The relationship between hospital volume and outcome in bariatric surgery at academic medical centers

OBJECTIVE: To examine the effect of hospital volume of bariatric surgery on morbidity, mortality, and costs at academic centers. SUMMARY BACKGROUND DATA: The American Society for Bariatric Surgery recently proposed categorization of certain bariatric surgery centers as "Centers of Excellence." Some of the proposed inclusion criteria were hospital volume and operative outcomes. The volume-outcome relationship has been well established in several complex abdominal operations; however, few studies have examined this relationship in patients undergoing bariatric surgery. METHODS: Using the International Classification of Diseases, 9th edition, diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all patients who underwent Roux-en-Y gastric bypass for the treatment of morbid obesity between 1999 and 2002 (n = 24,166). Outcomes of bariatric surgery, including length of hospital stay, 30-day readmission, morbidity, observed and expected (risk-adjusted) mortality, and costs were compared between high-volume (>100 cases/year), medium-volume (50-100 cases/year), and low-volume hospitals (<50 cases/year). RESULTS: There were 22 high-volume (n = 13,810), 27 medium-volume (n = 7634), and 44 low-volume (n = 2722) hospitals included in our study. Compared with low-volume hospitals, patients who underwent gastric bypass at high-volume hospitals had a shorter length of hospital stay (3.8 versus 5.1 days, P < 0.01), lower overall complications (10.2% versus 14.5%, P < 0.01), lower complications of medical care (7.8% versus 10.8%, P < 0.01), and lower costs ($10,292 versus $13,908, P < 0.01). The expected mortality rate was similar between high- and low-volume hospitals (0.6% versus 0.6%), demonstrating similarities in characteristics and severity of illness between groups. The observed mortality, however, was significantly lower at high-volume hospitals (0.3% versus 1.2%, P < 0.01). In a subset of patients older than 55 years, the observed mortality was 0.9% at high-volume centers compared with 3.1% at low-volume centers (P < 0.01). CONCLUSIONS: Bariatric surgery performed at hospitals with more than 100 cases annually is associated with a shorter length of stay, lower morbidity and mortality, and decreased costs. This volume-outcome relationship is even more pronounced for a subset of patients older than 55 years, for whom in-hospital mortality was 3-fold higher at low-volume compared with high-volume hospitals. High-volume hospitals also have a lower rate of overall postoperative and medical care complications, which may be related in part to formalization of the structures and processes of care.     

Abdominal surgery in the older Crohn's population

BACKGROUND: The surgical literature perceives that the elderly cohort of Crohn's patients may have increased risk with surgery. METHODS: A retrospective review and prospective database analysis of all patients with histologically proven Crohn' s disease who had a laparotomy at a single Sydney teaching hospital were performed. The last laparotomy of each patient was included in the analysis for morbidity and mortality to assess whether an older cohort was at an increased risk. RESULTS: A total of 156 patients had 298 laparotomies for histopathologically proven Crohn's disease. The frequency distribution of age at last laparotomy was bimodal, and the statistically determined cut-off age between younger and older cohorts was 55 years. Thirty-three patients were older than 55 years. There was no difference in duration of symptoms before first diagnosis (older, 17 months vs younger, 25 months), previous number of Crohn's operations (42.4 vs 39.8%), or duration of known Crohn's disease. Isolated large bowel disease was more common in the elderly cohort (42.4 vs 18.7%, chi2 = 8.09, P < 0.01). Small bowel and ileocaecal resections were more common in the younger cohort (72.4 vs 51.6%, chi2 = 5.19, P < 0.025). There was one death in each cohort (overall mortality 1.3%) and anastomotic leak rates (defined as the number of leaks per number of patients with anastomoses), were 4.3% (older) vs 5.3% (younger) despite frank sepsis present in 21.2% of all subjects at the time of surgery. The older group had more cardiac (18.2 vs 0.8%, P < 0.001) and respiratory complications (18.2 vs 2.4%; P = 0.0003) and a longer mean but not median postoperative hospital admission. CONCLUSIONS: In conclusion, clinical features and presentation are similar in the older and younger Crohn's patients having a laparotomy. However, in the older patient there is a greater likelihood of large bowel disease, ileocaecal resection is done less commonly, there is a higher risk of minor cardiopulmonary postoperative complications, but with similar mortality and anastomotic leak rates to the younger patient.     

