Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy

Role of Transcranial Doppler in Cardiac Surgery Patients

Abstract

Purpose of Review

This review discusses applications of transcranial Doppler (TCD) in cardiac surgery, its efficacy in preventing adverse events such as postoperative cognitive decline and stroke, and its impact on clinical outcomes in these patients.

Recent Findings

TCD alone and in combination with other neuromonitoring modalities has attracted attention as a potential monitoring tool in cardiac surgery patients. TCD allows not only the detection of microemboli and measurement of cerebral blood flow velocity in cerebral arteries but also the assessment of cerebral autoregulation.

Summary

Neuromonitoring is critically important in cardiac surgery as surgical and anesthetic interventions as well as several other factors may increase the risk of cerebral embolization (gaseous and particulate) and cerebral perfusion anomalies, which may lead to adverse neurological events. As an experimental tool, TCD has revealed a possible association of poor neurological outcome with intraoperative cerebral emboli and impaired cerebral perfusion. However, to date, there is no evidence that routine use of transcranial Doppler can improve neurological outcome after cardiac surgery.

Morbidity and Mortality in Patients 70 Years of Age and Over Undergoing Isolated Coronary Artery Bypass Surgery

Background and aim: Due to the constantly improving results of surgical revascularization for coronary heart disease even the elderly patients are offered more frequently this type of treatment. Since older age is a harbinger of reduced vital capacity and increased morbidity the results of coronary artery bypass grafting (CABG) in elderly as well as long-term benefit deserve a careful examination. Materials and methods: 1475 isolated CABG procedures performed between 1995 and 1997 in a university hospital cardiac surgery unit, divided in group I (age below 70, n = 1324) and group II (age 70 and over, n=151). A retrospective analysis of pre-operative, peri-operative and post-operative data. Results: Significant differences (lower BMI and BSA, advanced NYHA and CCS stage, higher prevalence of diabetes, renal dysfunction and extracardial atherosclerotic lesions) were found in elderly. CABG was performed in both groups with no differences in technique of procedure (only slightly longer duration of CPB in group II). However, there was markedly higher mortality (2.3 vs. 7.3 %, p < 0.005), incidence of NearMiss+ (18.4 vs. 36.4 %, p < 0.005) and post-operative morbidity (34.6 vs. 56.3 %, p < 0.005) in the older group, which was also expressed in a longer ICU stay and postoperative hospitalization. Conclusion: Coronary revascularization can be performed in elderly with higher but still acceptable risk. Higher mortality and associated morbidity is caused by higher preoperative prevalence of known risk factors as well as generally reduced vital capacity. Surgical procedure should not be denied to elderly population because of the age alone but a careful evaluation of an individual patient is required.

Effects of age on systemic inflamatory response syndrome and results of coronary bypass surgery

Background

Coronary artery bypass (CAB) surgery triggerssystemic inflammatory response syndrome (SIRS) via severalmechanisms. Moreover, age is directly correlated with SIRS.We evaluated the effect of age on SIRS and postoperativeoutcome after CAB surgery.

Methods

We retrospectively reviewed the records of 229 patients who had undergone CAB surgery. The patients were divided into three groups according to age: group 1, < 40 years (n = 61); group 2, 40–75 years (n = 83); and group 3, > 75 years old (n = 85). Pre- and peri-operative data were assessed in all patients. SIRS was diagnosed according to the criteria established by Boehme.

Results

The average pre-operative EuroSCORE value in group 3 was higher than in the other groups and body surface areas were significantly lower in group 3 than in the other groups (p < 0.05). The postoperative SIRS rates were 68.9% in group 1, 84.3% in group 2 and 91.8% in group 3 (group 1 vs group 3; p < 0.05). Mortality rates were not significantly different between the groups (p > 0.05). The predictive factors for SIRS were age, EuroSCORE rate, on-pump CAB surgery and intra-aortic balloon pump use.

Conclusion

Age was an important risk factor for SIRS during the postoperative period after CAB.

Coronary Bypass Surgery in Patients Aged 70 Years and Over: Mortality, Morbidity, Length of Stay and Hospital Cost

The objective of this investigation was to compare the outcome of isolated coronary artery bypass grafting surgery in patients ≥ 70 years with those < 70. The cardiac surgery database of the Institute was used to obtain the characteristics of patients undergoing coronary artery bypass grafting between January 2000 and September 2001. The patients were divided into those ≥ 70 years of age and those < 70 years old. A Parsonnet risk score was determined for each patient for the analysis of mortality, length of stay and hospital charges. During the study period, 1594 cases of isolated coronary artery bypass grafting were carried out. 184 (11.5%) cases were performed in the older group. The 30-day mortality for patients aged 70 and over was 7 (3.3%) out of 184 while that of patients < 70 years of age was 47 (3.8%) out of 1410 ( p < 0.740). The overall hospital mortality was 10 (5.4%) of 184 and 53 (3.8%) of 1410 ( p < 0.272) respectively. Apart from a higher incidence of wound infection in elderly patients, the frequency of other major complications was comparable in both groups. The average length of postoperative stay for the elderly patients was 10.4 ± 0.9 days compared to 8.7 ± 0.2 days for the younger group ( p < 0.049). The mean hospital charge in patients ≥ 70 was RM 25,160.38 ± 1656.75 whereas for patients < 70, it was RM 21,801.47 ± 308.91 ( p < 0.048). This study supports the continued performance of coronary artery bypass grafting in patients ≥ 70 years. Advanced age alone should not deter a cardiac surgeon from offering such a potentially beneficial intervention.

