Heart surgery in patients aged eighty years and above: determinants of morbidity and mortality

Outcomes after surgery in patients with previous stroke

BACKGROUND

Limited information is available on the association between a medical history of stroke and postoperative outcomes. This study investigated the outcomes following non-neurological surgery in patients with previous stroke.

METHODS

Using Taiwan's National Health Insurance Research Database, a nationwide cohort study was conducted of patients who underwent non-neurological surgery between 2008 and 2010 with a medical history of stroke in the 24-month period before operation. Patients who had non-neurological surgeries without previous stroke were selected as controls by the propensity score-matched pair method. Thirty-day postoperative complications and in-hospital mortality were compared between the two groups.

RESULTS

Some 1 426 795 adults underwent major inpatient non-neurological surgery, of whom 45 420 had a medical history of previous stroke. Patients with previous stroke who underwent surgery had an increased risk of postoperative pneumonia, septicaemia, acute renal failure, acute myocardial infarction, pulmonary embolism and 30-day in-hospital mortality (adjusted rate ratio (RR) 1·79, 95 per cent c.i. 1·61 to 1·99). Compared with controls, patients with previous stroke due to intracerebral haemorrhage (RR 3·41, 2·97 to 3·91), and those who were treated in intensive care (RR 2·55, 2·24 to 2·90) or underwent neurosurgery (RR 2·49, 2·12 to 2·92), had an increased 30-day in-hospital mortality rate. Postoperative mortality also increased with stroke-related co-morbidities, and with stroke 1-6 months before surgery (RR 3·31, 2·91 to 3·75).

CONCLUSION

Patients with previous stroke had a higher risk of adverse postoperative outcomes; their 30-day in-hospital mortality rate was nearly twice that of patients without previous stroke.

Morbidity and mortality of nonagenarians undergoing CoreValve implantation

Background

Nonagenarians are mostly denied from different therapeutic strategies due to high comorbidity index and risk-benefit calculation. We present the results of nonagenarians with high comorbidity index not eligible for conventional aortic valve surgery undergoing transcatheter aortic valve implantation (TAVI) with the CoreValve system.

Methods

Our retrospective analysis include baseline parameters, procedural characteristics, morbidity, mortality as well as twelve-lead surface ECG and echocardiographic parameters which were revealed preinterventionally, at hospital discharge and at 30-day follow-up. Clinical follow-up was performed 6 months after TAVI.

Results

Out of 158 patients 11 nonagenarians with a mean age of 92.6 ± 1.3 years suffering from severe aortic valve stenosis and elevated comorbidity index (logistic EuroSCORE of 32.0 ± 9.5%, STS score 25.3 ± 9.7%) underwent TAVI between January 2008 and January 2011 using the third-generation percutaneous self-expanding CoreValve prosthesis. Baseline transthoracic echocardiography reported a mean aortic valve area (AVA) of 0.6 ± 0.2 cm² with a mean and peak pressure gradient of 60.2 ± 13.1mmHg and 91.0 ± 27.4mmHg, respectively. The 30-day follow up all cause and cardiovascular mortality was 27.3% and 9.1%, respectively. One major stroke (9.1%), 2 pulmonary embolisms (18.2%), 1 periprocedural (9.1%) and 1 (9.1%) spontaneous myocardial infarction occured. Life-threatening or disabling bleeding occurred in 2 cases (18.2%), and minor bleeding in 7 cases (63.6%). Mean severity of heart failure according to NYHA functional class improved from 3.2 ± 0.8 to 1.36 ± 0.5 while mean AVA increased from 0.6 ± 0.2cm² to 1.8 ± 0.2cm². At 6-months follow-up 8 patients (72.7%) were alive without any additional myocardial infarction, pulmonary embolism, bleeding, or stroke as compared to 30-day follow-up.

Conclusion

Our case series demonstrate that even with elevated comorbidity index, clinical endpoints and valve-associated results are relatively favorable in nonagenarians treated with CoreValve.

Mitral valve surgical procedures in the elderly

BACKGROUND

Mitral valve (MV) surgical procedures in the elderly are associated with profound operative and long-term mortality. We report our experience and results for MV surgical procedures in the elderly, especially with regard to the influence of comorbidities.

METHODS

Our hospital database was assessed to identify all patients who underwent MV surgical procedures at the age of 70 years and older between 1999 and 2009. The data were retrospectively analyzed.

RESULTS

A total of 2,503 patients operated on during this 10-year period were identified. In 97% of patients, mitral regurgitation (MR) was the primary indication for operation, followed by coronary artery disease in 41.6% and aortic valve stenosis in 21.3%. The 30-day mortality rate was 3.1%, and the long-term survival at 5 years was 55.2% (95% confidence interval, 52.3% to 57.5%). Coronary artery bypass grafting was identified to be associated with inferior short-term and long-term survival. Numerous comorbidities significantly influenced long-term survival. The observed mortality was significantly lower than predicted by EuroSCORE (17.2%).

