Zusammenfassung
In den vergangenen Jahren ist die Anzahl herzchirurgischer Eingriffe bei älteren Patienten
weltweit angestiegen. Der Anteil über 75-jährigen Patienten liegt derzeit bei 20 %
und steigt weiter an. Überwiegend werden in dieser Altersgruppe Eingriffe an den Herzklappen
(häufig an der Aortenklappe), die aortokoronare Bypassoperation oder die Kombination
aus Aortenklappenersatz und aortokoronarer Bypassoperation durchgeführt. Im Gegensatz
dazu werden Verfahren der chirurgischen Herzinsuffizienztherapie wie die linksventrikuläre
Reduktionsplastik, die Implantation von mechanischen Unterstützungssystemen (Assist
Device) oder die Herztransplantation in dieser Patientengruppe nur sehr selten eingesetzt
oder gelten wegen des höheren Alters als kontraindiziert. Schwerpunkte dieser Übersichtsarbeit
ist die chirurgische Therapie der koronaren Herzerkrankung und die Kombination von
Bypassoperation und Klappenersatz. Ein weiterer Bestandteil sind altersspezifische
Risikofaktoren und chirurgische Optionen zur Senkung der perioperativen Morbidität
und Letalität.
Summary
Heart surgery has been performed in an increasing number of elderly patients in the
recent years. Currently about 20 % of all patients in cardiac surgery are older than
75 years, however their number is increasing constantly. Valve replacement (mainly
aortic valve replacement, AVR), coronary artery bypass grafting (CABG) or combined
procedures (AVR and CABG) are the most common procedures in the elderly. However,
surgical therapy of heart failure, implantation of assist devices or cardiac transplantation
have been performed only in a limited number of elderly patients. Surgical pathways
in the therapy of coronary artery disease or valve diesease are described. Furthermore,
age related morbidity and mortality and related surgical options to improve the outcome
are discussed.
Literatur
- 1
Akins C W, Daggett W M, Vlahakes G J, Hilgenberg A D, Torchiana D F, Madsen J C. et
al .
Cardiac operations in patients 80 years old and older.
Ann Thorac Surg.
1997;
64
606-614
- 2
Alexander K P, Anstrom K J, Muhlbaier L H, Grosswald R D, Smith P K, Jones R H. et
al .
Outcomes of cardiac surgery in patients > or = 80 years: results from the National
Cardiovascular Network.
J Am Coll Cardiol.
2000;
35
731-738
- 3
Allen K B, Griffith G L, Heimansohn D A, Robison R J, Matheny R G, Schier J J. et
al .
Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized
trial.
Ann Thorac Surg.
1998;
66
26-31
- 4
Allen K B, Heimansohn D A, Robison R J, Schier J J, Griffith G L, Fitzgerald E B.
Influence of endoscopic versus traditional saphenectomy on event-free survival: five-year
follow-up of a prospective randomized trial.
Heart Surg Forum.
2003;
6
E143-E145
- 5
Bergsland J, Hasnan S, Lewin A N, Bhayana J, Lajos T Z, Salerno T A.
Coronary artery bypass grafting without cardiopulmonary bypass - an attractive alternative
in high risk patients.
Eur J Cardiothorac Surg.
1997;
11
876-880
- 6
Blanche C, Blanche D A, Kearney B, Sandhu M, Czer L S, Kamlot A. et al .
Heart transplantation in patients seventy years of age and older: A comparative analysis
of outcome.
J Thorac Cardiovasc Surg.
2001;
121
532-541
- 7
Blanche C, Matloff J M, Denton T A, Czer L S, Fishbein M C, Takkenberg J J. et al
.
Heart transplantation in patients 70 years of age and older: initial experience.
Ann Thorac Surg.
1996;
62
1731-1736
- 8
Bonatti J.
Ascending aortic atherosclerosis - a complex and challenging problem for the cardiac
surgeon.
Heart Surg Forum.
