Invited Commentary

Abstract

The authors [1Likosky D.S. Dacey L.J. Baribeau Y.R. et al.Long-term survival of the very elderly undergoing coronary artery bypass grafting.Ann Thorac Surg. 2008; 85: 1233-1238Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar] believe that this article is significant because of the graying of the population and the anticipation of increasing numbers of octogenarians requiring coronary artery bypass grafting (CABG). Their stated purpose is to help physicians and patients make sound and informed treatment decisions, arguing that “…it is important to provide clinicians and this patient population accurate and reliable information regarding short and long-term outcomes.” To the extent that it is important for clinical decision-making to know these longer-term survival outcomes for octogenarians undergoing CABG, the article confirms existing studies, albeit with somewhat better methodology and greater authority (ie, larger number of patients, 20-year period of observation, confirmation of mortality by linking with the Social Security Administration’s Death Master File, and authorship by a respected group [Northern New England Cardiovascular Disease Study Group] with extensive registry data experience). We learn that “…short and long-term survival was most favorable for patients < 80 years, and worst [favorable] for patients > 85 years,” which are not particularly surprising findings. Median survival for the three cohorts was: (1) < 80 (n = 54,218) = 13.7 years; (2) 80 to 84 (n = 2,765) = 8.2 years; and (3) 85 and older (n = 608) = 7.7 years. However, publicly available data for 2004 reveal life expectancy for whites, both male and female, ages 80 and 85 in the United States to be 9.1 years and 6.7 years, respectively [2Miniño A.M. Heron M.P. Murphy S.L. Kochanek K.D. Deaths: final data for 2004. National Vital Statistics Reports, Centers for Disease Control and Prevention National Center for Health Statistics, U.S. Department of Health & Human Services: Hyatsville, MD. 2007; 55 (August 21): 1-120Google Scholar]. Perhaps this comparison shows that survival in selected octogenarians after CABG is not appreciably different than actuarial survival for the general population of the United States, which entitles the authors to claim, “Our findings reveal the long-term effect of CABG in Northern New England from 1987–2006, and demonstrates a favorable survivorship for octogenarians undergoing isolated CABG surgery.” However, I am not persuaded that these survival data add greatly to our clinical decision-making for these elders. Observational studies such as this one are rife with selection bias and suffer from changing selection criteria, varying with increasing age and evolving over a 20-year time span. For example, we are not told if patients failed medical therapy for angina, whether percutaneous coronary intervention was considered or was attempted and failed, or if CABG was truly an option or became the treatment of last resort. Unfortunately, the authors provide no information about recovery rates, hospital readmission rates, symptomatic and functional status at 1 year, and whether patients who were preoperatively capable of independent living remained this way postoperatively. The authors conclude that their survival data suggest “…that revascularization should remain a suitable option for the elderly population.” Survival data per se in this elderly population offer some value, but without information regarding quality of life, physicians and patients are left with a continuing, unresolved dilemma in clinical decision-making. Long-Term Survival of the Very Elderly Undergoing Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 85Issue 4PreviewIncreasing numbers of the very elderly are undergoing coronary artery bypass graft surgery (CABG). Short-term results have been studied, but few data are available concerning long-term outcomes. Full-Text PDF