CONCLUSIONS

MV operations in the elderly can be performed with a low early mortality and promising long-term survival. However, our large series demonstrates that comorbidities are to be attributed as the real burden for successful treatment of elderly patients undergoing MV procedures.

Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies

OBJECTIVE

This study was planned to evaluate the outcome of patients ≥80 years old undergoing isolated conventional aortic valve replacement (AVR).

METHODS

Systematic review of the literature and meta-analysis of data on octogenarians and nonagenarians who underwent isolated AVR were performed.

RESULTS

The literature search yielded 48 observational studies reporting on 13 216 patients ≥80 years old. Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8-7.5, 47 studies, 13,092 patients), and it was 5.8% (95% CI 4.8-6.9) in 18 studies with a mid-date from 2000 to 2006 and 7.5% (95% CI 6.8-8.2) in 30 studies with a mid-date from 1982 to 1999 (P = .004). Pooled proportion of postoperative stroke was 2.4% (95% CI 2.1-2.7, 21 studies, 8,436 patients), that of postoperative dialysis was 2.6% (95% CI 1.6-3.8, 10 studies, 1,945 patients), and that of postoperative implantation of a pacemaker was 4.6% (95% CI 3.6-5.8, 6 studies, 1,470 patients). Pooled survival rates at 1, 3, 5, and 10 years after isolated AVR were 87.6%, 78.7%, 65.4%, and 29.7%, respectively.

CONCLUSIONS

Immediate postoperative mortality and morbidity after isolated AVR in patients ≥80 years old are rather low. Postoperatively mortality decreased even further in the most recent series. Importantly, isolated AVR in these high-risk patients was associated with good late survival. These findings suggest that advanced age alone cannot be considered as a contraindication to conventional isolated AVR and that any new valve prosthesis implanted in these patients should be durable enough to guarantee the results so far offered by conventional surgery.

New-onset atrial fibrillation predicts long-term mortality after coronary artery bypass graft

OBJECTIVES

We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation.

BACKGROUND

POAF predicts longer hospital stay and greater post-operative mortality.

METHODS

A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease.

RESULTS

New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up.

CONCLUSIONS

In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.

Effects of an intervention on health behaviors of older coronary artery bypass (CAB) patients

Coronary artery bypass (CAB) patients are older increasingly more often than before. Effectiveness of cardiac rehabilitation among the elderly is not yet adequately known about. The purpose was to describe short-term (3-month), intermediate (6-month), and long-term (12-month) effects of health counseling, guidance, and adjustment education in groups on health, health behaviors, and functional abilities among older CAB patients. The study population was randomized to an intervention group (IG=49) and a control group (CG=68). Prior to CAB, intervention included one guidance and counseling group session and four sessions within 12 months following CAB. Intervention had positive effects on exercise activities, use of alcohol, and functional abilities among all participants, and on frequency of eating visible fat, fresh greens and vegetables among men. The intervention was effective with some exercise activities and functional abilities persisting for at least 1 year following CAB. Similar interventions may be arranged for older people. Health care professionals need to guide and encourage older people in their efforts to participate in them.

Long-term outcome of elderly patients requiring intensive care admission for abdominal pathologies: survival and quality of life

BACKGROUND

Medical developments have allowed the management of patients aged over 70 years with severe abdominal pathologies requiring intensive care unit (ICU) admission. These patients require enhanced life support and present a high ICU mortality. We investigated the outcome and quality of life (QOL) of elderly patients 2 years after their ICU stay for abdominal pathologies.

METHODS

Patients aged 70 years or over with abdominal pathologies, admitted to our ICU over a period of 2 years, were included. Two years following their ICU stay, a letter informed the patients about the present study. Consent to participate was obtained by telephone. QOL was assessed by the Euro-QOL and Short Form-36 questionnaires. Other patient-centered outcomes were evaluated.

RESULTS

Overall, 2780 patients were admitted to the ICU during the study period; 141 (5%) patients were eligible; 112 of the 141 (79%) survived their ICU stay, 95 (67%) survived their hospital stay and 52 (37%) were alive 2 years after their ICU stay; 36 of the 52 survivors (69%) answered the questionnaire. Their QOL 2 years after their ICU stay was decreased in comparison with an age-matched population. Eighty-one per cent of patients lived at home and 57% were totally independent. They perceived their ICU stay as positive and 75% stated that they would agree to go through intensive care again. Factors associated with 2-year survival were the absence of co-morbidity, absence of malignancy and a lower Simplified Acute Physiology II score on ICU admission.

