There was a time, not long ago, when Sime Brkic, 80, of Mentor, Ohio, might have been denied a heart bypass surgery.
Not only would his octogenarian status have raised concerns, but he's missing a kidney, which also would've worried surgeons. Yet on January 27, he had a triple bypass and tricuspid valve repair. By mid-February he was home with his wife, Naba, yearning to get back to his pastimes.
The couple hail from Zadar, Croatia. English is not Sime's native language, so Naba translated as he explained he was looking forward to playing cards – Cassino is his game – and returning to the bocce courts with his friends. The oldest of their six grandchildren is engaged, and the couple is excited about attending the ceremony later this year.
"It's amazing. He's pretty good," Naba says. "He's just anxious waiting to feel better."
As recently as the early 2000s, some cardiologists believed heart bypasses were too risky for the 80-and-older set. Those days are gone. It's a more individualized decision today, based on how well the patient will tolerate the procedure. That can look very different from one person to the next.
"There's no golden number. There's no threshold, there's no cutoff that you can hang your decision on," says Faisal Bakaeen, MD, the Cleveland Clinic cardiothoracic surgeon who performed Sime Brkic's procedure and is director of the clinic's Coronary Artery Disease Center.
"It's like buying a car. You can buy a 2000 model with low mileage or buy a 2020 with high mileage, and maybe the 2000 would be a more robust and reliable car."
'Innovation Across the Board'
Perspectives have changed over the last couple of decades for a simple reason: Surgeons are getting better at coronary artery bypass grafting (CABG), the most common type of bypass, with roughly 200,000 performed in the U.S. annually.
CABG addresses ischemia, or lack of blood flow to the heart, by creating a detour around arteries that have been narrowed by plaque. The breastbone is often split to access the heart. Using a vein from the patient's arm, leg, or chest (the left internal thoracic artery in the chest works best), the surgeon "bypasses" the narrowed artery.
There are variations. Surgeons can stop the heart or keep it beating, do the surgery robotically, access the heart via "keyhole" cuts between the ribs, or use a hybrid approach employing stenting.
"When you have a bypass graft that's durable, not only does it take care of the current obstruction, but it also takes care of future obstructions," Bakaeen says, explaining patients still need to watch their cholesterol and embrace healthy lifestyles.
A retrospective study published in 2022 examined the outcomes of 1,283 octogenarians who had CABG at the Mayo Clinic over an almost 27-year span. Not only was their median survival time about a year and a half longer than the general 80-and-older population, but there was a marked improvement in success rates over 27 years. Where an average of 1 in 16 patients died or had a post-operative stroke in the study's first three years, the number dropped to about 1 in 63 over the final three years.
Everything about treating heart problems has improved, says Michael Nanna, MD, an interventional cardiologist and assistant professor of internal medicine at Yale School of Medicine. Not only are the procedures more refined and the surgeons more skilled, but the pre- and post-op care are better, as well as the medications used to target cholesterol, blood pressure, weight loss, inflammation, and blood clot prevention.
"I think it's innovation across the board. The tools in our toolkit are getting better," he says. "It's not just true for bypass."
Assessing the Patient
Sime Brkic's frightening episode began when Naba found him pale, sweating profusely, and a little confused. She worried he was having a stroke and called an ambulance. Bloodwork at the hospital pointed to multiple heart problems. He needed surgery. Doctors weren't overly concerned about Sime's age.
"Every doctor that saw him, they said he was in such good shape, they were not worried much," she says.
Sime's acute coronary syndrome had restricted blood flow, leading to a heart attack, Bakaeen says. He was otherwise fine. Even the missing kidney was "not life-limiting in any way" and he was not "deconditioned," a state of muscle weakness and low endurance that can come with kidney problems, the doctor says. His surgery and rehabilitation went smoothly, as expected.
As with other bypass patients, Bakaeen has encouraged Brkic to resume normal activities, but "no heavy lifting – moving couches or bench pressing, extreme exercise – for six to eight weeks. Other than that, I want them to be active. I want them to get back on their feet."
Heart disease is the No. 1 cause of death in the U.S. More than age, the question of overall strength or robustness drives surgeons' decisions on whether heart bypass is the right remedy. The surgeon assesses how well they feel the patient will endure the procedure and recovery process. Bakaeen says he doesn't want patients "too frail."
If the heart is the driving factor in someone's poor condition and repairing it will make them stronger, surgery is an option even at a relatively advanced age. For instance, doctors concluded Brkic's kidney issue wasn't making his condition worse, so it didn't bar him from bypass surgery. They also concluded Brkic's heart issues were largely responsible for his symptoms and that the surgery would likely restore him to a healthy state.
"He's recovering well. He's pretty much to the level before the surgery, and he is stronger," says Bakaeen, who regularly performs bypasses on octogenarians.
Geriatric Bypass Is Not Without Risk
There are still more risks for older patients compared to younger ones having bypasses. That's true for most invasive procedures.
One of those risks involves cognitive dysfunction, or a decline in mental skills, in older patients after cardiac surgery. Nanna says much of the research on it is dated and suffers from poor methodology or study design. He tells his patients that the risk of long-term impairment is low, and while short-term impairment is more common, "the majority recover completely and return to pre-surgery cognitive capacity in the intermediate to long term."
Bakaeen concurs that the worrying studies are of a "historic vintage" and advises patients that the risk of cognitive decline is low thanks to advances in heart-lung machines, anesthesia, and care before surgery, among other improvements.
Those who have obesity, diabetes, poor renal function, or kidney disease also face higher risks, as do smokers. Some demographic groups – namely women and African Americans – tend to have worse outcomes after bypass surgery. Both are underrepresented in clinical trials.
Women have a higher risk of bleeding due to smaller, more delicate blood vessels and more tissue around their heart and chest, which can complicate surgery. They're also typically referred for surgery at a later age, and their angina symptoms, which alert doctors to coronary artery disease, can be different than those for men.
Meanwhile, studies show African Americans have less access to minimally invasive procedures and modern circulatory support devices, and they're more likely to be treated in hospitals with higher mortality rates. A 2023 article in The Journal of Thoracic and Cardiovascular Surgery found they had lower odds of having CABG and worse outcomes, though the reasons "merit further investigation."
Adverse outcomes among African Americans can also be driven by "social determinants of health," Nanna points out. These can include poverty, education level, air and water quality, and access to affordable housing, insurance, healthy foods, and health care.
'Age Is Just a Number': The Risk-Benefit Calculation
This is why Nanna and Bakaeen believe that each patient must be considered individually, especially older patients who tend to have lower risk tolerances.
"It's about the risk and benefits to the individual patient and how that patient processes the risk-benefit calculation for themselves," Nanna says.
That's why biological or physiological "age" is a better guideline than chronological age, he says. Biological age considers risk factors, biomarkers, genetics, physical strength, balance, and cognitive function, along with other variables.
They "combine to sort of lead to how robust they may be for any invasive procedure," Nanna says. "It's best summarized by saying, 'Age is just a number.'"
Adds Bakaeen: "We do take age into consideration, but we really want to lay our eyes on that patient and see if they're low-mileage or at a stage in their lifespan where the stress of surgery will be too much."
