Aortic Valve Replacement and Coronary Revascularization in Extremes of Age: Long-Term Survival and Functional Recovery

Background Extreme age is often considered a relative contraindication to open sternotomy for cardiac surgical procedures. However, data on concomitant coronary artery bypass grafting (CABG) in nonagenarians undergoing surgical aortic valve replacement (SAVR) remain limited. Methods We reviewed 107 consecutive patients aged ≥90 years who underwent SAVR, with or without CABG, at Mayo Clinic between 1993 and 2025. Patients undergoing additional cardiac procedures (n = 17) were excluded. We compared 45 patients undergoing SAVR+CABG with 45 patients undergoing isolated SAVR. Survival was analyzed using Kaplan-Meier estimates, and heart failure–related readmissions were assessed using a Fine-Gray competing risk model. Quality of life was assessed at 3 and 5 years postoperatively using structured self-reported physical activity surveys. Results Median age was 91.9 years (interquartile range, 90-93 years), and 47.8% were women. Median Society of Thoracic Surgeons predicated risk of morality was 9.6% (interquartile range, 7%–13%). Bypass and cross-clamp times were longer in the SAVR+CABG group ( P < .001), and the left internal mammary artery was used in 57.8% (n = 26) of CABG cases. Mortality at 30 days was 2.2% in SAVR+CABG vs 6.7% in isolated SAVR ( P = .616). Overall 5-year survival was 43.1% (95% CI, 33%-54%), and heart failure–related readmissions were similar between groups ( P = .66). At 3 years, 26 survey respondents reported physical activity levels equal to or exceeding age-matched peers; at 5 years, 25 (78.9%) maintained comparable or higher functional levels. Conclusions In selected nonagenarians, isolated SAVR, with or without CABG, can be performed with acceptable perioperative risk and durable functional outcomes, challenging the notion that extreme age alone is a contraindication to aortic valve intervention.