1999;
2
125-135
- 9
Branca P, McGaw P, Light R.
Factors associated with prolonged mechanical ventilation following coronary artery
bypass surgery.
Chest.
2001;
119
537-546
- 10
Brunvand H, Offstad J, Nitter-Hauge S, Svennevig J L.
Coronary artery bypass grafting combined with aortic valve replacement in healthy
octogenarians does not increase postoperative risk.
Scand Cardiovasc J.
2002;
36
297-301
- 11 Chapman, Violaiki. Die Zukunft der medizinischen Versorgung älterer Patienten. Homepage
der Bundesvereinigung für Gesundheit e. V. http://www.gesund-im-alter.de
- 12
Chai P J, Williamson J A, Lodge A J, Daggett C W, Scarborough J E, Meliones J N. et
al .
Effects of ischemia on pulmonary dysfunction after cardiopulmonary bypass.
Ann Thorac Surg.
1999;
67
731-735
- 13
Craver J M, Puskas J D, Weintraub W W, Shen Y, Guyton R A, Gott J P. et al .
601 octogenarians undergoing cardiac surgery: outcome and comparison with younger
age groups.
Ann Thorac Surg.
1999;
67
1104-1110
- 14
D’Alfonso A, Mariani M A, Amerini A, Codecasa R, Bellieni L, Proietti A. et al .
Off-pump coronary surgery improves in-hospital and early outcomes in octogenarians.
Ital Heart J.
2004;
5
197-204
- 15
Dahlberg P S, Orszulak T A, Mullany C J, Daly R C, Enriquez-Sarano M, Schaff H V.
Late outcome of mitral valve surgery for patients with coronary artery disease.
Ann Thorac Surg.
2003;
76
1539-1487
- 16
Desai N D, Pelletier M P, Mallidi H R, Christakis G T, Cohen G N, Fremes S E. et al
.
Why is off-pump coronary surgery uncommon in Canada? Results of a population-based
survey of Canadian heart surgeons.
Circulation.
2004;
110
(11 Suppl 1)
II7-12
- 17
Diegeler A, Autschbach R, Falk V, Walther T, Gummert J, Mohr F W, Dalichau H.
Open heart surgery in the octogenarians- a study on long term survival and quality
of life.
Thorac Cardiovasc Surg.
1995;
43
265-270
- 18
DiGregorio V, Zehr K J, Orszulak T A, Mullany C J, Daly R C, Dearani J A. et al .
Results of mitral surgery in octogenarians with isolated nonrheumatic mitral regurgitation.
Ann Thorac Surg.
2004;
78
807-813
- 19
Fernandez J, Chen C, Anolik G, Brdlik O B, Laub G W, Anderson W A. et al .
Perioperative risk factors affecting hospital stay and hospital costs in open heart
surgery for patients > or = 65 years old.
Eur J Cardiothorac Surg.
1997;
11
1133-1140
- 20
Filsoufi F, Aklog L, Adams D H, Byrne J G.
Management of mild to moderate aortic stenosis at the time of coronary artery bypass
grafting.
J Heart Valve Dis.
2002;
11
(Suppl 1)
S45-S49
- 21
Fiore A C, Swartz M T, Naunheim K S, Moroney D A, Canvasser D A, McBride L R. et al
.
Management of asymptomatic mild aortic stenosis during coronary artery operations.
Ann Thorac Surg.
1996;
61
1693-1697
- 22 Frank B, Hobbs B LD. Sixty five plus in the United States, current population reports,
special studies. US Bureau of the Census. US Government Printing Office, Washington,
DC. US 1996: 23-190
- 23
Friedman M, Sellke F W, Wang S Y, Weintraub R M, Johnson R G.
Parameters of pulmonary injury after total or partial cardiopulmonary bypass.
Circulation.
1994;
90
II262-II268
- 24
Fritz M K, Wiebalck A, Buchwald D, Reber D, Klak K, Laczkovics A M.