Ala55Val Polymorphism on UCP2 Gene Predicts Greater Weight Loss in Morbidly Obese Patients Undergoing Gastric Banding

BACKGROUND: Variability in weight loss has been observed from morbidly obese patients receiving bariatric operations. Genetic effects may play a crucial role in this variability. METHODS: 304 morbidly obese patients (BMI > or =39) were recruited, 77 receiving laparoscopic adjustable gastric banding (LAGB) and 227 laparoscopic mini-gastric bypass (LMGB), and 304 matched non-obese controls (BMI < or =24). Initially, all subjects were genotyped for 4 SNPs (single nucleotide polymorphisms) on UCP2 gene in a case-control study. The SNPs significantly associated with morbid obesity (P < 0.05) were considered as candidate markers affecting weight change. Subsequently, effects on predicting weight loss of those candidate markers were explored in LAGB and LMGB, respectively. The peri-operative parameters were also compared between LAGB and LMGB. RESULTS: The rs660339 (Ala55Val), on exon 4, was associated with morbid obesity (P = 0.049). Morbidly obese patients with either TT or CT genotypes on rs660339 experienced greater weight loss compared to patients with CC after LAGB at 12 months (BMI loss 12.2 units vs 8.1 units) and 24 months (BMI loss 13.1 units vs 9.3 units). However, this phenomenon was not observed in patients after LMGB. Although greater weight loss was observed in patients receiving LMGB, this procedure had a higher operative complication rate than LAGB (7.5% vs. 2.8%; P < 0.05). CONCLUSION: Ala55Val may play a crucial role in obesity development and weight loss after LAGB. It may be considered as clinicians incorporate genetic susceptibility testing into weight loss prediction prior to bariatric operations.     

Treating renal cell cancer in the elderly

OBJECTIVE: To determine whether age and comorbidity are predictors of peri-operative complications and/or mortality in surgery for renal cell cancer in a retrospective study of patients aged >75 years. PATIENTS AND METHODS: Between 1993 and 2003, 1023 radical nephrectomies or nephron-sparing surgery for renal cell cancer were performed in 115 consecutive patients aged > or = 75 years and in 908 consecutive patients aged <75 years. The preoperative American Society of Anesthesiologists (ASA) score was used for risk stratification. Operative mortality and early complications (within 30 days of surgery) were reviewed. RESULTS: The younger patients had significantly lower ASA scores than the older patients. There were early complications in 31 of the 908 younger patients (3.4%) and in two of the 115 older patients (1.7%). Peri-operative mortality was higher in the older than in the younger patients (1.7% vs 0.3%; P = 0.29). Overall morbidity and mortality correlated with increasing ASA score but not with age (P < 0.05). CONCLUSIONS: Despite greater comorbidity in older patients, their morbidity and mortality did not differ significantly from that of younger patients. Advanced age alone should thus not be used as a criterion to deny surgery for renal cell carcinoma. However, older patients should be counselled regarding a tendency for increased comorbidity-related peri-operative mortality.     

Age,Obesity Surgery,and Weight Loss

Some centers consider an age over 50 to be a contraindication for obesity surgery. This study was conducted to examine the relationship between age and one-year postoperative weight of patients receiving gastric restrictive surgery (n = 616) for morbid obesity. Patients were divided into four age groups (18-29, 30-39, 40-49, 50-65 years) matched for preoperative obesity. At one year there were no statistically significant differences in weight loss or postoperative obesity. There were four (0.6%) surgically related deaths. The mortality of patients aged 50 or older (1.1%) was not significantly higher than that of younger patients (0.6%). It was concluded that older age per se need not be a contraindication for surgery.     

Bariatric surgery trends: an 18-year report from the International Bariatric Surgery Registry

BACKGROUND: The epidemic of morbid obesity has increased bariatric procedures performed. Trend analyses provide important information that may impact individual practices. METHODS: Patient data from 137 surgeons were examined from 1987 to 2004 (41,860 patients) using Cochran-Armitage Trend test and Generalized Linear Model. RESULTS: Over an 18-year period, surgeon preference for combined restrictive-malabsorptive procedures increased from 33% to 94%, while simple gastric restriction decreased correspondingly (P < .0001). Surgeons per worksite doubled and cases per surgeon increased 71%. Laparoscopic procedures increased to 24%. The percentage of males, mean operative age, and initial body mass index (BMI) increased significantly (P < .0001). Postoperative hospital stay decreased from 5.0 to 3.9 days (P < .0001). The most common procedure in 2004 was Roux-en-Y gastric bypass (RYGB) (59%). CONCLUSION: Bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is more frequent. From 1987 to 2004, the general trend shows a clear preference for combined restrictive-malabsorptive operations.     