CONCLUSIONS

A high mortality rate and a decrease in QOL were observed in elderly patients with severe abdominal pathologies. Nonetheless, these patients were able to adapt well to their physical disabilities.

Valve surgery in octogenarians: in-hospital and long-term outcomes

BACKGROUND

Global population aging and greater age-related incidence of ischemic, degenerative and calcific valve disease have led to an increasing number of very elderly patients being referred for valve surgery. However, their preoperative risk factors, and in-hospital and long-term outcomes have not been thoroughly investigated.

METHODS

Three hundred seven consecutive patients 80 years and older (60% female; mean age 83+/-2.4 years) attending three major Italian cardiac centres to undergo valve surgery were evaluated. Seventy-nine patients underwent mitral valve surgery (isolated n=30, combined n=49) and 228 underwent aortic valve surgery (isolated n=134, combined n=94).

RESULTS

The most frequent in-hospital complications were atrial arrhythmias, need for inotropic support for more than 48 h, renal insufficiency, congestive heart failure, respiratory failure, and stroke or transient ischemic attack. The in-hospital mortality rate was 9.7% (30 of 307). Multivariate logistic regression identified the following clinical variables as predictors of in-hospital death: New York Heart Association functional class IV, diabetes, hypertension, renal insufficiency at presentation, rheumatic etiology and left ventricular ejection fraction of less than 45%. Late mortality occurred in 45 of 277 patients (16.2%), but there was a substantial improvement in the New York Heart Association functional class of the 232 long-term survivors (from 3.0+/-0.7 to 1.7+/-0.6; P<0.0001).

CONCLUSIONS

Surgery seems to be an effective therapeutic option for selected symptomatic octogenarians with valve disease, associated with good long-term survival and an improved functional class. Operative mortality is related more to patients' preoperative clinical status and increased comorbidity than the type of surgery per se.

Octogenarians Undergoing Coronary Artery Bypass Graft Surgery: Resource Utilization, Postoperative Mortality, and Morbidity

OBJECTIVE

The purpose of the present study was to examine resource utilization in octogenarians undergoing coronary artery bypass grafting (CABG) and compare it with usage in their younger cohorts at a tertiary care heart center. The resources examined were time to extubation, packed red blood cell transfusions, intensive care unit (ICU) length of stay (LOS), and preoperative and postoperative LOS. The study also examined differences in postoperative morbidity and mortality.

DESIGN

Retrospective hospital follow-up study of consecutive patients undergoing CABG using a prospectively designed database.

SETTING

University teaching tertiary care referral center for cardiac surgery.

PARTICIPANTS

Seventeen hundred forty-six male and female patients undergoing CABG surgery, including 155 octogenarians and 1591 patients younger than 80 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic, mortality, morbidity, and resource utilization data were collected from the records of patients undergoing CABG at the authors' institution over 3 years. There were 1746 patients: 155 octogenarians and 1591 nonoctogenarians. Octogenarians had a significantly higher incidence of preoperative stroke, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and left main disease. They weighed significantly less, and had lower preoperative and postoperative hematocrit. There was a significantly higher percentage of women in the octogenarian group. Mean time from the end of surgery to endotracheal extubation was 9.3 hours for octogenarians and 6.3 hours for their younger cohorts (p < 0.001). Blood transfusion was required in 88.4% of octogenarians compared with 58.6% of nonoctogenarians (p < 0.001). Mean ICU LOS was 1.9 days for octogenarians and 1.4 days for nonoctogenarians (p < 0.001). Mean postoperative LOS was 8.7 days for octogenarians and 5.8 days for nonoctogenarians (p < 0.001). Clinical and demographic variables were correlated with age 80 years or older. Multivariate linear and logistic regression models were constructed to show the combined effects of age and comorbid conditions on outcomes. Octogenarians had a significantly higher incidence of postoperative renal failure and neurologic complications. The 30-day mortality rate was 9.0% for the octogenarian group v 1.2% for the younger group (p < 0.001). Age 80 years or older was significantly associated with outcome, and was an independent predictor of increased resource utilization and postoperative mortality and morbidity.

CONCLUSIONS

The results demonstrated that octogenarians undergoing CABG required increased resource utilization and had significantly higher morbidity, with increased incidence of postoperative renal failure, neurologic complications, and 30- day mortality. Age 80 years or older was an independent predictor of increased resource utilization, postoperative morbidity, and mortality.

