Twenty Years of Cardiac Surgery in Patients Aged 80 Years and Older: Risks and Benefits

Clinical Outcomes after Surgical Aortic Valve Replacement in 681 Octogenarians: A Single-Center Real-World Experience Comparing the Old Patients with the Very Old Patients

Aortic valve disease is a lethal condition, once it becomes symptomatic. Surgical aortic valve replacement (SAVR) has, for a long time, been the only treatment option. In patients aged 85 and older, the consequences of SAVR have rarely been investigated. A total of 681 octogenarian patients were subdivided into a group with patients between 80 and 84 years (n = 527) and a group with patients aged 85 or older (n = 154). For each group, the temporal referral pattern, preoperative comorbid profile, operative data, postoperative need for resources, and adverse postoperative events including 30-day mortality and long-term survival were determined using the chi-squared test, Student's t-test, and log-rank test. For both age groups, the predictors for mortality were identified using a logistic regression analysis. In the oldest patient group, there were significantly more prior episodes of heart failure (75/154 vs. 148/527) and a greater need for urgent SAVR (45/150 vs. 109/515). The operative data and the need for postoperative resources were comparable, but the 30-day mortality was almost twice as high (24/154 vs. 45/527). The need for urgent SAVR was twice as high in the oldest group (odds ratio of 3.12 vs. 6.64). A logistic regression analysis for all 681 patients showed that age over 85 ranked fourth of six predictors for 30-day mortality. Five-year survival was favorable for both groups (67.8 ± 2.1% vs. 60.0 ± 4.3%). A Cox proportional hazard analysis failed to identify an age over 85 as a predictor for long-term mortality. Aortic valve disease and its effect on the left ventricle seemed to be more advanced in the highest age group. The mortality rate was almost double the need for urgent SAVR. This can be avoided by obtaining an earlier referral.

Long-Term Survival among Octogenarians Undergoing Aortic Valve Replacement with or without Simultaneous Coronary Artery Bypass Grafting: A 22-Year Tertiary Single-Center Experience

BACKGROUND

The impact of concomitant coronary artery bypass grafting (CABG) on aortic valve replacement (AVR) in octogenarians is still debated. We analyzed the characteristics and long-term survival of octogenarians undergoing isolated AVR and AVR + CABG.

METHODS

All octogenarians who consecutively underwent AVR with or without concomitant CABG at our tertiary cardiac center between 2000 and 2022 were included. Patients with redo, emergent, or any other concomitant procedures were excluded. The primary endpoints were 30-day and long-term survival. The secondary endpoints were early postoperative outcomes and determinants of long-term survival. Univariable and multivariable logistic regression analyses were performed to identify independent predictors of 30-day mortality, and Cox regression analysis was performed for predictors of adverse long-term survival.

RESULTS

A total of 1011 patients who underwent AVR (83.0 [81.0-85.0] years, 42.0% males) and 1055 with AVR + CABG (83.0 [81.2-85.4] years, 66.1% males) were included in our study. Survival at 30 days and at 1, 3, and 5 years in the AVR group was 97.9%, 91.5%, 80.5%, and 66.2%, respectively, while in the AVR + CABG group it was 96.2%, 89.6%, 77.7%, and 64.7%, respectively. There was no significant difference in median postoperative survival between the AVR and AVR + CABG groups (7.1 years [IQR: 6.7-7.5] vs. 6.6 years [IQR: 6.3-7.2], respectively, p = 0.21). Significant predictors of adverse long-term survival in the AVR group included age (hazard ratio (HR): 1.09; 95% CI: 1.06-1.12, p < 0.001), previous MI (HR: 2.08; 95% CI: 1.32-3.28, p = 0.002), and chronic kidney disease (HR 2.07; 95% CI: 1.33-3.23, p = 0.001), while in the AVR + CABG group they included age (HR: 1.06; 95% CI: 1.04-1.10, p < 0.001) and diabetes mellitus (HR: 1.48; 95% CI: 1.15-1.89, p = 0.002). Concomitant CABG was not an independent risk factor for adverse long-term survival (HR: 0.89; 95% CI: 0.77-1.02, p = 0.09).