Off-Pump Coronary Artery Bypass Surgery

Off-pump coronary artery bypass surgery has been adopted enthusiastically worldwide. However, despite more than 6 years’ experience and refinement, many surgeons use it only sporadically and some hardly at all. This reluctance persists despite support for the procedure because of the lack of properly designed risk models and/or randomized studies. Although it has not been overwhelmingly shown that off-pump surgery is superior to the conventional on-pump procedure, the technique has its place in our specialty. It has been shown to be better for noncritical end points in selected patients in the hands of selected surgeons. That there are differences in surgical skill among surgeons is something we all know but rarely discuss in public. Until now, disparities in skill have been most salient with uncommon and extraordinarily challenging operations. Perhaps the off-pump procedure should be regarded as the “challenging” aspect of coronary artery bypass surgery, and self-restraint may need to remain in force if we are to continue to achieve the highest level of clinical excellence.

In-hospital resource utilization in surgical and transcatheter aortic valve replacement

Background

Little is known about preoperative predictors of resource utilization in the treatment of high-risk patients with severe symptomatic aortic valve stenosis. We report results from the prospective, medical-economic “TAVI Calculation of Costs Trial”.

Methods

In-hospital resource utilization was evaluated in 110 elderly patients (age ≥ 75 years) treated either with transfemoral (TF) or transapical (TA) transcatheter aortic valve implantation (TAVI, N = 83), or surgical aortic valve replacement (AVR, N = 27). Overall, 22 patient-specific baseline parameters were tested for within-group prediction of resource use.

Results

Baseline characteristics differed between groups and reflected the non-randomized, real-world allocation of treatment options. Overall procedural times were shortest for TAVI, intensive care unit (ICU) length of stay (LoS) was lowest for AVR. Length of total hospitalization since procedure (THsP) was lowest for TF-TAVI; 13.4 ± 11.4 days as compared to 15.7 ± 10.5 and 21.2 ± 15.4 days for AVR and TA-TAVI, respectively. For TAVI and AVR, EuroScore I remained the main predictor for prolonged THsP (p <0.01). Within the TAVI group, multivariate regression analyses showed that TA-TAVI was associated with a substantial increase in THsP (55 to 61 %, p <0.01). Additionally, preoperative aortic valve area (AVA) was identified as an independent predictor of prolonged THsP in TAVI patients, irrespective of risk scores (p <0.05).

Conclusions

Our results demonstrate significant heterogeneity in patients baseline characteristics dependent on treatment and corresponding differences in resource utilization. Prolonged ThsP is not only predicted by risk scores but also by baseline AVA, which might be useful in stratifying TAVI patients.

Trial registration

German Clinical Trial Register Nr. DRKS00000797

Does quality of life improve in octogenarians following cardiac surgery? A systematic review

OBJECTIVES

Current outcome measures in cardiac surgery are largely described in terms of mortality. Given the changing demographic profiles and increasingly aged populations referred for cardiac surgery this may not be the most appropriate measure. Postoperative quality of life is an outcome of importance to all ages, but perhaps particularly so for those whose absolute life expectancy is limited by virtue of age. We undertook a systematic review of the literature to clarify and summarise the existing evidence regarding postoperative quality of life of older people following cardiac surgery. For the purpose of this review we defined our population as people aged 80 years of age or over.

METHODS

A systematic review of MEDLINE, EMBASE, Cochrane Library, trial registers and conference abstracts was undertaken to identify studies addressing quality of life following cardiac surgery in patients 80 or over.

RESULTS

Forty-four studies were identified that addressed this topic, of these nine were prospective therefore overall conclusions are drawn from largely retrospective observational studies. No randomised controlled data were identified.

CONCLUSIONS

Overall there appears to be an improvement in quality of life in the majority of elderly patients following cardiac surgery, however there was a minority in whom quality of life declined (8-19%). There is an urgent need to validate these data and if correct to develop a robust prediction tool to identify these patients before surgery. Such a tool could guide informed consent, policy development and resource allocation.

Clinical results of cardiovascular surgery in the patients older than 75 years

BACKGROUND

The balance of the risks and the benefits of cardiac surgery in the elderly remains a major concern. We evaluated the early and mid-term clinical results of patients aged over 75 years who underwent major cardiovascular surgery.

METHODS

Two hundred and fifty-one consecutive patients, who underwent cardiac surgery at Seoul National University Bundang Hospital between July 2003 and June 2011, were included in this study (mean age, 78.7±3.4 years; male:female=130:121). Elective surgery was performed in 112 patients, urgent in 90, and emergency in 49.

