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eComment. Should we operate on nonagenarians in the transcatheter aortic valve implantation era?

With the increasing age of the general population, the necessity for cardiac surgery in nonagenarians is also increasing, and this population shows a high incidence of degenerative calcific aortic stenosis (AS). Thus, cardiovascular surgeons are faced with the fact that an increasing number of very elderly patients are referred for aortic valve replacement (AVR). However, decision-making on nonagenarians is difficult due to the lack of clinical experience or evidence-based results upon which to develop optimal treatment alternatives. It should be based on careful assessment of the wishes of the patient and family, the relative medical risks and benefits, and the economic costs of the alternatives [1–3]. 
 
I read with great interest the article by Assmann and colleagues [4]. The authors have shared with us their results of 49 consecutive cardiac surgical operations in nonagenarians. They reported a remarkable postoperative morbidity and an overall in-hospital mortality of 10%, including 13% in the AVR subgroup. I fully agree with their conclusions regarding nonagenarians and would also like to add a brief comment on this topic. 
 
Owing to improvements in preoperative and postoperative care, AVR in selected nonagenarians may be performed with an acceptable mortality. Age itself should not be a contraindication to surgery or an indication for transcatheter aortic valve implantation (TAVI). The choice of therapeutic plan for those patients justifies a multidisciplinary approach. 
 
Today, approximately one-third of elderly patients with severe AS are not referred for surgery because of the high perioperative risk perceived by both patients and physicians. Recently, TAVI as an alternative modality to surgery has emerged in these high-risk patients. However, the safety and effectiveness of TAVI in nonagenarians has not been fully elucidated [5]. Furthermore, TAVI is associated with a higher incidence of major stroke, atrioventricular conduction system injury and major vascular complications. 
 
Although AVR in nonagenarians can be performed successfully in selected patients, increased mortality and morbidity rates, as well as prolonged length of stay, are associated with this age group [1, 2]. In the literature, reported morbidity rates are as high as 100%, and mortality is reported to range between 7% and 18% [1–3]. Edwards and Taylor [2] reported that in 35 nonagenarians who had undergone AVR, there was an apparent significantly higher risk of early mortality (17%) and morbidity (77%). The most recent study on nonagenarians by Easo et al. [3] showed an in-hospital mortality of 17.6% and a postoperative morbidity of 58%. 
 
In this age group, careful preoperative clinical evaluation combined with the use of risk scoring enables an adequate selection of low-risk patients who are suitable candidates for AVR, with excellent outcomes [3]. 
 
In recent years, economic considerations (scarce health care resources) and ethical factors have also come to play an important role in the decision-making regarding surgical AVR in nonagenarians. 
 
In summary, I think that by using appropriate selection criteria, AVR may be performed successfully in nonagenarians without prohibitive cost and with acceptable long-term survival and quality of life. It would therefore seem reasonable to operate on nonagenarians. 
 
Conflict of interest: none declared