As the human lifespan increases and healthcare quality improves, more people are reaching an advanced age only to present with cardiac disorders that are usually treated uneventfully in young patients. The balance between enhanced initial risks and reduced eventual benefits in the elderly has often led to difficult medical decisions, and at times painful ethical and economical considerations.

Although there may be, on an individual basis, a substantial discrepancy between chronological and physiological age, the ability of elderly patients to withstand a major physiological insult such as cardiac surgery is reduced because of associated comorbidities, limited functional reserve of vital organs, and diminished defence and adaptation capacities. In the 1970s, an increase in mortality after cardiac surgery was apparent in patients older than 70 years. With the development of less traumatic heart–lung machines, more effective myocardial protection strategies, and improved perioperative care, mortality in the more robust patients—that is, the septuagenarians—dropped to levels of younger age groups.1Nowadays, the range of benefit of cardiac surgery remains narrow in patients 80 years of age or older, the age group discussed here.