RESULTS

Early mortality was 12.7% (32/251). Follow-up completion was 100%, and the mean follow-up duration was 2.8±2.2 years. Late mortality was 24.2% (53/219). There were 283 readmissions in a total of 109 patients after discharge. However, the reason for readmission was related more to non-cardiac factors (71.3%) than to cardiac factors. The overall survival estimates were 79.2% at the 1-year follow-up and 58.4% at the 5-year follow-up. Patients who underwent elective surgery had a lower early mortality rate (elective, 4.5%; urgent, 13.3%; emergency, 30.6%) and better overall survival rate than those that underwent urgent or emergency surgery (p <0.001).

CONCLUSION

The timing of cardiac surgery was found to be an independent risk factor for early and late mortality. Thus, earlier referral and intervention may improve operative results. Further, comprehensive coordinated postoperative care is needed for other comorbid problems in aged patients.

The validity of the VA surgical risk tool in predicting postoperative mortality among octogenarians

BACKGROUND

To examine the validity of Veterans Affair-VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians.

METHODS

This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions.

RESULTS

There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 ± .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 ± .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days.

CONCLUSIONS

VA risk tool predicted both perioperative and overall mortality. Relatively strong power of this tool in predicting overall mortality may be unique to this age group because of their advanced age.

Preoperative renal dysfunction and clinical outcomes of cardiac surgery in octogenarians

BACKGROUND

The proportion of elderly individuals is growing and the prevalence of chronic kidney disease (CKD) among elderly people undergoing cardiac surgery is increasing constantly. The aim of this study was to determine the influence of different degrees of preoperative renal dysfunction on postoperative outcomes in patients older than 80years of age.

METHODS

This is an observational study that included adult patients undergoing cardiac surgery in which data were collected prospectively. Patients were divided into groups according to their preoperative plasma creatinine and eGFR levels.

RESULTS

From February 1997 to January 2010, 318 octogenarians underwent cardiac surgery. Of these, 140 patients (44%) had abnormal preoperative creatinine levels. A significantly higher incidence of postoperative sepsis (4% vs. 17%, p 0.03), CVA (1% vs. 6%, p 0.03), and prolonged hospital stay (16±13 vs. 20±16days, p 0.04) were detected in patients with preoperative kidney dysfunction. Subgroup analysis revealed that preoperative CKD stage IV (eGFR 15-30ml/min/1.73m(2)) but not CKD stage III (eGFR 30-60ml/min/1.73m(2)) and preoperative creatinine >1.8mg/dl were independently associated with increased incidence of postoperative CVA (OR 4; 95% CI 0.07-0. 8, p=0.05 for eGFR, and OR 7.8; 95% CI 1.2-60, p=0.003 for creatinine). However, no significant increment in postoperative mortality with decreasing eGFR or increasing preoperative creatinine was demonstrated.

CONCLUSIONS

A substantial increase in the risk of postoperative CVA and sepsis, but not mortality, was demonstrated in octogenarians with advanced but not mild degrees of preoperative CKD. Compared to younger patients, a high burden of comorbidities in octogenarians may have a greater influence on outcomes post cardiac surgery than impaired renal function. Our data may provide a rationale for modified risk stratification in octogenarian candidates for cardiac surgery.

Coronary artery surgery in octogenarians: evolving strategies for the improvement in early and late results

The purpose of this study was to investigate retrospectively early and late outcomes of coronary artery bypass grafting (CABG) in a large series of octogenarians. We retrospectively reviewed the data of 241 octogenarian patients who underwent CABG between April 2002 and April 2009 at our institution. Mean age was 84.7 ± 1.8 years. Patients affected by concomitant coexistent organic aortic, mitral, or tricuspid valve disease were excluded from the study. Patients with functional secondary ischemic mitral incompetence were included in the study. The majority of the patients were male. Angina pectoris functional class III/IV accounted for 164 patients (68%). Left ventricular ejection fraction ≤35% was diagnosed in 38 patients (15.8%). Early mortality rate was 5.8% (14 patients). Causes of death were cardiac related in 10 patients. Preoperative independent predictors of in-hospital mortality obtained with multivariate analysis were extracardiac arteriopathy, New York Heart Association class III/IV, and previous percutaneous transluminal coronary angioplasty (PTCA). The overall mean follow-up was 41.6 ± 25.9 months (range 1-87.6 months). Among the 222 contacted survivors, there were 16 (7.2%) deaths during the follow-up. The actuarial survival was 91.9% at 1 year and 83.5% at 5 years. On multivariate analysis, time to late death was adversely affected by preoperative extracardiac arteriopathy and previous PTCA. Advanced age alone should not be a deterrent for CABG if it has been determined that the benefits outweigh the potential risk. A careful selection of optimal candidates, based on the evaluation of their systemic comorbidities, appears mandatory in order to obtain the greatest benefit for these high-risk patients.

Critical analysis of early and late outcomes after isolated coronary artery bypass surgery in elderly patients

BACKGROUND

The proportion of elderly (≥80 years) patients undergoing coronary artery bypass surgery (CABG) is increasing.