Metabolic surgery in patients over 60 years old: short- and long-term results

Purpose: Laparoscopic Roux-en-Y gastric bypass can treat obesity related comorbidities and can prolong life expectancy. It remains unclear whether this type of surgery is also indicated in obese patients with advanced age.

Materials and methods: In this retrospective monocentric study, we investigated the morbidity and outcomes of weight and metabolic control of bariatric surgery in patients older than 60 years and compared these findings with those of younger patients.

Results: At 18 months after RY gastric bypass, weight losses of respectively 30?±?11% and 34?±?9% of total initial body weight were measured in the older and younger patients (p?p?=?0.11). There was no mortality in either group, but there were significantly more complications and there was a longer hospital stay in the older patients.

Conclusion: RY gastric bypass comes with a significantly higher morbidity and hospital stay in older patients, but weight loss and improvement of DM are similar as in the younger patients.     

Analysis of autogenous vein femoral-infrapopliteal bypass for limb salvage in the elderly

The hypothesis that older patients undergoing femoral-infrapopliteal bypass have a similar outcome as a matched younger group of patients undergoing the same operation was tested. Seventy-six femoral-infrapopliteal autogenous saphenous vein bypasses for critical limb ischemia were performed from 1985 to 1990. By using the life-table method, the primary and secondary patency, limb salvage and survival rates are analyzed and compared for older and younger age groups. Forty cases (53%) were performed in an elderly group, defined as age 70 or older. At 4 years, there was no significant difference between age groups in limb salvage and patency rates. However, operative mortality for the older age group was 12%, compared with 0% in the younger group (P = 0.0004). Thus, femoral-infrapopliteal autogenous vein bypass can be performed with comparable limb salvage and patency rates for an older age group, but the risk of operative mortality appears to be increased with age.     

Avoidance of complications in older patients and Medicare recipients undergoing gastric bypass

HYPOTHESIS: Perioperative morbidity and mortality do not increase in carefully evaluated and managed Medicare and elderly patients undergoing gastric bypass. DESIGN: Retrospective review of a prospectively maintained bariatric database. SETTING: Academic tertiary care medical center. PATIENTS: We reviewed our database of 928 consecutive patients who underwent gastric bypass from March 24, 1998, through May 31, 2006. Of these patients, 36 underwent revision surgery and were excluded. The remaining 892 patients were separated into 4 groups by age and Medicare status. Group 1 consisted of 46 patients 60 years or older at the time of gastric bypass (range, 60-66 years). Group 2 consisted of 846 patients 59 years or younger at the time of gastric bypass (range, 18-59 years). Group 3 consisted of 31 Medicare recipients (age range, 31-66 years). Group 4 consisted of 861 non-Medicare recipients (age range, 18-64 years). MAIN OUTCOME MEASURES: Groups were compared in terms of demographics, morbidity, and mortality. RESULTS: No differences were found in outcomes between older vs younger and Medicare vs non-Medicare patients for any postoperative complication or mortality. CONCLUSIONS: Bariatric surgery can be performed in carefully selected Medicare recipients and patients 60 years or older with acceptable morbidity and mortality. No difference was found in the occurrence of complications in Medicare patients, patients younger than 60 years, or patients 60 years and older. We believe that these results reflect careful patient selection, intensive preoperative education, and expert operative and perioperative management. Our results indicate that bariatric surgery should not be denied solely based on age or Medicare status.     

Medium to long-term outcomes of bariatric surgery in older adults with super obesity

Background

Indications and outcomes of bariatric surgery in older adults suffering from morbid obesity remain controversial. We aimed to evaluate safety and medium to long-term outcomes of bariatric procedures in this patient population.