Outcome of elderly patients undergoing open-heart surgery in a developing country

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8%. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31%) patients were above the age of 65 years. The mortality rate was 2.2% for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6%). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Cardiac surgery in an Iranian teaching hospital: outcome and risk factors

Cardiac surgery in Iran has been associated with different facilities, equipment and patient populations in comparison to countries from which most of the academic papers used for identification of risk factors related to outcome and subsequent establishment of risk stratification models originate from. During a 15-month period all patients admitted for adult cardiac surgery using cardiopulmonary bypass (CBP) in a university affiliated teaching hospital were enrolled in a prospective study. Appropriate statistical tests were used to analyze data for mortality and morbidity. There were 730 adults (63% male, 37% female), with age ranged from 16 to 82 (mean, 51.4 +/- 14.4). A mortality rate of 5.3% and morbidity of 14.8% (major + minor) were observed in the whole group. Factors correlated with mortality were: age (p = 0.019), emergency surgery (p < 0.0001), redo cardiac surgery (p = 0.01), left ventricular (LV) aneurysm (p < 0.001), presence of catastrophic states (p < 0.001), low ejection fraction (p = 0.04), history of hypertension (p = 0.05), the individual surgeon (p < 0.0001), and CPB duration (p < 0.0001). Factors affecting morbidity included: female gender (p = 0.04), age (p = 0.03), emergency surgery (p = 0.001), redo surgery (p = 0.008), and catastrophic states (p < 0.001). The mortality in our study group may be compared with reports presented in the literature. Factors such as age, emergency surgery, redo cardiac surgery, and catastrophic states are statistically related to both mortality and morbidity.

Outcome for cardiothoracic surgical patients requiring multidisciplinary intensive care

BACKGROUND AND OBJECTIVE

Patients who require multidisciplinary intensive care after cardiac surgery have a poor prognosis. The aim was to investigate factors in the mortality of this group of patients at 6 months.

METHODS

A retrospective analysis was made of the 6-month mortality rate in 301 adults who required admission to a multidisciplinary intensive care unit following cardiac surgery from 1991 to 1997. Mortality was correlated with clinical and patient characteristic variables.

RESULTS

The intensive care mortality rate was 34% and at 6 months after patients' discharge from intensive care it was 51%. There were positive correlations with death at 6 months for ventricular failure (odds ratio of death 3.4, P = 0.002), sepsis (odds ratio 3.0, P = 0.004) and age over 80 yr (odds ratio of death 9.2, P = 0.034). Patients who had undergone isolated coronary artery graft surgery (odds ratio of death 0.28, P = 0.036) or thoracic surgery (odds ratio of death 0.22, P = 0.042) had better 6-month outcomes. Patients with respiratory or renal failure in the absence of ventricular failure or sepsis had a 6-month mortality rate of 36%; but the lower mortality rate did not achieve statistical significance.

CONCLUSIONS

The 6-month mortality rate of 51% in a group of patients requiring multidisciplinary intensive care after cardiac surgery is consistent with previous studies; mortality was particularly high in extreme old age and in patients referred with sepsis or ventricular failure. Those patients with uncomplicated respiratory or renal failure had a better outcome than the group as a whole.

Multivessel off-pump revascularization in octogenarians: early and midterm outcomes

BACKGROUND

Octogenarians are increasingly being referred for coronary artery revascularization. However, the prevalence of comorbid events and the propensity for neurologic dysfunction place octogenarians at higher risk for cardiopulmonary bypass-induced morbidity and mortality. Therefore, octogenarian patients represent a particularly attractive target for application of off-pump coronary artery bypass grafting.

METHODS

From January 1999 to August 2001, 113 octogenarians had off-pump coronary artery bypass grafting. Their data were prospectively entered into the cardiac surgery database and analyzed retrospectively. Follow-up information was obtained through telephone survey.

RESULTS

The mean age of the patients was 83 +/- 2.5 years, and the mean number of grafts per patient was 3.3 +/- 1. The most prevalent postoperative complication was atrial fibrillation (43%). Postoperative neurologic complications were seen in 5 patients (4%). There was one postoperative death (30-day mortality rate, 0.9%). The mean follow-up was 13.2 +/- 7 months and was complete for 90% of the patients. At the time of telephone survey, 85 (87%) of 98 patients were free from angina, and 91 (88%) were free from cardiac-related readmission. There were three late deaths. The majority of octogenarians (66%) reported that in retrospect, they would have the operation again.

CONCLUSIONS

Off-pump multivessel revascularization in octogenarians is associated with excellent early and intermediate outcomes and provides a satisfactory quality of life.

Does gender affect outcome of cardiac surgery in octogenarians?

