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

Prediction models for prolonged intensive care unit stay after cardiac surgery: systematic review and validation study

BACKGROUND

Several models have been developed to predict prolonged stay in the intensive care unit (ICU) after cardiac surgery. However, no extensive quantitative validation of these models has yet been conducted. This study sought to identify and validate existing prediction models for prolonged ICU length of stay after cardiac surgery.

METHODS AND RESULTS

After a systematic review of the literature, the identified models were applied on a large registry database comprising 11 395 cardiac surgical interventions. The probabilities of prolonged ICU length of stay based on the models were compared with the actual outcome to assess the discrimination and calibration performance of the models. Literature review identified 20 models, of which 14 could be included. Of the 6 models for the general cardiac surgery population, the Parsonnet model showed the best discrimination (area under the receiver operating characteristic curve=0.75 [95% confidence interval, 0.73 to 0.76]), followed by the European system for cardiac operative risk evaluation (EuroSCORE) (0.71 [0.70 to 0.72]) and a model by Huijskes and colleagues (0.71 [0.70 to 0.73]). Most of the models showed good calibration.

CONCLUSIONS

In this validation of prediction models for prolonged ICU length of stay, 2 widely implemented models (Parsonnet, EuroSCORE), although originally designed for prediction of mortality, were superior in identifying patients with prolonged ICU length of stay.

Off-pump coronary artery revascularization in octogenarians: is it better?

PURPOSE OF REVIEW

Octogenarians are the fastest growing stratum of the population and have the highest prevalence of coronary artery disease. In the past, physicians have been reluctant to provide these patients with optimal care. Seniors are frequently excluded from large randomized trials and generally not included in published guidelines. The purpose of this review is to revisit the demography and epidemiology of coronary artery disease in this population as well as therapeutic strategies used.

RECENT FINDINGS

Recent publications have shown significant advancement in medical and invasive treatment of coronary artery disease in elderly, with special focus on the potential benefit of off-pump coronary artery bypass (OPCAB) surgery.

SUMMARY

Although OPCAB surgery has gained popularity over the past 15 years, its benefit regarding operative mortality and major complications has not been clearly defined in the general population. There is a body of literature supporting its benefit in the elderly population. OPCAB surgery has the potential of decreasing operative mortality and major postoperative complications such as stroke, delirium, atrial fibrillation, and decline in neurocognitive functions in these patients. Off-pump surgery is technically more demanding and has been blamed for providing less complete revascularization and lower graft patency rate, especially in less experienced hands. However, with the upcoming demographic explosion of senior citizens in western societies, OPCAB surgery has definitely to be a part of the armamentarium of modern cardiac surgeons.

Transcatheter aortic valve implantation: what has been done and what is going to be done

Transcatheter valve implantation is developing into an effective and reproducible therapy for aortic valve stenosis. The origin of this technique was pursued in 1992 when Andersen demonstrated the feasibility of percutaneous implantation of catheter-based valve prosthesis. Since then a lot of technical and device advances have been made and to date, transcatheter aortic valve implantation has became a concrete alternative to surgical replacement. This paper aims to go over all the current devices, from the most widely used to the newest technology, focusing on device description, procedural issues, potential complications and clinical studies currently available in literature.

Coronary artery bypass graft surgery in the elderly patients

The purpose of this retrospective study was to determine the results of coronary artery surgery in the elderly patients and to compare the outcome with a younger group. Two hundred thirteen patients aged 70 years and older who underwent on-pump coronary artery surgery were retrospectively studied and data were compared with those of 524 patients aged 50–69. The groups were similar with respect to preoperative characteristics except for sex distribution and the incidences of peripheral vascular disease and prior cerebrovascular accident. The use of internal mammarian artery grafts was significantly lower in the elderly patients (80.3% versus 91.6%, p<0.001). The 30-day mortality for the elderly group was 4.7% while that of younger group was 2.3%. The elderly patients had a significantly higher incidence of postoperative low cardiac output, pulmonary complications and acute renal failure. The elderly group also had also significantly longer intensive care unit length of stay (1.9 versus 1.7 days, p=0.006) and postoperative length of stay (10.1 versus 7.4 days, p<0.001). Although mortality and complication rates are higher, coronary artery surgery can be performed with acceptable risk in the elderly patients. Old age alone should not be a deterrent factor for surgical revascularization in coronary artery disease.

Incentive spirometry with expiratory positive airway pressure reduces pulmonary complications, improves pulmonary function and 6-minute walk distance in patients undergoing coronary artery bypass graft surgery

BACKGROUND

The use of the incentive spirometry (IS) with expiratory positive airway pressure (EPAP) to prevent postoperative pulmonary complications (PPC) after coronary artery bypass graft (CABG) is not well established. This study sought to determine the effects of IS+EPAP after CABG.