Conversion of failed laparoscopic gastric banding to gastric bypass as safe and effective as primary gastric bypass in morbidly obese patients

BackgroundTo determine whether the medium-term outcome of secondary gastric bypass (SGB) after laparoscopic adjustable gastric banding (LAGB) is comparable to the outcome of primary gastric bypass (PGB) in morbidly obese patients in terms of complications and weight loss. Controversy exists among bariatric surgeons regarding the choice of primary operation for morbid obesity. Some prefer to start with LAGB as a low-risk operation for all patients and perform revisional surgery in the case of failure. Others prefer to tailor the primary operation to the individual patient.MethodsA total of 55 patients who had undergone SGB after failed LAGB from 2002 to 2006 were compared with 81 patients who had undergone PGB for morbid obesity during the same period in our hospital by a single surgeon.ResultsThe mean operative time in the PGB group was shorter (73 ± 22 min, range 50–100) compared with the SGB group (99 ± 32 min, range 55–180; P <.001). The median length of admission did not differ significantly between the PGB and SGB groups (4 ± 6.6 d, range 3–55, versus 4 ± 2.9 d, range 3–16, respectively; P = .13). No significant differences were found in the occurrence of complications between the PGB and SGB groups (29.6% versus 30.9%, respectively, P = .87). No patient died. At 2 and 3 years postoperatively, no significant difference was found in percentage of patients treated with good or excellent outcomes using the criteria of MacLean (2 y, PGB 60.0% versus SGB 58.8%, P = .94; 3 y, PGB 75.0% versus SGB 72.7%, P = .91).ConclusionIn this series, gastric bypass as a secondary procedure after failed LAGB was as safe and effective as PGB. Conversion to gastric bypass appears to be the treatment of choice after failed LAGB.     

Esophageal adenocarcinoma in patients < or = 50 years old: delayed diagnosis and advanced disease at presentation

During the past decade, we encountered an increasing number of young patients with esophageal adenocarcinoma. It is not clear whether young patients have more aggressive course and worse prognosis. Our aim was to compare clinicopathological characteristics/treatment results of patients with esophageal adenocarcinoma who were < or = 50 and > 50 years of age. We studied 263 consecutive patients with resectable esophageal adenocarcinoma: 32 (12.1%) were < or = 50 years old. Dysphagia was present in 69 per cent of patients < or = 50 years old and in 48 per cent of older patients (P = 0.019). The median duration of dysphagia was 3.5 months in younger patients compared to 2 months in patients > 50 years (P < 0.0001). Seven of 22 (31.8%) young and three of 108 (2.8%) older patients with dysphagia reported dysphagia for > or = 6 months (P < 0.0001). Fifty per cent of younger patients were stage III/IV and > 70 per cent were node positive (P = 0.04 and P = 0.02 vs patients > 50 years, respectively). Five-year survival was 32.6 per cent for < or = 50 years and 45.5 per cent for > 50 years. More than 10 per cent of esophageal adenocarcinoma patients undergoing surgery are now < or = 50 years of age. They usually present with dysphagia, are symptomatic for a longer time before diagnosis, and have more advanced disease compared to older patients. With appropriate aggressive treatment, survival is similar. Liberal use of endoscopy and aggressive diagnostic approach are paramount in young patients with dysphagia/symptoms of gastroesophageal reflux disease (GERD).     

Outcome of bariatric surgery in older patients

Background

People are living longer than they were expected to 2 decades ago. Increased life expectancy and reduced mortality encompasses a simultaneous increase in the number of older adults with obesity that entails an increase of co-morbidities, such as diabetes, hypertension, cancer, and many other diseases. The aim of our study was to compare the outcomes of bariatric surgery in patients age ≥65 in comparison with younger patients.

Advanced age and sex as predictors of adverse outcomes following gastric bypass surgery.