The long-term results of cardiac surgery in 212 consecutive octogenarians (116 men, 96 women) were reviewed retrospectively. Preoperative functional status, Euroscore, and the incidences of hypertension and chronic obstructive pulmonary disease were similar in both sexes. Women had more diabetes mellitus (45% versus 25%; p < 0.05) but less renal dysfunction (16% versus 29%; p < 0.05). Men required emergency procedures more frequently (p < 0.05). Women underwent complete revascularization more often and had more arterial grafts. Hospital mortality was similar (11.5% in women versus 12.9% in men), but women had more complications (76% versus 64%), longer convalescence (24.3 versus 18.5 days), fewer psychiatric disorders (14% versus 23%) and less heart block (9% versus 19%). Men had a slightly better outcome in terms of functional class and Euroqol score during follow-up of up to 114 months. Median survival was longer in women (3.15 versus 2.96 years) but 1-, 3-, and 5-year survival rates and late deaths were similar. Outcomes appear to be equitable for both sexes among octogenarians.

Outcomes in nonagenarians after heart valve replacement operation

BACKGROUND

Changes in the age profile of the United Kingdom population and improvements in preoperative and postoperative care have resulted in increasing numbers of very elderly patients undergoing heart valve replacement (HVR) operations. Although HVR operations in nonagenarians are relatively uncommon, the demand for cardiac operations in this age group may increase over time. Outcomes after HVR operations in nonagenarians have not been well described yet. Therefore, the aim of this study was to determine outcomes in terms of early mortality and long-term survival in 35 nonagenarians after HVR operation.

METHODS

Data from the United Kingdom Heart Valve Registry were analyzed and nonagenarian patients were identified. Additional analyzed data include gender, valve position, valve type, valve size, operative priority, follow-up time, and date and cause of death. Kaplan-Meier actuarial curves were calculated to determine accurate 30-day mortality and long-term survival.

RESULTS

On average five HVR operations are performed annually in the United Kingdom in nonagenarians with equal numbers of males and females. Aortic valve replacement with a bioprosthetic valve was the most common operation and 86% were elective admissions. Fourteen patients died within the review period; mean time to death was 402 days. Overall 30-day mortality was 17%, which was higher for males compared with females; females also displayed better long-term survival.

CONCLUSIONS

HVR operations in nonagenarians carry a significantly higher risk of early mortality and reduced long-term survival. Despite increases in the age profile of the population, elective HVR operation with patients aged 90 years or older is likely to remain an infrequent surgical procedure reserved for very carefully selected patients.

Psychological status and the role of coping style after coronary artery bypass graft surgery. Results of a prospective study

The results of a prospective study in patients who underwent a first coronary artery bypass graft operation are presented. The goals of this project consisted in assessing the psychological changes during the first year after surgery. For that purpose, 330 consecutive patients were recruited. They were assessed by means of several psychological scales before and on three occasions after surgery. These scales were: the Heart Patients' Psychological Questionnaire (HPPQ), the State-Trait Anxiety Scale (STAI), the Symptom Check List (SCL-90), the Maastricht Questionnaire (MQ) and the Marlowe Crowne Desirability Scale. Furthermore, the study focused on the differential influence of three coping styles. The data demonstrate a clear overall improvement in psychological status over the first year, more specifically during the first 6 months after CABG. Patients were less anxious, less depressed, less exhausted and experienced more subjective well-being. However, almost 30% of all patients did not experience that average favourable evolution. The final psychological end-state was predicted by psychological variables, measured pre-operatively (somatic complaints, hostility and dysphoria) and short-term post-operatively (anxiety). No single medical variable could predict patients' psychological end-state. Finally, the most favourable change was made by patients who display the sensitising coping style, resulting in lower anxiety and depression. Health care providers, physicians as well as nursing staff and psychologists, should therefore use psychodiagnostic tools in order to identify patients at risk for negative psychological outcome. Appropriate therapeutic interventions may consequently be developed and evaluated in future research.

Updated review of the coronary artery bypass grafting option in octogenarians: good tidings

This review of the literature is presented in an attempt to keep pace with the constantly changing statistics in postsurgical outcomes, which reflect the considerable strides in technology and technical skills that have been made during the past decade in cardiovascular surgery. Although there is still much to be done in terms of improving surgical techniques and managing emergency cases, the reported results of coronary artery bypass grafting in octogenarians are similar to or even better than those obtained with medical or angioplastic approaches, and the life expectancy and quality of life are similar to or better than those of age-matched controls.

Feasibility and risks of heart surgery in very elderly: analysis of 200 consecutive patients of 80 years and above

A continuing increase in the number of very elderly patients with symptomatic heart disease referred for cardiac surgery has been observed in the past. Since 1990 all patients of 80 years and above have been included in a prospective study. We report on the results of the first 200 consecutive patients (mean age: 82.2+/-2.1 years). Operative procedures ranged from isolated myocardial revascularization and valve replacement to very complex operations. In a majority of patients, the operations had to be performed as urgent or emergency cases because of advanced heart disease. Overall 30 day mortality was 9.5%. More than two thirds of patients needed treatment of perioperative complications. During long-term follow-up, cardiac surgery in octogenarians has proved to be very effective with excellent functional status and quality of life. Because of favorable results elderly patients should not be denied the benefits of cardiac surgery requiring utilization of significant medical resources.