CONCLUSIONS

The long-term survival of octogenarians who underwent AVR or AVR + CABG was similar and was not affected by adding concomitant CABG. However, octogenarians who underwent concomitant CABG with AVR had significantly higher in-hospital mortality. Each decision should be discussed within the heart team.

Clinical Results and Quality of Life after Nonelective Cardiac Surgery in Octogenarians

Background We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery.

Patients and Methods We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model.

Results The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1–39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0–1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30–51) for the elective patients and 42 (35–49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48–60) and 58 (52–60), respectively (p = 0.351).

Conclusion Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.

The impact of coronary artery bypass grafting added to aortic valve replacement on long-term outcomes in octogenarian patients: a reconstructed time-to-event meta-analysis

The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.

The early and long-term outcomes of coronary artery bypass grafting added to aortic valve replacement compared to isolated aortic valve replacement in elderly patients: a systematic review and meta-analysis

In aged population, the early and long-term outcomes of coronary revascularization (CABG) added to surgical aortic valve replacement (SAVR) compared to isolated SAVR (i-SAVR) are conflicting. To address this limitation, a meta-analysis comparing the early and late outcomes of SAVR plus CABG with i-SAVR was performed. Electronic databases from January 2000 to November 2021 were screened. Studies reporting early-term and long-term comparison between the two treatments in patients over 75 years were analyzed. The primary endpoints were in-hospital/30-day mortality and overall long-term survival. The pooled odd ratio (OR) and hazard ratio (HR) with 95% confidence interval (CI) were calculated for in-early outcome and long-term survival, respectively. Random-effect model was used in all analyses. Forty-four retrospective observational studies reporting on 74,560 patients (i-SAVR = 36,062; SAVR + CABG = 38,498) were included for comparison. The pooled analysis revealed that i-SAVR was significantly associated with lower rate of early mortality compared to SAVR plus CABG (OR = 0.70, 95% CI 0.66–0.75; p < 0.0001) and with lower incidence of postoperative acute renal failure (OR = 0.65; 95% CI 0.50–0.91; p = 0.02), need for dialysis (OR = 0.65; 95% CI 0.50–0.86; p = 0.002) and prolonged mechanical ventilation (OR = 0.57; 95% CI 0.42–0.77; p < 0.0001). Twenty-two studies reported data of long-term follow-up. No differences were reported between the two groups in long-term survival (HR = 0.95; 95% CI  0.87–1.03; p = 0.23). CABG added to SAVR is associated with worse early outcomes in terms of early mortality, postoperative acute renal failure, and prolonged mechanical ventilation. Long-term survival was comparable between the two treatments.

Impact of comorbidities on older patients undergoing open heart surgery

BACKGROUND

The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery.

METHODS

Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019.

RESULTS

In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death.

CONCLUSION

Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Long-term outcomes of hospital survivors following an ICU stay: A multi-centre retrospective cohort study

Background

The focus of much Intensive Care research has been on short-term survival, which has demonstrated clear improvements over time. Less work has investigated long-term survival, and its correlates. This study describes long-term survival and identifies factors associated with time to death, in patients who initially survived an Intensive Care admission in Victoria, Australia.

Methods

We conducted a retrospective cohort study of adult patients discharged alive from hospital following admission to all Intensive Care Units (ICUs) in the state of Victoria, Australia between July 2007 and June 2018. Using the Victorian Death Registry, we determined survival of patients beyond hospital discharge. Comparisons between age matched cohorts of the general population were made. Cox regression was employed to investigate factors associated with long-term survival.

