surgery.

Later on, the problem worsened, aneurysm expended and Dr

DeBakey lost consciiousness.

OR 2/09/2006 Repair of dissecting TAA ( 7 h, DHCA 24m)

Surgeon: J. Pool

Anesthesiology : S. Shenaq

AGE IS NOT A CONTRAINDICATION FOR REPAIR OF AORTIC ANEURYSM !

President Bush and Congressional leaders awarded

Dr. DeBakey with the nation's highest civilian honor

Washington DC May 2008

Cooley receiving a framed copy of their collaborative paper

“Surgical consideration of intrathoracic aneurysms of the

aorta and great vessels”

DeBakey et al Ann Thorac Surg 1952;135:660-680

Died on natural causes – July 2008

{

Conclusions - TAA - April 2015 (SCA):

1) Early diagnosis – medical & surgical treatment

2) TEE in every patient!

3) Detailed preoperative evaluation and strategy for OR

4) Optimized elective patients for operation.

5) Antibiotic prophylaxis!!! Dental clearance!!!

6) Optimize prevention of CNS (Sjv02) and spinal cord injury

(DHCA, distl controlled perfusion, CSF drainage, steroids or other)

7) Utilize hemodynamic, SSEP + MEP monitoring in OR and CICU

8) Maximize perfusion parameters intraoperatively

9) In CICU – monitoring as in OR, prevent hypoxemia and anemia –

prevent the late spinal cord ischemia.

10) Create harmony in the operating room!

Conclusions

An aggressive surgical approach offers symptomatic

benefit in geriatric group of cardiovascular patients.

Optimal preoperative evaluation and preparation for

surgery, anesthetic management and monitoring,

experience surgery with critical care is mandatory for

good results.

The age should not be a deterring factor in performing

the surgery.

Long-term survival is largely determined by concurrent

medical conditions.

From left: 1.Drs. DeBakey; 2. Cooley&DeBakey; 3. Griepp, Shenaq, Cooley;

4. Crawford; 5. Coselli.

GRACIASありがとうΕΥΧΑΡΙΣΤΩMAHALO 谢谢

СПАСИБО תודה

امتنان

CÁM ƠN ANH ASANTE

MULTUMIRIFALEMNDERIT

KIA ORA TEŞEKKÜR

TAK

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DANK UMERCI

TERIMA KASIHKÖSZÖNÖM D’AKUJEM

GRAZIE DANKE

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Thank You

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