Needs of the older patient in the intensive care unit following heart surgery

Cardiac surgery among older people is becoming commonplace in Australia. However, there is little evidence that critical care nursing management has addressed the unique needs of this patient population during the postoperative recovery stage. Their specific physiologic and psychological differences identify them as having particular needs in regard to nursing care. For many years, cardiac patients were carefully screened and only those who had reduced risk factors were considered for surgery. Now there are increasing referrals of older patients with a range of conditions and increased risk factors. These people present with more difficult surgical problems and tend to have a complicated postoperative period. As a result they are proving to be a clinical management challenge. In light of the evidence presented, clear examination of the unique needs of the very elderly during the immediate postoperative phase is suggested to provide the basis for a comprehensive overhaul of patient management with positive implications for standards of care.

[Pre and perioperative factors determining early in-hospital mortality in patients over 75 years of age undergoing cardiac surgery]

INTRODUCTION AND OBJECTIVES

To know the in-hospital morbidity and mortality and the related factors in patients over 75 years old undergoing cardiac surgery.

PATIENTS AND METHODS

A retrospective analysis was carried out in 252 out of 2043 consecutive patients (129 female, 123 male) over 75 years of age (mean age 77.8 years; range 75 to 89 years) undergoing open heart surgery from january 1, 1994 to november 30, 1997. Isolated aortic valve replacement was performed in 128 patients, 78 underwent isolated coronary artery bypass grafting and 46 combined surgery. Preoperative determinants of morbidity and mortality were analyzed.

RESULTS

The overall hospital mortality was 15.1%, 13.2% in the aortic group, 12.8% in the coronary group and 23.9% in the combined surgery group. The overall morbidity rate was 38.6% and 25.8%, 34.2% in the aortic and coronary groups, respectively. Preoperative risk factors were prior surgery (p < 0.0004) and emergency operation (p < 0.04). In aortic valve replacement, NYHA class IV (p < 0.05), prior operation (p < 0. 01) and emergency surgery (p < 0.01) were determinant. Perioperative factors of early mortality were: prolonged cross-clamping > 60 min (p < 0.02), cardiopulmonary bypass time > 90 min (p < 0.002), need for inotropic drugs (p < 0.005) and postoperative complications (p < 0.00001). Mean postoperative length of hospital stay was 12.8 +/- 8. 5 days.

CONCLUSIONS

Despite the greater rate of early morbimortality in patients over 75 years of age, cardiac surgery may be performed avoiding emergency surgery, functional grade IV and prolonged length of surgery.

Functional status outcomes of patients with a coronary artery bypass graft over time

OBJECTIVE

To examine functional status outcomes among patients with a coronary artery bypass graft (CABG) over time (ie, at baseline; 3 months, 6 months, and 12 months after surgery) and the impact of selected patient characteristics (ie, age, sex, comorbidities, and cardiac rehabilitation participation) on functional outcomes.

DESIGN

A prospective, repeated-measures design was used to examine functional status in patients with a CABG over time.

SETTING

A midwestern community hospital and regional cardiac referral center was the setting for enrolling patients with a CABG.

OUTCOME MEASURES

Functional status outcomes were measured by using the Medical Outcomes Study (MOS) Short Form 36 (SF-36) and Modified 7-Day Activity instruments.

METHODS

Baseline data were obtained by patient interview in the hospital setting after CABG surgery. At 3 months, 6 months, and 12 months after surgery, telephone interviews were conducted to administer research instruments.

RESULTS

Baseline scores on 7 of the 8 subscales of the MOS SF-36 were significantly lower than at 3 months, 6 months, or 12 months after surgery. Role-emotional functioning baseline scores were not significantly lower than 3-month scores; however, baseline scores were significantly lower than 6-month and 12-month scores. Three-month subscale scores were also significantly lower than 6-month or 12-month scores except for the subscales measuring social and general health functioning. Functional status as measured by the Modified 7-Day Activity tool did not demonstrate any significant differences between 3-month, 6-month, or 12-month activity levels. There were no significant differences by age group on any of the 8 subscales of the MOS SF-36 instrument. Women and subjects with more than 1 comorbidity had a significantly lower preoperative level of physical functioning. Cardiac rehabilitation participants had lower preoperative scores on role-emotional functioning than subjects who were not in rehabilitation.