OBJECTIVES: This study aimed to determine whether advanced age or sex was predictive of adverse outcomes after Roux-en-Y gastric bypass. METHODS: The Pennsylvania State Discharge Database was searched for records of morbidly obese patients who underwent Roux-en-Y gastric bypass. The SASs MIXED Procedure was used to test whether mortality alone or adverse outcomes (postoperative complications, nonroutine hospital transfer and mortality) were significantly related to sex or advanced age (>50 years). The presence of comorbidities was used as a blocking variable. RESULTS: Between 1999 and 2001, 4,685 patients underwent Roux-en-Y gastric bypass in Pennsylvania, of which 82% were female and 20% were older than 50 years of age. Comorbidities were present in 71% of patients. Twenty-eight deaths (0.6%) and 813 adverse outcomes (17.4%) occurred. Mortality was greater in males than in females (1.2% vs. 0.47%, P<0.05) without comorbid interaction. Mortality did not increase with age. Adverse outcomes were related to both sexes (24% male, 16% female, P<0.05) and age (< or = 50, 16% vs. > 50, 23%, P<0.05) with a small comorbid interaction. CONCLUSION: Adverse outcomes are more frequent among males and older patients and are influenced by comorbidities. Male patients have a higher mortality that was not affected by the presence of comorbidities.     

Guideline Recommended Gastric Cancer Care in the Elderly: Insights into the Applicability of Cancer Trials to Real World

Background

Given the underrepresentation of older persons in cancer trials, the association between increasing age and receipt of recommended gastric cancer care in the United States was examined.

Materials and Methods

Using the 1998–2006 SEER database, 8637 Medicare-eligible patients, aged ≥65 years who underwent gastrectomy for nonmetastatic gastric adenocarcinoma were identified. Multivariate analyses was used to assess the effect of increasing age on receipt of recommended gastric cancer care (adequate lymph node evaluation [≥15 lymph nodes] and adjuvant radiation therapy for AJCC Ib–IVM0) and cancer-specific mortality controlling for covariates.

Results

While 61% of gastric cancer operations were performed in patients ≥65 years, less than 30% received adequate lymphadenectomy or adjuvant radiation therapy. Older patients were less likely to receive adequate nodal evaluation and adjuvant radiotherapy (P < 0.0001). These findings persisted on multivariate analyses. Older age was also associated with worse cancer-specific mortality. Because an age-tumor location interaction for cancer mortality (P = 0.047) was observed, stratified analyses were performed which showed that the adverse effect of older age on cancer-specific mortality was augmented in proximal gastric cancers.

Conclusions

This population-based study showed significant age-based variations in gastric cancer care. These results should encourage assessment of generalizability of gastric cancer trials to this expanding population of elderly in the era of comparative effectiveness research.     

Matching older kidneys with older patients does not improve allograft survival

Centers may restrict the use of some donor kidneys on the belief that overall graft survival is improved by giving older kidneys to older recipients and vice versa. The prevalence and the effect on graft survival (determined by death, return to dialysis, or retransplantation) of this practice among 74,297 first cadaver kidney transplantations in 1988 to 1998 was examined by using data from the United States Renal Data System. Giving older kidneys to older recipients is common; recipients > or =55 yr old received donor kidneys that were > or =55 yr old 46.2% more often than expected, but they received kidneys that were 18 to 29 yr old 33.6% less often than expected (chi(2) P < 0.0001). Both recipient and donor age have important effects on graft survival, although the effects of donor age are much stronger than those of recipient age. Compared with recipients 18 to 29 yr old, recipients > or =55 yr old were 25% (95% confidence interval, 15 to 35%, P < 0.0001) more likely to have graft failure (adjusted for donor age and other risk factors). On the other hand, donor kidneys > or =55 yr old were 78% (95% confidence interval, 58 to 99%, P < 0.0001) more likely to fail compared with kidneys 18 to 29 yr old. However, giving older kidneys to older recipients had little independent effect on graft survival, once the intrinsic effects of recipient and donor age were taken into account. For example, transplanting donor kidneys > or =55 yr old into recipients > or =55 yr old reduced the risk of graft failure only -6% (95% confidence interval, -18 to 8%, P = 0.3923) after the independent effects of donor and recipient age per se were taken into account. Thus, giving older kidneys to older recipients is a common practice that does not improve overall graft survival.     