METHODS

A retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program between June 2001 and December 2009 was performed. Isolated CABG was performed in 21,534 patients; of these, 1,664 (7.7%) were at least 80 years old (group 1). Patient characteristics, morbidity, and short-term mortality of these patients were compared with those aged less than 80 years (group 2). The long-term outcome of group 1 patients after CABG surgery was compared with an age and sex-matched Australian population.

RESULTS

Patients over 80 years old were more likely to be female (36.6% vs 17.3%, p < 0.001) and presented significantly more often with heart failure, hypertension, and triple-vessel disease (all p < 0.05). The 30-day mortality was higher in group 1 patients (4.2% vs 1.5%, p < 0.001). Group 1 patients also had an increased risk of complications, including prolonged (>24 hours) ventilation (14.2% vs 8.2%, p < 0.001), renal failure (7.3% vs 3.4%, p < 0.001), and mean intensive care unit stay (60.7 vs 42.5 hours, p < 0.001). The 5-year survival of elderly patients (73%) was comparable with the age-matched Australian population. Independent risk factors for 30-day mortality in group 1 patients included preoperative renal failure (p = 0.010), congestive heart failure (p = 0.014), and a nonelective procedure (p = 0.016).

CONCLUSIONS

Elderly patients who undergo isolated CABG have significantly lower perioperative risks than have been previously reported. The long-term survival of these patients is comparable with an age-adjusted population.

Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic valve stenosis

OBJECTIVE

The presence of pulmonary hypertension historically has been considered a significant risk factor affecting early and late outcomes after valve replacement. Given the number of recent advances in the management of pulmonary hypertension after cardiac surgery, a better understanding of its impact on outcomes may assist in the clinical management of these patients. The purpose of this study was to determine whether pulmonary hypertension remains a risk factor in the modern era for adverse outcomes after aortic valve replacement for aortic valve stenosis.

METHODS

From January 1996 to June 2009, a total of 1080 patients underwent aortic valve replacement for primary aortic valve stenosis, of whom 574 (53%) had normal systolic pulmonary artery pressures (sPAP) and 506 (47%) had pulmonary hypertension. Pulmonary hypertension was defined as mild (sPAP 35-44 mm Hg), moderate (45-59 mm Hg), or severe (≥ 60 mm Hg). In the group of patients with pulmonary hypertension, 204 had postoperative echocardiograms.

RESULTS

Operative mortality was significantly higher in patients with pulmonary hypertension (47/506, 9%, vs 31/574, 5%, P = .02). The incidence of postoperative stroke was similar (P = .14), but patients with pulmonary hypertension had an increased median hospital length of stay (8 vs 7 days, P = .001) and an increased incidence of prolonged ventilation (26% vs 17%, P < .001). Preoperative pulmonary hypertension was an independent risk factor for decreased long-term survival (relative risk 1.7, P = .02). Those with persistent pulmonary hypertension postoperatively had decreased survival. Five-year survival (Kaplan-Meier) was 78% ± 6% with normal sPAP and 77% ± 7% with mild pulmonary hypertension postoperatively, compared with 64% ± 8% with moderate and 45% ± 12% with severe pulmonary hypertension (P < .001).

CONCLUSIONS

In patients undergoing aortic valve replacement, preoperative pulmonary hypertension increased operative mortality and decreased long-term survival. Patients with persistent moderate or severe pulmonary hypertension after aortic valve replacement had decreased long-term survival. These data suggest that pulmonary hypertension had a significant impact on outcomes in patients undergoing aortic valve replacement and should be considered in preoperative risk assessment.

In-hospital complications after transcatheter aortic valve implantation revisited according to the Valve Academic Research Consortium definitions

OBJECTIVES

To determine the occurrence of in-hospital complications after transcatheter aortic valve implantation (TAVI) according to the Valve Academic Research Consortium (VARC) criteria in addition to the length of stay (LOS).

BACKGROUND

The absence of uniformity in endpoint definitions challenges the comparison between previously reported major adverse cerebro- and cardiovascular event rates after TAVI. To address this, in 2009, the VARC was established aiming to provide standardized endpoint definitions for TAVI clinical trials.

METHODS

Between November 2005 and September 2010, we prospectively enrolled 150 consecutive patients who underwent TAVI with the Medtronic CoreValve System in our institution. Complications, prosthetic valve associated endpoints, and therapy-specific endpoints were defined according to the definitions provided by the VARC.

RESULTS

The mean age (±SD) was 81 (±7) years and 55% were female. Thirty-day or in-hospital mortality was 11%, and the 30-day combined safety endpoint was 22%. Seventy-six patients (51%) had ≥1 cardiovascular and/or noncardiovascular complication of whom 16 also underwent a new permanent pacemaker implantation (PPI). In the 74 patients with uneventful TAVI, 12 patients (8%) underwent PPI. TAVI was truly uneventful in 62 patients (41%). Bleeding complications were observed most frequently (31%), followed by acute kidney injury (18%), vascular complications (16%), and stroke/TIA (11%). The median LOS in patients with a complicated and a truly uncomplicated TAVI was 14.0 (8.0-20.5) and 8.0 (7.0-10.8) days, respectively (P < 0.001).