CONCLUSION

Findings from this study can assist nurses and other health care workers to gain a perspective of the recovery and rehabilitation trajectory of patients with a CABG. The results of the study provide a basis for determining areas of functional limitations during recovery from CABG surgery. Study results can also be the foundation for evaluating outcomes of patients with a CABG when specific interventions (eg, pain management, psychosocial support, physical strengthening, fatigue management) are implemented during hospitalization, home recovery, and rehabilitation to target optimal psychosocial and physiologic functioning of patients with a CABG.

Late outcomes of open heart surgery in patients 70 years or older

BACKGROUND

The purpose of this study is to examine the long-term survival and quality of life, including the influence of comorbidities, in patients 70 years of age and over after open heart surgery.

METHODS

This was a retrospective study of 401 consecutive patients, who were 70 years of age or older at the time of surgery. Survival and quality of life of these patients were measured at 6- to 8-year follow-up.

RESULTS

The 5-year survival rate was 85%, and was comparable with the age- and gender-matched West Virginia population. Survival declined with increasing preexisting comorbidities. Of the 176 respondents completing the quality of life (SF-36) survey, most scores were similar to or substantially better than the US population normative scores for individuals 70 years of age or older.

CONCLUSIONS

Survival rates vary by presence or absence of specific comorbid conditions. Quality of life in the appropriately selected elderly after open heart surgery appears to be similar to the US population normative scores.

Cardiac surgery in octogenarians--The Green Lane Hospital Experience 1995-1998

BACKGROUND

An increasing number of patients aged 80 years and over are being considered and accepted for cardiac surgery.

AIM

To review the experience of surgery in this elderly group of patients at our institution.

METHODS

Hospital records of octogenarians undergoing surgery between January 1995 and September 1998 were reviewed and follow-up was obtained by general practitioner (GP) and patient questionnaires.

RESULTS

Thirty-seven patients underwent cardiac surgery. The mean age was 82.8+/-1.4 years (range 80.8 to 86.2 years). Twenty-three (62%) were male. All were independent pre-operatively with severe symptoms and minor co-existing morbidity. All operations were urgent except two (emergency). Twenty patients (54%) had isolated coronary surgery, six (16%) aortic valve replacement alone, and 11 (30%) combined surgery. There were four (11%) early deaths and five (14%) peri-operative neurological events. The mean duration of post-operative intensive care stay was 2.4+/-3.9 days (range 0.05 to 16, median 1.0) and post-operative hospital stay 14.0+/-13.9 days (range 0 to 79, median 11). At the time of follow-up (mean duration 20.0+/-11.2 months) two further patients had died (non-cardiac). Twenty-six of the 31 survivors were living at home (23 independently), one with relatives, and four in residential care. Their cardiac symptoms were well controlled. The GPs of all hospital survivors, and all surviving patients themselves, felt that cardiac surgery had been beneficial.

CONCLUSIONS

Cardiac surgery in the very elderly has been reserved for those with severe disease or symptoms and little co-morbidity. Early mortality is higher than for the general population undergoing cardiac surgery, but post-operative resource use is acceptable and the intermediate-term outcome for survivors is good.

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients

OBJECTIVE

To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE).

METHODS

From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis.

RESULTS

Mean age (+/- standard deviation) was 62.5+/-10.7 (range 17-94 years) and 28% were female. Mean body mass index was 26.3+/-3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P = 0.001), female gender (P = 0.001), serum creatinine (P = 0.001), extracardiac arteriopathy (P = 0.001), chronic airway disease (P = 0.006), severe neurological dysfunction (P = 0.001), previous cardiac surgery (P = 0.001), recent myocardial infarction (P = 0.001), left ventricular ejection fraction (P = 0.001), chronic congestive cardiac failure (P = 0.001), pulmonary hypertension (P = 0.001), active endocarditis (P = 0.001), unstable angina (P = 0.001), procedure urgency (P = 0.001), critical preoperative condition (P = 0.001) ventricular septal rupture (P = 0.002), noncoronary surgery (P = 0.001), thoracic aortic surgery (P = 0.001).

CONCLUSION

A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.

[Arterial myocardial revascularization in the 9th decade of life. Personal results and review of the literature]

