The prevalence of renal failure after cardiac operation varies from 2% to 15%, depending on the procedure and degree of preoperative renal dysfunction [23]. If it occurs, the mortality rate may be as high as 80%. Because the elderly have lower baseline glomerular filtration rate, are likely to have hypertension and an altered renal autoregulatory curve, and are more likely to have diabetes mellitus, they are at a higher risk of renal failure than their younger counterparts. The use of preoperative diuretics for those with depressed ejection fraction and radiopaque dyes often worsens preoperative renal function . Unfortunately, there has been no large investigation regarding the prevention of renal dysfunction in the elderly patient undergoing CPB. The most important principle might be that recovery of renal function after bypass is directly related to the recovery of cardiac function.

CPB provides many alterations to the normal physiologic milieu. The optimal mean arterial pressure, perfusion flow, mode of perfusion (pulsatile versus nonpulsatile), pH and CO₂ management, temperature, and hematocrit have not been established for the elderly patient undergoing CPB. As previously mentioned, aortic cannula sites should be carefully chosen with the assistance of epiaortic ultrasound scanning to minimize embolized atheromatous debris. Perfusion flows range from 1.2 to 2.4 L/min/m², with perfusion pressures varying from 30 to 80 mm Hg. No difference in outcomes has been demonstrated for flows within this range or for pulsatile versus nonpulsatile flows. Temperature management for CPB should be dictated by institutional preference. Grigore et al. demonstrated no difference in postoperative cognitive function between patients who underwent hypothermic CPB (30°C) versus normothermic CPB (35°C) [50].

The optimum hematocrit while on CPB and immediately after for the elderly patient has not been determined. The absolute safe level will depend on many variables, including adequacy of myocardial revascularization, myocardial function, and, possibly, the age of the patient. The adequacy of tissue oxygenation and perfusion as determined by the mixed venous oxygen saturation determines transfusion in most centers. Blood-sparing strategies such as cell salvage techniques and retrograde autologous prime should routinely be used to conserve hematocrit and decrease the need for transfusion. The elderly might be a group for whom a higher hematocrit is beneficial. Mathew et al. demonstrated that profound hemodilution (hematocrit 15–18%) during CPB was associated with a decline in cognition 6 weeks postoperatively [51]. However, transfusion delivers new risks, most of which are related to the inflammatory response. Increased sternal wound infection, longer intensive care unit stays, and increased renal failure associated with blood transfusion should be weighed against evidence of poor tissue oxygen delivery.

The ideal anesthetic for cardiac surgery in the elderly provides hemodynamic stability, amnesia, analgesia, organ protection, and the ability for rapid emergence postoperatively. Although numerous studies have attempted to demonstrate the superiority of specific agents with mixed results, there are several key trends in the literature that are shaping current practice. The use of benzodiazepines for sedation should be minimized and/or avoided due to their association with postoperative delirium [52]. Dexmedetomidine should be used for postoperative sedation. When initiated in the post-CPB period, a dexmedetomidine infusion is associated with decreased delirium, postoperative atrial fibrillation , time to extubation, and mortality [53–56]. However, due to its lack of amnestic properties, volatile anesthesia should be continued until the procedure is complete and neuromuscular blockade has been reversed.

With admittedly little scientific evidence to support some of their assertions, some authors empirically recommend the following: [1] alpha-stat blood gas management, [2] higher perfusion pressures throughout the perioperative period, [3] higher mean arterial pressures while on CPB, [4] higher hematocrit before termination of CPB (>24%), [5] selection of the aortic cannulation site with the assistance of epiaortic ultrasound scanning, [6] the use of cerebral oximetry in high-risk patients, [7] avoidance of benzodiazepines, and [8] the use of dexmedetomidine for postoperative sedation.