CONCLUSION

TAVI was associated with ≥1 cardiovascular and/or noncardiovascular event in 51% of the patients; new PPI was needed in another 8%, and TAVI was truly uncomplicated in 41%. Complications and need for new PPI significantly prolonged LOS.

Poor performances of EuroSCORE and CARE score for prediction of perioperative mortality in octogenarians undergoing aortic valve replacement for aortic stenosis

BACKGROUND AND OBJECTIVE

Although results of cardiac surgery are improving, octogenarians have a higher procedure-related mortality and more complications with increased length of stay in ICU. Consequently, careful evaluation of perioperative risk seems necessary. The aims of our study were to assess and compare the performances of EuroSCORE and CARE score in the prediction of perioperative mortality among octogenarians undergoing aortic valve replacement for aortic stenosis and to compare these predictive performances with those obtained in younger patients.

METHODS

This retrospective study included all consecutive patients undergoing cardiac surgery in our institution between November 2005 and December 2007. For each patient, risk assessment for mortality was performed using logistic EuroSCORE, additive EuroSCORE and CARE score. The main outcome measure was early postoperative mortality. Predictive performances of these scores were assessed by calibration and discrimination using goodness-of-fit test and area under the receiver operating characteristic curve, respectively.

RESULTS

During this 2-year period, we studied 2117 patients, among whom 134/211 octogenarians and 335/1906 nonoctogenarians underwent an aortic valve replacement for aortic stenosis. When considering patients with aortic stenosis, discrimination was poor in octogenarians and the difference from nonoctogenarians was significant for each score (0.58, 0.59 and 0.56 vs. 0.82, 0.81 and 0.77 for additive EuroSCORE, logistic EuroSCORE and CARE score in octogenarians and nonoctogenarians, respectively, P < 0.05). Moreover, in the whole cohort, logistic EuroSCORE significantly overestimated mortality among octogenarians.

CONCLUSION

Predictive performances of these scores are poor in octogenarians undergoing cardiac surgery, especially aortic valve replacement. Risk assessment and therapeutic decisions in octogenarians should not be made with these scoring systems alone.

Perioperative management of patients who have pulmonary disease

The identification of risk factors and optimization of respiratory status are crucial to the successful management of patients who have pulmonary disease and are undergoing a surgical procedure. This article explores the approach to pulmonary patients, from the preoperative assessment to the intraoperative and postoperative periods. The management of specific pulmonary disorders in the perioperative period is discussed.

Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE

BACKGROUND

With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification.

METHODS

All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

RESULTS

In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum.

CONCLUSIONS

Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective

BACKGROUND

With the recent advent of percutaneous valve therapy, an increased need for the evaluation of outcomes after open aortic valve replacement (AVR) in elderly patients is warranted. This study compares the short- and long-term survival outcomes of octogenarians after AVR with younger age groups in the modern surgical era.

METHODS

A retrospective review was performed on patients who underwent isolated, primary AVR from 1996 to 2006 at the Emory Healthcare Hospitals. Five-hundred fifteen patients were divided into three age groups: 60 to 69 (n = 206), 70 to 79 (n = 221), and 80 to 89 years of age (n = 88). Outcomes were compared among the age groups using logistic regression and analysis of variance techniques. Long-term survival between age groups was compared using the Cox proportional hazards model. Kaplan-Meier plots were used to determine survival rates.

RESULTS

The groups were similar with respect to in-hospital mortality (p = 0.66) and hospital length of stay (p = 0.08). Preoperative predictors of in-hospital mortality included stroke (odds ratio [OR] 5.36), chronic lung disease (OR 4.51), and renal failure (OR 1.39). As expected, age significantly impacted long-term survival (hazard ratio [HR] 1.06). Other predictors of long-term survival included stroke (HR 2.15), current smoker (HR 2.03), diabetes (HR 1.53), and renal failure (HR 1.4). The Kaplan-Meier estimate of median survival for octogenarians was 7.4 years.

CONCLUSIONS

In the modern era, octogenarians have acceptable short- and long-term results after open AVR. Comparisons of less invasive techniques for AVR should rely on outcomes based in the modern era and decisions regarding surgical intervention in patients requiring AVR should not be based on age alone.

Health-related quality of life after cardiac surgery

Health-related quality of life (HRQOL) assessments are designed to reflect a patient's perspective of how a disease has affected their overall health status. Patient-centered outcomes are of value both for risk assessment and as an outcome measure. Strategies for analyzing HRQOL data are inconsistent primarily because the data frequently do not meet underlying assumptions of traditional methods for statistical analyses and require a careful analytic approach.

Concomitant ablation of atrial fibrillation in octogenarians: an observational study

BACKGROUND

Cardiac surgery is increasingly required in octogenarians. These patients frequently present atrial fibrillation (AF), a significant factor for stroke and premature death. During the last decade, AF ablation has become an effective procedure in cardiac surgery. Because the results of concomitant AF ablation in octogenarians undergoing cardiac surgery are still not clear, we evaluated the outcome in these patients.