Results

A total of 130,775 patients from 23 ICUs were included (median follow-up 3.6 years post-discharge). At 1-year post-discharge, survival was 90% compared to the age-matched cohort of 98%. All sub-groups had worse long-term survival than their age-matched general population cohort, apart from elderly patients admitted following cardiac surgery who had better or equal survival. Multiple demographic, socio-economic, diagnostic, acute and chronic illness factors were associated with long-term survival.

Conclusions

Australian patients admitted to ICU who survive to discharge have worse long-term survival than the general population, except for the elderly admitted to ICU following cardiac surgery. These findings may assist during goal-of-care discussions with patients during an ICU admission.

Long-term survival after surgical aortic valve replacement in patients aged 80 years and over

 

OBJECTIVES

Surgical aortic valve replacement can be safely performed in people aged 80 years and older with early benefits on both symptomatic and prognostic ground. While new approaches are advocated to treat this elderly and frail population, data on long-term outcomes are not available.

METHODS

We conducted a retrospective analysis of 1870 patients aged 80 years and over who underwent first time surgical aortic valve replacement during the period 2000-2019. The Kaplan-Meier method was used to calculate survival and comparisons among groups were performed by log-rank test. Cox analysis was used to determine the independent risk factors for late mortality.

RESULTS

The patients' mean age was 84 years and 53% were male. Isolated aortic valve replacement was performed in 42% of the patients, and coronary artery bypass grafting (n = 956), mitral valve (n = 94) or aortic surgery (n = 69) were associated in the remaining cases. One hundred eighty-one patients (8%) sustained at least 1 postoperative complication (reopening for bleeding or tamponade 3%, renal replacement therapy 3%, new cerebral stroke 1.5%). In-hospital mortality was 3.2% in the overall population (60/1870) and 2.2% after isolated aortic valve replacement (18/790). Survival was 90%, 66%, 31% and 14% at 1, 5, 10 and 15 years, respectively, and was similar to the expected survival of a sex- and age-matched population (log-rank P = 0.96). A complicated postoperative course was an independent risk factor for mortality during the follow-up [hazard ratio 1.32 (1.03, 1.68), P = 0.026].

CONCLUSIONS

Surgical aortic valve replacement can be performed with an acceptable early mortality rate and provides excellent long-term survival in people aged 80 years and older.

Impact of sarcopenia on the progress of cardiac rehabilitation and discharge destination after cardiovascular surgery

[Purpose] To investigate the factors that affect the progress of cardiac rehabilitation, length of stay in the hospital, and discharge destination after cardiovascular surgery. [Participants and Methods] This was a prospective observational study. Sixty-seven patients scheduled to undergo open-heart surgery were included in the study. We evaluated physical and psychiatric functions pre- and post-surgery. Sarcopenia was defined as a short physical performance battery score of <9.5. [Results] Sarcopenia was a significant factor of delay of the day of the first rehabilitation, independence in 100-m walking, and exercise training at the rehabilitation gym. Comparisons between pre- and post-surgery were performed in the sarcopenia group. No significant decreases in physical and psychiatric functions were found. The discharge transfer rate was significantly different between the sarcopenia and non-sarcopenia groups. Sarcopenia and the decline in balance score significantly correlated with discharge transfer. [Conclusion] Cardiac rehabilitation can achieve recovery of physical and psychiatric functions even in patients with sarcopenia; however, the discharge transfer rate among the patients with sarcopenia was high. Improving balance ability may result in early home discharge.

Association of Preoperative Geriatric Assessment With Length of Stay After Combined Cardiac Surgery

BACKGROUND

For older patients undergoing cardiac surgery, geriatric factors are known to increase postoperative complications and prolong length of stay (LOS). Comprehensive geriatric assessment (CGA) is an evidence-based method for geriatric evaluation to develop an individualized-care plan to optimize physical, functional, and social issues. This study analyzed the association between preoperative CGA and hospital LOS after combined cardiac surgery.

METHODS

This retrospective monocentric study included all patients aged 75 years and greater who underwent combined cardiac surgery between 2014 and 2017. Hospital LOS, intensive care unit LOS, and postoperative complications were compared between patients with or without preoperative CGA before and after propensity-score matching.