The incidence of abdominal aortic aneurysm (AAA) in the United States is approximately 55,000 per year with an average age at presentation of 72.3 years [57]. An analysis of 25,576 patients from the NSQIP database revealed an annual increase in 30-day mortality of 6% for open repair (OAR) and 4% for endovascular repair (EVAR) for each year increase in patient age [58]. In the randomized EVAR 1 trial, in which the average age at intervention was 74 years, EVAR was associated with less 30-day mortality than OAR (1.8% vs 4.3%) [59]. In patients ≥80 years old, the early postoperative survival benefit of EVAR vs. OAR is even more pronounced (30-day mortality 2.3% vs. 8.6%) [60]. Due to the early survival benefit, EVAR has become the treatment of choice for AAA in the elderly population [61]. Complex -juxtarenal aneurysms involving mesenteric and renal vessels are now repaired using endografts. A pooled analysis of 1725 patients undergoing juxtarenal AAA repair using open, fenestrated endovascular, or chimney endovascular technique showed no difference in 30-day mortality, although, open repair was associated with increased renal complications and chimney repair with increased stroke rate [62]. Due to the expanded use of endovascular repair techniques, regional and local anesthesia are now options for AAA repair. While randomized controlled trials do not exist comparing regional (RA), local (LA), and general anesthesia (GA) for EVAR, several retrospective studies have investigated this topic. An analysis of 1261 patients in the ENGAGE registry revealed no difference in perioperative morbidity and mortality among the three groups. Patients who received RA and LA had shorter procedure times and decreased ICU admission and hospital length of stay. Although patients with higher ASA classification were more likely to receive GA possibly confounding these results [63]. The choice of anesthetic technique should be based on patient comorbidities, the complexity and duration of the procedure , and the experience of the surgical and anesthesia teams.

Due to the curative intent of surgical resection for lung cancer, age alone should not be a factor in evaluating a patient’s surgical candidacy. Elderly patients should undergo risk stratification based on pulmonary function testing, cardiopulmonary reserve, and other comorbidities [64]. Recent analysis of the NSQIP database identified increasing age as a risk factor for increased complications and mortality following lobectomy [65]. There are evidence-based perioperative management strategies to reduce the rate of postoperative pulmonary complications. One lung ventilation (OLV) and surgical manipulation increase the risk of acute lung injury (ALI) during lung resection surgery. Protective lung ventilation strategies can reduce the rate of ALI during lung resection surgery. The use of low tidal volumes (<8 ml/kg), limiting peak inspiratory pressure (<35 cm H₂O), using PEEP (4–10 cm H₂O), and frequent recruitment maneuvers resulted in decreased incidence of ALI, atelectasis, and ICU admissions [66]. Additionally the use of volatile anesthetics versus propofol during single-lung ventilation may be protective against ALI. A meta-analysis of eight randomized controlled trials encompassing 365 patients undergoing OLV demonstrated that volatile anesthetics were associated with decreased pulmonary complications and shorter hospital length of stay [67]. Intraoperative fluid management also plays a role in preventing postoperative pulmonary complications. The link between excessive fluid administration and pulmonary complications was first described by Zeldin et al. in 10 patients following pneumonectomy [68]. Similar results have described following less extensive resections [69, 70]. Current best practice dictates limiting fluid administration to <2 L in the intraoperative and early postoperative periods [71]. Pain control is another area in which anesthesiologists can positively impact outcomes following lung resection surgery. Multiple studies have demonstrated the benefits of regional anesthesia in preventing postoperative pulmonary complications following thoracotomy [72, 73]. Additionally, several studies have demonstrated paravertebral blockade can decrease postoperative pain scores following video-assisted thoracic surgery [74, 75]. Regional analgesia, thoracic epidural or paravertebral block , should be offered to all patients without contraindications undergoing thoracic surgery.

Although advancements have been made in caring for elderly patients with cardiothoracic and vascular disease, there are still important questions to be answered. One high interest area of active research is the utility of the percutaneous procedures discussed above in different patient populations. There is an ongoing research evaluating TAVR in low-risk patients. MitraClip is being evaluated for the treatment of functional MR. Randomized controlled trials are being conducted evaluating cerebral oximetry treatment algorithms and their subsequent impact on cardiac surgical outcomes.