METHODS

Among 200 patients undergoing concomitant AF ablation (87% persistent AF), 28 patients were >/= 80 years (82 +/- 2.4 years). The outcome was analysed by prospective follow up after 3, 6, 12 months and annually thereafter. Freedom from AF was calculated according to the Kaplan-Meier method.

RESULTS

Octogenarians were similar to controls regarding AF duration (48 +/- 63.2 versus 63 +/- 86.3 months, n.s.) and left atrial diameter (49 +/- 6.1 versus 49 +/- 8.8 mm, n.s.), but differed in EuroSCORE (17.3 +/- 10.93 versus 7.4 +/- 7.31%, p < 0.001), prevalence of paroxysmal AF (25.0 versus 11.0%, p = 0.042) and aortic valve disease (67.8 versus 28.5%, p < 0.001). ICU stay (8 +/- 16.9 versus 4 +/- 7.2 days, p = 0.027), hospital stay (20 +/- 23.9 versus 14 +/- 30.8 days, p < 0.05), and 30-d-mortality (14.3 versus 4.6%, p = 0.046) were increased. After 12 +/- 6.1 months of follow-up (95% complete), 14 octogenarians (82%) and 101 controls (68%, n.s.) were in sinus rhythm; 59% without antiarrhythmic drugs in either group (n.s.). Sinus rhythm restoration was associated with improved NYHA functional class and renormalization of left atrial size. Cumulative freedom from AF demonstrated no difference between groups. Late mortality was higher in octogenarians (16.7 versus 6.1%, p = 0.065).

CONCLUSION

Sinus rhythm restoration rate and functional improvement are satisfactory in octogenarians undergoing concomitant AF ablation. Hence, despite an increased perioperative risk, this procedure should be considered even in advanced age.

Cardiac anesthesia and surgery in geriatric patients

The average age of US population is steadily increasing, with more than 15 million people aged 80 and older. Coronary artery disease and degenerative cardiovascular diseases are particularly prevalent in this population. Consequently, an increasing number of elderly patients are referred for surgical intervention. Advanced age is associated with decreased physiologic reserve and significant comorbidity. Thorough preoperative assessment, identification of the risk factors for perioperative morbidity and mortality, and optimal preparation are critical in these patients. Age-related changes in comorbidities and altered pharmacokinetics and pharmacodynamics impacts anesthetic management, perioperative monitoring, postoperative care, and outcome. This article updates the age-related changes in organ subsystems relevant to cardiac anesthesia, perioperative issues, and intraoperative management. Early and late operative outcome in octogenarians undergoing cardiac surgery are reviewed. The data clearly indicate that no patient group is "too old" for cardiac surgery and that excellent outcomes can be achieved in selected group of elderly patients.

Temporal trends of outcomes for nonagenarians undergoing coronary artery bypass grafting, 1993 to 1999

Temporal trends in length of stay, discharge disposition, and long-term mortality outcomes were examined in nonagenarians who underwent coronary artery bypass grafting (CABG) from 1993 to 1999. A total of 4,224 fee-for-service Medicare beneficiaries (2,068 women, 2,156 men) aged>or=90 years underwent CABG from 1993 to 1999. The number of procedures increased from 325 in 1993 to 883 in 1999 among all fee-for-service Medicare patients aged>or=65 years. Approximately half of CABG procedures were performed on women each year. The mean length of stay decreased from 18.0+/-10.8 to 13.3+/-8.8 days from 1993 to 1999 but remained longer for women (p<0.001). A greater percentage of women than men were discharged to skilled nursing facilities. The overall crude mortality rates remained relatively stable at 13.5% at 30 days and 59.0% at 5 years. Men and women had comparable short-term mortality outcomes, but men had higher mortality rates for 2- to 5-year outcomes. In conclusion, the number of CABG procedures in nonagenarians is increasing, with a substantial portion attaining survivorship that is equivalent to projected life expectancy.

Valve structure and survival in octogenarians having aortic valve replacement for aortic stenosis (+/- aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and valve structure on both early and late survival in octogenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). Although a number of reports are available in octogenarians having AVR for AS, none have described aortic valve structure. Most have limited numbers of patients and few have described late results. We analyzed survival and valve structure in 196 octogenarians having AVR for AS from 1993 to 2005 at Baylor University Medical Center, including 118 (60%) with and 78 (40%) without simultaneous CABG. Sixty-day mortality, which was identical to 30-day mortality, was similar (10% and 11%) in the groups with and without simultaneous CABG. Unadjusted analysis of late survival (up to 13 year follow-up) was not affected by gender (male vs female), aortic valve structure (bicuspid vs tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient > 50 vs < or =50 mm Hg), or by performance of CABG. Of the 196 patients, 54 (28%) had a congenitally bicuspid aortic valve, and 142 (72%) had a tricuspid aortic valve. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect survival in octogenarians having AVR for AS.

Management of anaesthesia in elderly patients

Increasing numbers of very elderly patients require surgery. Elderly patients are at increased risk of perioperative morbidity and mortality because of the high incidence of co-existing age-related diseases. With greater experience, outcomes from major operations in octogenarians have improved. The increased risks of surgery in the elderly must, however, be individually weighed against the benefits to be gained from symptom relief and improved quality of life.