RESULTS

Mean age of the 407 patients was 79.6 years; 114 underwent a preoperative CGA (28%). For 305 patients (74.9%), coronary artery bypass was associated with aortic valve replacement. After propensity-score matching, a significant difference was found between the 2 groups (preoperative CGA versus none) for in-hospital LOS (12 versus 13 days; P = .04) and intensive care unit LOS (3 versus 4 days; P = .01). In multivariable analysis, a significant association remained between hospital LOS and CGA (P = .02), renal function (P = .02), mitral replacement (P = .001), and complications (P = .001).

CONCLUSIONS

Our results favor the use of systematic preoperative CGA. These encouraging results need to be validated by prospective studies that assess the impact of individualized-care plan established after CGA on postoperative outcomes. With an aging population, efforts are required to determine how to implement preoperative individualized-care plans to improve postoperative outcomes for vulnerable patients undergoing cardiac surgery.

Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older

Degenerative aortic stenosis is the most common structural heart valve disease affecting the aging population. Catheter-based heart valve interventions are less invasive and very useful for very elderly patients. However, we often consider open heart surgery for these patients because of anatomical reasons and co-existing cardiac diseases, i.e., severe coronary artery disease. We aimed to analyze the outcomes of very elderly patients aged ≥ 85 years undergoing aortic valve replacement (AVR) with or without coronary artery bypass grafting (CABG). Twenty-nine very elderly patients aged ≥ 85 years who underwent AVR with CABG (n = 11, Group AC) or isolated AVR (n = 18, Group A) were examined. The overall mean age of the patients was 87.2 ± 2.6 (range 85-94) years. The estimated operative mortality rate, calculated using the Japan score, EuroSCORE II, and STS risk score, was 5.72%-10.88% in Group AC and 5.63%-8.30% in Group A. Aortic cross-clamp time (126.5 ± 29.0 vs. 96.9 ± 29.2 min, p = 0.016) was significantly longer in Group AC than in Group A. Although the major morbidity rate was higher in Group AC than in Group A (36% vs. 6%, p = 0.0336), the length of intensive care unit stay and hospital stay was comparable between both groups. There was no 30-day and hospital mortality in both groups. Eleven patients died during follow-up (senility, 5; cerebrovascular events, 2; renal failure, 1; unknown, 3). There were no significant differences in survival rates during follow-up (log-rank p value = 0.1051). The 1-, 2-, 3-, 4- and 5-year survival rates were 91%, 80%, 69%, 69% and 69%, respectively, in Group AC and 94%, 94%, 94%, 94% and 88%, respectively, in Group A. In conclusion, AVR with or without CABG could be safely performed in carefully selected very elderly patients with acceptable early- and long-term results. AVR with CABG in very elderly patients aged ≥ 85 offers similar results to isolated AVR in terms of 30-day mortality, hospital mortality, and long-term survival.

Surgical treatment of elderly patients with severe aortic stenosis in the modern era - review

Surgical treatment of severe aortic stenosis offers good early and long-term results, even in elderly patients. Despite the implementation of percutaneous methods for the very high-risk group, surgical valve replacement remains the gold standard. The advanced age of patients should not be the only indicator limiting the possibility of surgery. In this review we present the most important information on the results of aortic stenosis surgical treatment in the groups of older patients. New methods such as percutaneous and minimally invasive methods of surgery are also discussed. Additionally, the presented information is referred to current guidelines for the treatment of severe aortic stenosis.