METHODS

Thirty-four patients undergoing CABG were randomly assigned to a control group or IS+EPAP group. Maximal respiratory pressures, pulmonary function test, 6-minute walk test and chest x-ray were performed at baseline as well as 1 week and 1 month after CABG.

RESULTS

Maximal inspiratory pressure was significantly higher in the IS+EPAP group compared to controls at both 1 week and 1 month (P<.001). Maximal expiratory pressure was significantly higher at 1 month compared to 1 week in IS+EPAP group (P<.01). At 1 month, forced vital capacity and forced expiratory volume in 1 second was significantly higher in IS+EPAP compared to controls (P<.05). Inspiratory capacity was higher at 1 month in IS+EPAP group compared to controls (P<.05). The distance walked in 6-minute walk test was higher at 1 month in IS+EPAP group (P<.001) compared to controls. Lastly, radiological injury score at 1 week was lower in IS+EPAP compared to controls (P<.004).

CONCLUSIONS

In patients undergoing CABG, IS+EPAP results in improved pulmonary function and 6-minute walk distance as well as a reduction in PPC.

Aortic surgery requiring hypothermic circulatory arrest in octogenarians

BACKGROUND

Recent improvements in the outcomes of cardiovascular operation in octogenarians have resulted in an increase in the number of referrals of elderly patients for aortic surgery requiring hypothermic circulatory arrest.

METHODS

This was a retrospective chart review.

RESULTS

Between 2000 and 2007, 12 octogenarians with aortic aneurysms underwent surgery requiring hypothermic circulatory arrest. There were seven men with a median age of 83 years (range, 80-87 years). Diagnoses of aortic disease included acute type A aortic dissection in seven patients and degenerative thoracic aneurysm in five. Operation was performed through median sternotomy in eight patients and posterolateral thoracotomy in four. The median duration of hypothermic circulatory arrest was 50 minutes (range, 15-84 minutes). Method of brain protection during hypothermia was selective antegrade cerebral perfusion in five patients, retrograde cerebral perfusion in two, and arrest alone in five. The hospital mortality rate was 8%. Major postoperative complications occurred in six (50%) patients, with transient neurologic dysfunction in two patients and no stroke.

CONCLUSION

Although postoperative complications were common, the clinical outcome of aortic surgery requiring hypothermic circulatory arrest was acceptable.

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.

Coronary Artery Bypass Grafting: Patients' and Health Professionals' Views of Recovery After Hospital Discharge

Background: Coronary artery bypass grafting (CABG) is effective in relieving symptoms and reducing mortality but some patients report no improvement or a decline in quality of life and hence do not experience a good recovery after surgery. Little published research has explored patients' and particularly health professionals' views on barriers and facilitators to recovery or the processes by which these factors affect recovery.

Aims: To identify post-discharge facilitators and barriers to recovery after CABG.

Methods: Semi-structured interviews were conducted with 11 patients who had previously undergone elective, isolated, first-time CABG and with 10 health professionals experienced in caring for these patients.

Results: Thematic analysis identified the following themes: person characteristics, including the impact on recovery of anxiety, depression, optimism and determination; rehabilitation classes; social support; and the effect of surgery. Findings indicate a complex relationship between the various barriers and facilitators to recovery and explore possible processes by which these influences on recovery operate.

Conclusions: Findings have indicated areas where health professionals can intervene to aid patients' long-term recovery, and thereby maximise the benefits of CABG, by providing information, support and reassurance particularly to patients who appear anxious and/or depressed.

Age deteriorates palmar microcirculation following radial artery harvesting

The effect of age as a risk factor for deterioration of palmar microcirculation after radial artery harvesting for coronary revascularization is unknown. In 114 patients aged 61.7 +/- 6.7 years undergoing radial artery harvesting, superficial and deep tissue oxygen saturation, postcapillary venous filling, and capillary blood flow were determined using a combined laser Doppler spectrophotometry system 25 +/- 5 months after surgery. Superficial and deep oxygen saturation at the harvested thenar eminence decreased with age. In the nondonor hand, oxygen saturation declined in the first and second digits. Postcapillary venous filling pressure in both thenars increased with age. It was concluded that neurological complications do not correlate with age. Palmar tissue oxygen saturation, palmar capillary blood flow, and blood velocity decrease, while postcapillary venous filling pressure significantly increases with age. Radial artery harvesting for coronary revascularization does not compromise palmar microcirculation to the same extent as age. A cut-off value of <or= 67 years was determined by microcirculatory assessment; beyond this, significant deterioration of palmar microcirculation is more likely to occur.

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.