Aortic valve replacement in octogenarians: risk factors for early and late mortality

BACKGROUND

Excellent outcomes after aortic valve replacement (AVR) in elderly patients can be achieved, yet some practitioners are reticent to refer elderly patients for surgery. This study analyzed risk factors for mortality in patients aged 80 years and older undergoing AVR with or without concomitant coronary artery bypass grafting (CABG).

METHODS

A retrospective review was performed of 245 patients (129 women) with a mean age of 83.6 +/- 2.9 years who had AVR with (n = 140) or without CABG (n = 105) at a single institution from 1993 to 2005. Data were analyzed with a multivariate logistic regression for predictors of operative mortality, Kaplan-Meier estimates of survival, and a Cox multivariate proportional analysis of factors influencing long-term survival.

RESULTS

Mean preoperative New York Heart Association (NYHA) classification was 3.1 +/- 0.9, and 78% (192/245) of patients were classified as NYHA class III or IV. Operative (30-day) mortality was 9% (22/245). Independent risk factors for operative mortality included postoperative renal failure (odds ratio [OR], 20.9; 95% confidence interval [CI], 6.5 to 67.6; p < 0.001), postoperative permanent stroke (OR, 11.3; 95% CI, 1.7 to 75.1; p = 0.019), or intraoperative/postoperative intraaortic balloon pump (IABP) placement (OR, 14.9; 95% CI 2.9 to 75.8; p = 0.002). Survival after surgery was 82% (n = 183) at 1 year and 56% (n = 88) at 5 years. Prognostic factors for decreased long-term survival were regurgitant valve pathology (hazard ratio [HR], 6.0; 95% CI, 2.5 to 14.2; p = 0.002), intraoperative/postoperative IABP (HR, 2.9; 95% CI, 1.4 to 6.0; p = 0.010), postoperative renal failure (HR, 3.5, 95% CI, 2.2 to 5.7; p < 0.001), and postoperative stroke (HR, 7.0, 95% CI, 3.2 to 15.9; p < 0.001). Performing concomitant CABG was protective in terms of operative mortality (OR, 0.3; 95% CI, 0.09 to 0.83; p = 0.017) and improved long-term survival (HR, 0.7, 95% CI, 0.47 to 0.96; p = 0.020). Preoperative NYHA classification did not affect operative or long-term survival.

CONCLUSIONS

Patients aged 80 years and older who undergo AVR have acceptable short-term and long-term survival regardless of NYHA status. Concomitant CABG improved operative and long-term survival in this population. Despite their increased age, aggressive surgical treatment is warranted for most patients.

Outcome of heart surgery procedures in octogenarians: is age really not an issue?

Survival rates are a well-known marker for quality performance of a cardiac surgery department, as well as standard of procedures, freedom of reoperation, postoperative complications, length of hospital stay, improvement in New York Heart Association classification and quality of life after surgery. Until recently there has not been any great interest of surgeons in topics concerning the costs of postoperative care, as long as the results were successful. However, satisfactory results after cardiac surgery in aged people require successful procedures, as well as meticulous perioperative care. The expenses of healthcare are constantly growing and approaches to optimize costs in all departments of medicine have a high priority. Exact evaluation of comorbidities and prevention of complications in aged people, as well as attentive strategies concerning expenses, may help to reduce mortality, postoperative complications and costs.

Discharge to Home Rates Are Significantly Lower for Octogenarians Undergoing Coronary Artery Bypass Graft Surgery

BACKGROUND

The incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. We sought to evaluate clinical outcomes of octogenarians undergoing CABG using an audited state-wide mandatory database.

METHODS

New York State Department of Health's Cardiac Reporting System was analyzed from 1998 to 2002. In all, 88,154 patients undergoing isolated CABG were identified. Patients were divided into four age groups: less than 50 years (group 1, n = 6,527), 50 to 64 years (group 2, n = 30,088), 65 to 79 years (group 3, n = 43,369), and 80 years and above (group 4, n = 8,170).

RESULTS

Of all patients, 9.3% were octogenarians. In addition to marginally worse coronary artery disease, octogenarians generally manifested a higher incidence of preoperative risk factors such as cerebrovascular disease, peripheral vascular disease, and congestive heart failure compared with younger patients at baseline. Both length of hospital stay and in-hospital mortality rate were significantly higher among octogenarians. The incidence of postoperative complications was higher among octogenarians. Multivariate analysis demonstrated renal failure requiring dialysis (odds ratio [OR] = 4.4), myocardial infarction within 6 hours before surgery (OR = 3.6), chronic obstructive pulmonary disease (OR = 1.7), congestive heart failure at admission (OR = 1.7), emergent operation (OR = 1.6), Canadian Cardiovascular Society functional class IV (OR = 1.5), hypertension (OR = 1.4), and low ejection fraction (OR = 0.98) to be significant independent predictors of in-hospital mortality of octogenarians. Discharge to home rates were significantly lower for octogenarians.

CONCLUSIONS

Although early outcomes in octogenarians are acceptable, these factors alone are not sufficient to reflect overall success of CABG in these patients, given the strikingly lower discharge to home rates. Attention to full functional recovery in octogenarians is essential.

Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians

BACKGROUND

Off-pump coronary artery bypass (OPCAB) surgery has been successfully used in diverse patient populations and has been postulated to be safer than conventional coronary artery bypass (CCAB) surgery in some high-risk patients, including the elderly.

OBJECTIVE

To compare the safety of OPCAB surgery versus CCAB surgery in the octogenarian population of two large southwestern Ontario cardiac surgical units.

RESULTS

Two hundred thirty-six consecutive octogenarians underwent primary isolated coronary artery bypass surgery from November 2000 to March 2005. Patients undergoing OPCAB surgery tended to have higher Parsonnet scores, while patients undergoing CCAB surgery had a greater number of emergent operations. The Canadian Cardiovascular Network predicted that mortality risk was similar in both groups. In-hospital mortality was similar between groups, as was postoperative myocardial infarction and new onset of renal dysfunction. However, in the OPCAB group, there was a decreased incidence of postoperative neurological dysfunction (2.3% in the OPCAB group versus 10.5% in the CCAB group, P=0.01), in particular cerebrovascular accidents (1.5% in the OPCAB group versus 7.6% in the CCAB group, P=0.05), and a decreased incidence of prolonged intubation (5.3% in the OPCAB group versus 13.3% in the CCAB group, P=0.04). Multivariable analysis found that cardiopulmonary bypass had no significant impact on mortality or length of stay.

CONCLUSIONS

In octogenarian patients, OPCAB surgery is as safe as CCAB surgery in terms of mortality and major morbidity. Furthermore, a significant reduction in neurological dysfunction and prolonged intubation was seen in the OPCAB group compared with the CCAB group.

Risk Evaluation of Cardiac Surgery in Octogenarians

OBJECTIVE

To assess the predictive value of risk factors in the European System for Cardiac Operative Risk Evaluation (EuroSCORE) for cardiac surgery on octogenarians.

DESIGN

An observational study of octogenarians undergoing cardiac surgery and average-aged controls matched according to the cardiac surgical procedure.

SETTING

A university hospital.

PARTICIPANTS

One hundred sixty-two consecutive patients 80 years or older who underwent cardiac surgery between January 1, 2001, and June 30, 2003, and 162 average-aged controls.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Risk factors according to the EuroSCORE (The European System for Cardiac Risk Evaluation) model and EuroScore algorithm without an age component (EuroSCOREex) were evaluated. The EuroSCORE model and EuroSCOREex predicted mortality (odds ratio 1.4) and morbidity (odds ratio 1.2 and 1.3, respectively) equally well in both age groups. Adding age group information into the EuroSCOREex model in combined data, the odds ratio estimate was 3.5 for age group. The 30-day mortality of octogenarians was 8.6% versus 1.9% in controls (p < 0.01). Incidences of organ-related complications were comparable. Octogenarians spent more days in the hospital's intensive care unit and surgical ward than did controls (3.4 +/- 3.3 days v 2.7 +/- 3.1 days, p < 0.01; 9.9 +/- 5.8 days v 8.6 +/- 3.8 days, p = 0.02). Only 31 (19.1%) octogenarians were discharged home, whereas the corresponding number was 66 (40.7%) in controls (p < 0.01).

CONCLUSIONS

Risk factors other than age were not higher in octogenarians, and the EuroSCORE model predicted mortality and morbidity. Age was an important single risk factor predicting mortality.

Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians

BACKGROUND

Emergency surgery for acute type A dissection is associated with a high mortality rate in aged patients. This study was designed to explore perioperative risk factors and prognosis in octogenarians with acute type A aortic dissection.

METHODS

Twenty-four octogenarians, of 134 consecutive patients with acute type A dissection between 1995 and 2005 who underwent emergency surgery, were reviewed. The median age was 82 years (80 to 90); the patients were 10 men and 14 women. All 24 patients underwent conservative tear-oriented surgery under deep hypothermic circulatory arrest with cerebral perfusion; the procedures were 23 ascending aortic replacements and one entire arch replacement.

RESULTS

The hospital mortality rate was 13% (3 of 24 patients), without statistical significance compared with 6% in patients younger than 80 years. The late mortality rate was 38% (9 of 24 patients), with significance compared with 9% in the other patients. Five- and 10-year survivals ware 55% and 42%, respectively, compared with 83% and 73%, respectively (p = 0.0013), in the other patients. Univariate and multivariate analysis demonstrated that age 80 or greater was not an independent risk factor of hospital death. Risk factors of late death in younger-aged patients were pneumonia and reoperation.

CONCLUSIONS

Emergency surgery for octogenarians with acute type A aortic dissection was successfully performed using a conservative intimal tear-oriented procedure, resulting in satisfactory early and late survival. Aggressive surgical treatment is mandatory for improving the outcome of this medical emergency in octogenarians.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

OBJECTIVE

To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortality

DESIGN AND SETTING

Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital.

PATIENTS

578 consecutive ICU patients aged 80 years or older.

RESULTS

Demographic, physiological, and laboratory values derived from the first 24h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality.

CONCLUSION

Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.