Older, active, and opting for heart surgery

There was, Anne Casali decided, simply no other option. Her heart had begun to betray her, so she would have surgery to fix it, even at her age -- 90.

To do otherwise would mean abandoning the life that defined and sustained her: jaunts through her Longmeadow neighborhood, hours spent selling lace on the Internet, afternoons brewing batches of savory spaghetti sauce in the kitchen.

"I'm very, very active, and I cannot see sitting still, biding time," said Casali, diagnosed with aortic stenosis, stiffening of a valve that channels blood through the heart. "They told me if I didn't have this surgery, I would have to sit still all day and that's not me. That's not me at all."

So, Casali was wheeled into Operating Room 37 at Brigham and Women's Hospital , where she got a new valve made of cow tissue, and joined the expanding ranks of patients undergoing heart surgery well into their 80s and beyond.

Two decades ago, few if any cardiac surgeons would have risked operating on a patient as old as Casali. She would have received orders to head home and take it easy, commencing a gentle slide toward death as a worn-out valve robbed her of breath and mobility.

But from 1997 to 2004, federal figures show, heart valve surgery in patients 85 and older rose by 34 percent. The number of procedures to clear arteries -- called angioplasty -- more than doubled, from about 11,600 a year to more than 26,000 annually.

This dramatic shift reflects a confluence of medical and social forces: Surgery has become less invasive and technology more precise. Powerful medications such as statins have delayed the arrival of serious heart problems until patients are older. As the population has aged, personal and societal expectations about how the later years of life should unfold have changed radically.

Former President Gerald R. Ford , underwent angioplasty at 93, a few months before his death, and a year ago, pioneering heart surgeon Michael E. DeBakey had surgery at the age of 97 to patch his aorta.

"There's this group of elderly people who are really sharp, really well-preserved," said Dr. Lawrence H. Cohn , the Brigham surgeon who successfully replaced Casali's heart valve last summer. "But you just can't do business as usual with this super-elderly group -- you've got to minimize the trauma and maximize the recovery."

To be sure, neither the elderly nor their physicians enter into surgery lightly, said Dr. Frank Sellke, chief of cardiothoracic surgery at Beth Israel Deaconess Medical Center.

Older patients have less capacity than younger ones to bounce back from the rigors of surgery. Their kidneys don't work as well, and they tend to bleed more. Studies show that octogenarians are more likely to suffer serious complications or die after cardiovascular procedures than younger patients, although those same studies have concluded that the risks are not unacceptably high.

"Where a younger person could tolerate the complications from a procedure, things can really spiral downward pretty quickly in an older person," said Dr. Deepak Bhatt , an interventional cardiologist at Cleveland Clinic. "In an older person, it only takes one thing to go wrong and things can snowball and the person doesn't recover."

Even with more heart operations among the advanced elderly, they constitute only a small fraction of the total number of cardiac surgery patients. For example, nearly 90,000 US patients underwent heart valve surgery in 2004, but only 3,700 were 85 and older.

Specialists expect the number to increase, especially with the aging of the baby boomers, a generation less willing than its forebears to accept the limitations of growing old. And as the demand for expensive heart procedures intensifies -- valve replacement surgery costs about $50,000 -- so, too, will questions about the ethics and economics of who should get medical services.

"Should age itself ever be an exclusion criteria? There really is no specific answer to that," said George Annas , who specializes in medical ethics at Boston University. "Is there a limit on what percentage of our gross domestic product we can spend on our medical care? Right now, the answer looks like no. One other way to ask that is: Is there anything more important than life and health?"

Heart disease remains the nation's number one killer, and even among robust elderly people, the heart and its vessels show the strain of years of wear and tear.

A decade ago, replacing a valve or undergoing bypass surgery almost always meant a surgeon had to saw apart the whole length of a patient's breast plate, a traumatic operation ending in a protracted, painful recovery. And anesthesia wasn't as gentle: "The older agents were much more toxic, more likely to damage the kidney or the liver, especially in older and more fragile people," said Dr. Steven Nissen , chief of cardiovascular medicine at Cleveland Clinic.

Now, surgeons can use less invasive techniques. Instead of cracking open the whole sternum, they make a 3- to 4-inch incision, just big enough to snip out a faulty valve, and replace it with a new one. High-tech medical snapshots allow surgeons to see if the valve is in the right place and functioning.

Still, surgeons won't operate on patients with Alzheimer's disease or terminal cancer, for example. If a patient is incapable of appreciating an enhanced quality of life, or destined to die soon from another condition, then it is neither ethically nor economically appropriate to repair their hearts, doctors said.

"You have to do the right thing," said Dr. Richard Shemin , chief of cardiothoracic surgery at Boston Medical Center . "Sometimes, you'll get focused on wanting to treat the disease and not focusing on the whole person. Sometimes, you have to let nature take its course."

Two cases illustrate the point.

At 95, Doris Blum, enduring a thickened heart valve and a blocked artery, spoke to Dr. Cohn, who grew up down the street from her in San Francisco.

He evaluated Blum. Other than her heart condition, she had no serious medical problems, and her mind was crystal clear.

"Do you say [to patients], 'You're 95 years old, we're going to throw you on the garbage heap?' " Cohn said.

If you want the surgery, he told her, you should have it.

"Because I'm 95 years old, it took a few minutes to make the decision," Blum said last month by telephone from her home on San Francisco's Nob Hill. "It was a clear-cut analysis of the problem -- if they didn't proceed with surgery, the ultimate result would be complete invalidism that would last maybe a year at the most.

"I gave it the consideration necessary and I decided that I was going to proceed with the plans for surgery. And that's what I did."

The surgery was Dec. 26. Three weeks later, Blum was out on the town for dinner with her sons.

Boston Medical's Shemin confronted a dramatically different type of patient in late January.

The 87-year-old woman was referred to him with a diagnosis of a single faulty valve. But on the same day surgery was scheduled, specialists discovered the patient actually had two defective valves, a third that was leaking, and other woes.

"I told her the easiest thing for me to do would be to take her to the operating room and perform the technical maneuvers of the operation," Shemin said.

Instead, he consulted with the patient and her three daughters and, jointly, they decided that because of the risk of complications and the likelihood of a prolonged recovery, the woman would forgo surgery.

Stephen Smith can be reached at stsmith@globe.com.