Off-pump versus on-pump coronary artery bypass surgery. Comparison of 270 case-matched
elderly patients.
Z Kardiol.
2004;
93
612-617
- 25
Gillinov A M, Wierup P N, Blackstone E H, Bishay E S, Cosgrove D M, White J. et al
.
Is repair preferable to replacement for ischemic mitral regurgitation?.
J Thorac Cardiovasc Surg.
2001;
122
1125-1141
- 26
Goldstein D J, Beauford R B, Luk B, Karanam R, Prendergast T, Sardari F. et al .
Multivessel off-pump revascularization in patients with severe left ventricular dysfunction.
Eur J Cardiothorac Surg.
2003;
24
72-80
- 27
Higgins T L, Estafanous F G, Loop F D, Beck G J, Lee J C, Starr N J. et al .
ICU admission score for predicting morbidity and mortality risk after coronary artery
bypass grafting.
Ann Thorac Surg.
1997;
64
1050-1058
- 28
Hilton T C.
Aortic valve replacement for patients with mild to moderate aortic stenosis undergoing
coronary artery bypass surgery.
Clin Cardiol.
2000;
23
141-147
- 29
Hochrein J, Lucke J C, Harrison J K, Bashore T M, Wolfe W G, Jones R H. et al .
Mortality and need for reoperation in patients with mild-to-moderate asymptomatic
aortic valve disease undergoing coronary artery bypass graft alone.
Am Heart J.
1999;
138
791-797
- 30
Ishida M, Kobayashi J, Tagusari O, Bando K, Niwaya K, Nakajima H. et al RP> .
Comparison of off-pump and on-pump coronary artery bypass grafting in midterm results.
Jpn J Thorac Cardiovasc Surg.
2004;
52
240-246
- 31
Kalmar P, Irrgang E.
Cardiac surgery in Germany during 2000: A report by the German Society for Thoracic
and Cardiovascular Surgery.
Thorac Cardiovasc Surg.
2001;
49
33-38
- 32
Kalmar P, Irrgang E.
Cardiac Surgery in Germany during 2003: A report by the German Society for Thoracic
and Cardiovascular Surgery.
Thorac Cardiovasc Surg.
2004;
52
312-317
- 33
Kiaii B, Moon B C, Massel D, Langlois Y, Austin T W, Willoughby A. et al .
A prospective randomized trial of endoscopic versus conventional harvesting of the
saphenous vein in coronary artery bypass surgery.
J Thorac Cardiovasc Surg.
2002;
123
204-212
- 34
King R M, Pluth J R.
Concomitant mitral valve repair or replacement and coronary revascularization.
J Card Surg.
1986;
1
233-246
- 35
Kirsch M, Guesnier L, LeBesnerais P, Hillion M L, Debauchez M, Seguin J. et al .
Cardiac operations in octogenarians: perioperative risk factors for death and impaired
autonomy.
Ann Thorac Surg.
1998;
66
60-67
- 36
Lee J H, Swain B, Andrey J, Murrell H K, Geha A S.
Fast track recovery of elderly coronary bypass surgery patients.
Ann Thorac Surg.
1999;
68
437-441
- 37
Lutz C W, Hillmann R, Lutter G, Schöllhorn J, Beyersdorf F.
Endoscopic vs. conventional vein harvesting: first results with a new, non-disposable
system.
Thorac Cardiovasc Surg.
2001;
49
321-327
- 38
Lutz C W, Schlensak C, Lutter G, Schöllhorn J, Beyersdorf F.
Minimal-invasive, video-assisted vein harvesting for cardiac and vascular surgical
procedures.
Eur J Cardiothorac Surg.
1997;
12
519-521
- 39
Mack M J, Brown P P, Kugelmass A D, Battaglia S L, Tarkington L G, Simon A W. et al
.
Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical
and percutaneous procedures.
Ann Thorac Surg.
2004;
77
761-766
- 40
Matt P, Bernet F, Grapow M, Zerkowski H R.