The rate of the population being 80 years of age and even older, has an increasing tendency in the Federal Republic of Germany. In 1996, a total of 87,372 patients received surgery supported by the heart-lung-machine, 2,383 patients out of these (2.7%) were 80 years of age and older. In view of the limited life expectance, the arterial revascularization in this age category is faced with controverse discussions. We analysed our patients in relation to this aspect. Between January 1, 1995 and June 30, 1997, 4,338 patients underwent surgery supported by the heart-lung-machine. Hundred and fifty-five out of these (3.6%) were in the 9th decade of life. Seventy-seven patients out of the 155 (49.7%, 34 women, 43 men, 80 to 88 years old, mean: 82 years of age) underwent an isolated myocardial revascularization. We performed 55 (71%) elective, 16 (21%) urgent and 6 (8%) emergency surgeries. Twelve patients (15.6%) solely received venous bypasses (Group I), 65 (84.4%) additionally also received unilateral bypasses of the internal mammaria artery (IMA) (Group II). Three patients died at our facility (3.9%), 3 further patients died during the follow-up treatment in outlying hospitals, the in-patient mortality rate in Group I therefore presented a rate of 8.3%, in Group II 7.7% and in total, a rate of 7.8%. In 1996, the in-patient mortality rate could be reduced to 3.6%. The follow-up observation time ranged between 7 and 138 weeks (median 44 weeks). The survival rate for patients with an IMA-bypass after 1 year was 86.3%, after 2 years 77%, and for the entire collective 85.3% and 75%. Whereas 96% of the patients could pre-operatively be related to Class III or IV of the NYHA-classification, 55 of the 63 survivors (87%) belonged to Class I (6%) or II (81%). Two Group I patients (22.2%), 3 Group II patients (5.6%) and 7.9% of the total collective complained about repeated angina symptoms. The myocardial revascularization with the internal mammaria artery performed on patients in the 9th decade of life, achieves an acceptable morbidity and mortality compared to solely venous coronary bypasses. The more prolonged follow-up observation period will clarify, whether the arterial myocardial revascularization also proves to be the superior method in this age category.

Cardiac surgery in the elderly

OBJECTIVE

There has been a gradual increase in the number of elderly patients referred for cardiac surgery. These patients present a difficult challenge, they are usually symptomatic yet at high risk for intervention. The aim of this study is to review our experience with cardiac surgery in patients aged 80 years or older.

PATIENTS AND METHODS

Between January 1981 and October 1997, 242 patients; 135 female, 107 male, mean age 82.8 years (range 80-95) underwent surgery on cardiopulmonary bypass in our unit. Surgery was performed on 14 as an emergency and 136 on an urgent (patient restricted to a hospital bed due to symptoms) basis. Pre-operatively 182 (75.2%) were in NYHA functional class 3 or 4.

RESULTS

Early mortality was 14 (5.7%). A mitral valve procedure and emergency surgery were significantly associated (P < 0.05) with an increased risk of operative mortality. Median ITU and in-hospital stay was 1 day (range 0-33) and 10 (range 6-49) days, respectively. Ninety-three percent of patients were living independently at home 2 months post-operatively. Survival (+/-SEM) is 98% complete (totals 557 patient years) and including early mortality at 1 and 5 years was 85.5+/-2.4% (n = 154), and 67.7+/-4.3% (n = 33). Survival for patients undergoing isolated aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) at 5 years was 64.8+/-7.8% and 79.7+/-7.4%, respectively. Survival was significantly worse in patients undergoing a mitral procedure. Using Cox's proportional hazards model only type of operation (mitral surgery) was significantly associated with worse survival.

CONCLUSION

Cardiac surgery can be performed in a selected elderly population with a low operative mortality. Post-operatively elderly patients attain an excellent quality of life and survival. Emergency and mitral surgery in this group of patients is less rewarding.

Is cardiac surgery justified in patients in the ninth decade of life?

BACKGROUND

Due to aging of the population the upper-age limit for cardiac operations has constantly been extended. In the current era of health care reform the ability to provide appropriate care for geriatric patients at acceptable costs is a major individual and societal concern. The objective of this study was to evaluate the results of cardiac surgery in octogenarians regarding overall morbidity and mortality as well as to quality of life.

METHODS

Between February 1992 and August 1995, 101 consecutive octogenarians underwent several types of cardiac operations. Operative procedures consisted of coronary artery bypass grafting (CABG) in 45 patients, valve replacement or repair in 33 patients, and combined CABG and combined procedures in 19 patients. All surviving patients were mailed a questionnaire 3 to 62 months (22.1+/-15.4 months) postoperatively concerning the postoperative course and quality of life (97.5% follow-up).

RESULTS

The early mortality was 15.5% in the CABG group, 3.0% in the valve group, and 21.7% in the combined procedure group; 5-year actuarial survival was 79.1% in the CABG group, 86.9% in the valve group, and 58.8% in the combined procedure group, respectively. The questionnaire sent to the survivors revealed that 81.0% of patients considered their functional status better or much better than before surgery. Of the survivors, 97.3% stated that according to their opinion the operation was worthwhile.

CONCLUSION

Cardiac surgery is justified for carefully selected patients in the ninth decade of life. Although these patients are at increased risk of operative death and surgical complications compared with younger patients, the majority regain a life expectancy in the range of that of the global population. Furthermore, they are presented the chance to retain or maintain an independent lifestyle.