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Ludski J, Carp B, Makar T, Yii M, Lee DK, Weinberg L. Outcomes and complications of nonagenarians undergoing cardiac surgery: a scoping review protocol. BMJ Open 2023; 13:e072293. [PMID: 37463807 PMCID: PMC10357299 DOI: 10.1136/bmjopen-2023-072293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Continually rising life expectancy and a shift towards an ageing population are resulting in an increasing population of nonagenarians. By 2030, the global population of nonagenarians is expected to exceed 30 million. The incidence of symptomatic cardiac disease is reported to occur in 25% of those aged over 75 years. Therefore, the number of nonagenarians undergoing cardiac surgery is also expected to increase. A linear relationship between advanced age and surgical risk has previously been demonstrated; however, it is not yet known whether this knowledge extends to the perioperative course and mortality of nonagenarians undergoing cardiac surgery. This scoping review aims to review the literature, assess whether a deficiency exists in the published literature and potentially identify knowledge gaps to guide future efforts to improve the understanding of nonagenarians undergoing cardiac surgery. METHODS AND ANALYSIS Following the relevant aspects of the Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Review guidelines, electronic databases of MEDLINE, EMBASE and the Cochrane Library will be systematically searched, with additional reference tracking of eligible studies. Studies reporting the outcomes of nonagenarians undergoing open cardiac surgery or minimally invasive cardiac surgery requiring cardiopulmonary bypass will be included. Screening and data extraction will be performed by two reviewers independently. The data will be analysed and summarised descriptively with a narrative approach. Qualitative data that capture quality-of-life outcomes will be subjected to thematic analysis where feasible. Additionally, reporting results will highlight similarities and differences in nonagenarian selection for surgery. ETHICS AND DISSEMINATION Ethics approval was not required. The findings will be disseminated through professional networks, conference presentations and publications in scientific journals.
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Affiliation(s)
- Jarryd Ludski
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Bradly Carp
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Tim Makar
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Michael Yii
- Department of Cardiac Surgery, Epworth Eastern Hospital, Box Hill, Victoria, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Korea (the Republic of)
| | - Laurence Weinberg
- Department of Anesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, University of Melbourne, Parkville, Victoria, Australia
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Frailty Is Superior to Age for Predicting Readmission, Prolonged Length of Stay, and Wound Infection in Elective Otology Procedures. Otol Neurotol 2022; 43:937-943. [PMID: 35970157 DOI: 10.1097/mao.0000000000003636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the predictive ability of the 5-point modified frailty index relative to age in elective otology patients. STUDY DESIGN Retrospective database analysis. SETTING Multicenter, national database of surgical patients. PATIENTS We selected all elective surgical patients who received tympanoplasty, tympanomastoidectomy, mastoidectomy, revision mastoidectomy, and cochlear implant procedures from 2016 to 2019 from the National Surgical Quality Improvement database. INTERVENTIONS Therapeutic. MAIN OUTCOME MEASURES Readmission rates, discharge disposition, reoperation rates, and extended length of hospital stay. RESULTS Utilizing receiver operating characteristics with area under the curve (AUC) analysis, nonrobust status was determined to be a superior predictor relative to age of readmission (AUC = 0.628 [p < 0.001] versus AUC = 0.567 [p = 0.047], respectively) and open wound infection relative to age (AUC = 0.636 [p = 0.024] versus AUC = 0.619 [p = 0.048], respectively). Nonrobust otology patients were more likely to have dyspnea at rest and an American Society of Anesthesiology score higher than 2 before surgery (odds ratios, 13.304 [95% confidence interval, 2.947-60.056; p < 0.001] and 7.841 [95% confidence interval, 7.064-8.704; p < 0.001], respectively). CONCLUSION Nonrobust status was found to be a useful predictor of readmission and prolonged length of stay in patients undergoing elective otology procedures, which generally have low complication rate. Given the aging population and corresponding increase in otology disease, it is important to use age-independent risk stratification measures. Frailty may provide a useful risk stratification tool to select surgical candidates within the aging population.
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Weinberg L, Walpole D, Lee DK, D'Silva M, Chan JW, Miles LF, Carp B, Wells A, Ngun TS, Seevanayagam S, Matalanis G, Ansari Z, Bellomo R, Yii M. Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study. Front Cardiovasc Med 2022; 9:865008. [PMID: 35911518 PMCID: PMC9330044 DOI: 10.3389/fcvm.2022.865008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care. Methods After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012–December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients. Results A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90–94] and the median body mass index was 25.0 (kg/m2) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility. Conclusion In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- *Correspondence: Laurence Weinberg
| | - Dominic Walpole
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Dong Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - Michael D'Silva
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Jian Wen Chan
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Lachlan Fraser Miles
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Bradly Carp
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | - Adam Wells
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, VIC, Australia
| | - Tuck Seng Ngun
- Department of Anaesthesia, Austin Health, Melbourne, VIC, Australia
| | | | - George Matalanis
- Department of Cardiac Surgery, Austin Health, Melbourne, VIC, Australia
| | - Ziauddin Ansari
- Department of Intensive Care, Epworth Eastern Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Michael Yii
- Department of Cardiac Surgery, Epworth Eastern Hospital, Melbourne, VIC, Australia
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MacDowall J, Tully P, Guha R, Ferguson M, Tan C, Weinberg L. Characteristics, comorbidity burden and outcomes in centenarians undergoing surgery in a university hospital: A case series. Int J Surg Case Rep 2021; 88:106563. [PMID: 34743060 PMCID: PMC8578033 DOI: 10.1016/j.ijscr.2021.106563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/30/2021] [Accepted: 10/30/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction As the population ages, so too does the age of those requiring surgery. People over the age of 100, centenarians, often have a greater degree of comorbidity and frailty than their younger counterparts but may also have a greater incidence of events requiring surgical intervention. There is, however, a dearth of literature describing the clinical course and practical considerations for this vulnerable population undergoing surgery. We aimed to describe the demographics of centenarians undergoing surgery, the procedures they receive, their intraoperative anaesthesia management, and their postoperative outcomes. Presentation of cases A retrospective cohort study was completed to understand key perioperative and intraoperative variables linked to improved outcomes. Of the 25 patients included in this study, 22 (88%) were female and the median age was 101 years. Emergency cases predominated (72%) and 44% of surgeries occurred after hours. 60% underwent an intermediate risk surgery, and no centenarians underwent high risk surgery in this study period. Discussion 64% of patients experienced at least one episode of intraoperative hypotension, with a median 3.5 epochs per patient. 68% of patients experienced postoperative complications and 20% of patients had a complication of Clavien-Dindo severity ≥ III. In centenarians, the risk of high severity postoperative complications was independent of the intrinsic procedural risk. Conclusion Centenarian patients have an elevated burden of comorbidity, presenting often in the emergent setting. However, age alone should not preclude surgical intervention as expert multidisciplinary care can have acceptable outcomes. Centenarian patients undergoing surgery are frail Most centenarian patients experience postoperative complications Surgery in centenarians can be feasible and undertaken safely Appropriate patient selection leads to acceptable outcomes Centenarians should not be denied surgery based on age alone
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Affiliation(s)
| | - Patrick Tully
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Ranj Guha
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | | | - Chong Tan
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Melbourne, Australia; Department of Surgery, The University of Melbourne, Austin Health, Melbourne, Australia; Department of Critical Care, The University of Melbourne, Melbourne, Australia.
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