Herzchirurgie beim alten Patienten.
Schweiz Med Forum.
2003;
47
1144-1146
- 41
Miller D J, Samuels L E, Kaufman M S, Morris R J, Thomas M P, Brockman S K.
Coronary artery bypass surgery in nonagenarians.
Angiology.
1999;
50
613-617
- 42
Morgan J A, John R, Mancini D M, Edwards N M.
Should heart transplantation be considered as a treatment option for patients aged
70 years and older?.
J Thorac Cardiovasc Surg.
2004;
127
1817-1819
- 43
Mortasawi A, Arnrich B, Rosendahl U, Albert A, Delmo-Walter E M, Walter J. et al .
Ist das Alter eine unabhängige Determinante der Letalität in der Herzchirurgie wie
es im EuroScore behauptet wird?.
Z Gerontol Geriat.
2003;
36
63-70
- 44
Mortasawi A, Arnrich B, Walter J, Florath I, Rosendahl U, Alexander A. et al .
Einfluss des Alters auf die postoperative Komplikationen und Letalität in der Herzchirurgie.
Herz.
2003;
28
429-436
- 45
Olsson M, Janfjall H, Orth-Gomer K.
Quality of life in octogenarians after valve replacement due to aortic stenosis. A
prospective comparison with younger patients.
Eur Heart J.
1996;
17
583-589
- 46
Peterson E D, Alexander K P, Malenka D J, Hannan E L, O’Conner G T, McCallister B D.
et al .
Multicenter experience in revascularization of very elderly patients.
Am Heart J.
2004;
148
486-492
- 47
Peterson E D, Cowper P A, Jollis J G, Bebchuk J D, DeLong E R, Muhlbaier L H. et al
.
Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years
or older.
Circulation.
1995;
92
II85-II91
(Suppl 9)
- 48
Potger K C, McMillan D, Connolly T, Southwell J, Dando H, O’Shaughnessy K.
Coronary artery bypass grafting: an off-pump versus on-pump review.
J Extra Corpor Technol.
2002;
34
260-266
- 49
Ricci M, Karamanoukian H L, Abraham R, Von Fricken K, D’Ancona G, Choi S. et al .
Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary
bypass.
Ann Thorac Surg.
2000;
69
1471-1475
- 50
Schlensak C, Doenst T, Preusser S, Wunderlich M, Kleinschmidt M, Beyersdorf F.
Cardiopulmonary bypass reduction of bronchial blood flow: a potential mechanism for
lung injury in a neonatal pig model.
J Thorac Cardiovasc Surg.
2002;
123
1199-1205
- 51
Stahle E, Bergstrom R, Nystrom S O, Hansson H E.
Early results of aortic valve replacement with or without concomitant coronary artery
bypass grafting.
Scand J Thorac Cardiovasc Surg.
1991;
25
29-35
- 52
Stamou S C, Dangas G, Dullum M K, Pfister A J, Boyce S W, Bafi A S. et al .
Beating heart surgery in octogenarians: perioperative outcome and comparison with
younger age groups.
Ann Thorac Surg.
2000;
69
1140-1145
- 53
Thulin L I, Sjogren J L.
Aortic valve replacement with and without concomitant coronary artery bypass surgery
in the elderly: risk factors related to long-term survival.
Croat Med J.
2000;
41
406-409
- 54
Yanagi K, Toyama M, Tanabe H, Ozaki S, Kawase I.
Morbidity and mortality of coronary artery bypass surgery in patients 75 years of
age or older.
Nippon Kyobu Geka Gakkai Zasshi.
1992;
40
1978-1986
Dr. Georg Trummer
Abteilung Herz- und Gefäßchirurgie, Chirurgische Universitätsklinik, Herz-Kreislauf-Zentrum
Hugstetter Straße 55
79106 Freiburg
Phone: 0761/2702818
Fax: 0761/270 2550
Email: georg.trummer@klinikum.uni-freiburg.de
