Invited Commentary

Abstract

It’s not the years…it’s the mileage.Indiana Jones, Raiders of the Lost Ark, 1981Sorabella and colleagues [1Sorabella R.A. Wu Y.S. Bader A. et al.Aortic root replacement in octogenarians offers acceptable perioperative and late outcomes.Ann Thorac Surg. 2016; 101: 967-973Abstract Full Text Full Text PDF Scopus (12) Google Scholar] present a small series (n = 34) of octogenarians undergoing aortic root replacement between 2005 and 2012 and compare the early and late outcomes with a larger (n = 592) contemporaneously operated cohort of younger patients. The authors found “moderately worse but acceptable perioperative mortality and late survival” among the older cohort and reasonably concluded that further studies are needed “to determine which subset of octogenarians are at the highest operative risk and may benefit from a conservative approach.” Despite the fact that age greater than or equal to 80 years was not associated with the composite outcome of in-hospital death or stroke in this underpowered study, more robust data such as those from Williams and colleagues [2Williams J.B. Peterson E.D. Zhao Y. et al.Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar] on nearly 46,000 patients undergoing proximal aortic operations (including more than 17,000 root replacements) in North America and captured in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database found age greater than 70 years to be a significant predictor of both mortality and major morbidity among patients undergoing elective repair; risk increased further with each additional 5-year increment after 70 years. However, this does not mean that we should deny aged patients otherwise indicated complex open aortic operations but rather, as Sorabella and colleagues suggest, we should select our patients wisely. Unfortunately, the STS risk calculator does not provide guidance in this regard at the present time because aortic procedures are not currently modeled. However, sound clinical judgment, including assessment of other predictors of adverse outcome with proximal aortic operations as demonstrated in the Williams study [2Williams J.B. Peterson E.D. Zhao Y. et al.Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162Abstract Full Text Full Text PDF PubMed Scopus (133) Google Scholar]—such as chronic kidney disease, severe lung disease, New York Heart Association class IV heart failure, redo procedures, or previous coronary bypass grafting—as well as published frailty assessments [3Ganapathi A.M. Englum B.R. Hanna J.M. et al.Frailty and risk in proximal aortic surgery.J Thorac Cardiovasc Surg. 2014; 147: 186-191Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar] and the all-important “eyeball test” should lead us to select those octogenarians most fit for operation. When teaching our residents about risk assessment around surgical procedures, I often paraphrase the Indiana Jones quote at the beginning of this article that “it’s not the years but the miles,” with the point being that there are many “low-mileage” octogenarians fit for operation just as there are “high-mileage” younger patients who are unfit. As Sorabella and colleagues have shown, selection of these “low-mileage” older patients is possible, and their 81.9% actuarial 5-year survival demonstrates clear clinical benefit for this properly chosen cohort. Aortic Root Replacement in Octogenarians Offers Acceptable Perioperative and Late OutcomesThe Annals of Thoracic SurgeryVol. 101Issue 3PreviewAs the proportion of the population more than 80 years of age increases, cardiac surgeons will increasingly be consulted to operate on this high-risk patient group. The aim of this study is to evaluate the perioperative and late outcomes of octogenarians undergoing aortic root replacement in comparison with younger patients. Full-Text PDF