Expanding the donor pool: lung transplantation with donors 55 years and older

The scarcity of donor organs is one of the major limitations to lung transplantation. This has led to a progressive expansion of criteria for donor selection in lung transplantation. This study evaluated the outcome of recipients of lungs from donors >/=55 years. We performed a retrospective analysis of 212 consecutive lung transplantations. Recipients were divided into two groups, those receiving lungs from donors >/=55 years (older donor group) and those receiving lungs from donors <55 years (younger donor group). Recipient baseline characteristics, time in the intensive care unit (ICU), early mortality, and long-term survival (Kaplan-Meier) were compared between the groups. Forty-one donors (19%) were >/=55 years. Mean recipient age in the older donor group was higher than in the younger donor group (52 +/- 8 vs. 47 +/- 12 years; P = .015). Indication for transplantation did not differ between the groups. ICU stay was comparable between the two groups (6 +/- 12 vs. 7 +/- 11 days; P = .64). Actual 30-day mortality (10.8% vs. 6.4%; P = .32), 1-year mortality (17.1 vs. 19.6%; P = .50), and cumulative long-term survival (65% and 62% at 5 years, P = 1.00) did not differ between the older and younger donor group. This study indicated that transplantation of lungs from selected donors aged >/=55 years did not impair short-or long-term results. The use of lungs from elderly donors may help to increase the number of donor organs for lung transplantation.     

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (≤35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a ≥15% mean reduction in TC and a ≥50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P ≤0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperatively (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 ± 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m². This group was divided into patients whose weight remained stable (N = 54) and patients who regained ≥l5% of their lost weight or lost less than 50% of excess weight (N = 3 7). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining ≥15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.     

Clinicopathological characteristics of gastric carcinoma in young patients

Background and aims Gastric carcinoma is a common disease that usually affects older patients, rarely younger patients. Although the relationship between prognosis and the age of patients with gastric carcinoma is controversial, most investigators have suggested that young patients have a poorer prognosis. This study examined the clinicopathological features of young patients with gastric carcinoma.Patients and methods We retrospectively reviewed the hospital records of 1,833 patients with gastric carcinoma to compare the clinicopathological findings in young (aged <36 years) and older (aged 36 years) patients during the period 1988 to 1998 in a tertiary referral center in Gwangju City. Overall survival was the main outcome measure.Results Of the 1,833 patients, 137 (7.5%) were in the young age group. There were no significant differences in depth of invasion, lymph node invasion, hepatic metastasis, peritoneal dissemination, tumor stage or rate of curative resection. A significantly higher percentage of young patients had poorly differentiated histology (P=0.0001). The young patients with curatively resected gastric carcinoma had a better survival rate than young patients with non-resected gastric carcinoma (P<0.001). The 5-year survival rates of young and older patients did not differ statistically (39.6% vs 42.4%; P=0.254).Conclusion Young patients with gastric carcinoma do not have a worse prognosis than older patients. The important prognostic factor was whether the patients underwent curative resection.     

Heart transplantation in patients seventy years of age and older: A comparative analysis of outcome

OBJECTIVE: Advanced age has traditionally been considered a contraindication for heart transplantation because of the reported adverse effect of increased age on long-term survival. However, as the field of transplantation continues to evolve, the criteria regarding the recipient's upper age limit have been expanded and older patients are being considered as potential candidates. We analyzed the outcome of heart transplantation in patients 70 years of age and older and compared these results with those in younger patients (<70 years) over a 4-year period. METHOD: We retrospectively analyzed the results of 15 patients 70 years of age and older who underwent heart transplantation between November 1994 and May 1999 and compared them with results in 98 younger patients undergoing transplantation during the same period RESULTS: The older age group had a higher preoperative left ventricular ejection fraction (P =.02), higher incidence of female donors (P =.02), and longer cardiac allograft ischemic time (P =.01). No differences were found regarding incidence of diabetes mellitus, donor age, donor/recipient weight ratio, and mismatch (<0.80). The 30-day or to-discharge operative mortality was similar in both groups (0% in the older vs 5.1% in younger patients). Actuarial survival at 1 year and 4 years was not statistically different between the older and younger patients (93.3% +/- 6.4% vs 88.3% +/- 3.3% and 73.5% +/- 13.6% vs 69.1% +/- 5.8%, respectively). The length of intensive care unit stay and total post-transplantation hospital stay, incidence of rejection, and incidence of cytomegalovirus infection were similar between the groups. CONCLUSIONS: Heart transplantation in selected patients 70 years of age and older can be performed as successfully as in younger patients (<70 years of age) with similar morbidity, mortality, and intermediate-term survival. Advanced age as defined (> or =70 years) should not be an exclusion criterion for heart transplantation. The risks and benefits of transplant surgery should be applied individually in a selective fashion.