Long term outcomes of radial artery grafting in patients undergoing coronary artery bypass surgery

Single arterial left internal thoracic artery (LITA) based coronary artery bypass surgery (LITA-SABG) has been the principal revascularization strategy for over 25 years across all patient demographics. In line with the current emphasis being placed on personalized medicine, which tailors individual, patient-specific therapy to optimize outcomes, coronary artery bypass grafting (CABG) techniques have also evolved to achieve enhanced results among specific groups of patients with coronary artery disease. Most notable has been the development of multi-arterial bypass grafting (MABG) techniques, using either the radial artery (RA) or the right internal thoracic artery (RITA) in conjunction with the LITA, as both techniques have been shown to enhance long term survival of CABG patients. This article reviews the latest data on the long-term outcomes of RA-MABG and considers its impact in various sub-cohorts of CABG that are increasingly being treated by cardiac surgeons. The primary aim of this review is to highlight the advantages of RA-MABG over LITA-SABG and thereby potentiate its adoption into clinical practice. Our secondary aim is to summarize the results of RA-MABG in specific CABG sub-cohorts, to more closely align CABG surgery with the emerging consensus that personalized medicine enhances healthcare value.

Clinical Outcomes of Elderly Patients with Non ST-Segment Elevation Myocardial Infarction Undergoing Coronary Artery Bypass Surgery

The aim of this study is to investigate the clinical outcomes of the elderly patients with Non ST-segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass surgery (CABG) compared to non-elderly patients. Patients with NSTEMI and undergoing CABG (n=451) who were registered in the Korea Acute Myocardial Infarction Registry between December 2003 and August 2012 were divided into two groups.; the non-elderly group (<75 years, n=327) and the elderly group (≥75 years, n=124). In-hospital mortality was higher in the elderly group (4.9% vs. 11.3%, p=0.015), but cardiac death, myocardial infarction, and major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, percutaneous revascularization, and redo-CABG after a one-year follow up were not different between the two groups. Predictors of in-hospital mortality in patients with NSTEMI undergoing CABG were left ventricular (LV) dysfunction (ejection fraction ≤40%) [hazard ratio (HR): 2.76, 95% confidence interval (CI): 1.16–6.57, p=0.022] and age (HR: 1.05, 95% CI: 1.01–1.10, p=0.047). So elderly NSTEMI patients should be considered for CABG if appropriate, but careful consideration for surgery is required, especially if the patients have severe LV systolic dysfunction.

Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.

Is the EuroSCORE II reliable to estimate operative mortality among octogenarians?

Objectives

Concerns have been raised about the predictive performance (PP) of the EuroSCORE I (ES I) to estimate operative mortality (OM) of patients aged ≥80. The EuroSCORE II (ES II) has been described to have better PP of OM but external validations are scarce. Furthermore, the PP of ES II has not been investigated among the octogenarians. The goal of the study was to compare the PP of ES II and ES I among the overall population and patients ≥ 80.

Methods

The ES I and ES II were computed for 7161 consecutive patients who underwent major cardiac surgery in a 7-year period. Discrimination was assessed by using the c- index and calibration with the Hosmer-Lemeshow (HL) and calibration plot by comparing predicted and observed mortality.

Results

From the global cohort of 7161 patients, 832 (12%) were ≥80. The mean values of ES I and ES II were 7.4±9.4 and 5.2±9.1 respectively for the whole cohort, 6.3±8.6 and 4.7±8.5 for the patients <80, 15.1±11.8 and 8.5±11.0 for the patients ≥80. The mortality was 9.38% (≥80) versus 5.18% (<80). The discriminatory power was good for the two algorithms among the whole population and the <80 but less satisfying among the ≥80 (AUC 0.64 [0.58–0.71] for ES I and 0.67 [0.60–0.73] for the ES II without significant differences (p = 0.35) between the two scores. For the octogenarians, the ES II had a fair calibration until 10%-predicted values and over-predicted beyond.

Conclusions

The ES II has a better PP than the ES I among patients <80. Its discrimination and calibration are less satisfying in patients ≥80, showing an overestimation in the elderly at very high-surgical risk. Nevertheless, it shows an acceptable calibration until 10%- predicted mortality.

Quality of life in elder adults one-year after coronary bypass

BACKGROUND

Survival rates in the elderly after cardiac surgery have improved over the last decades and therewith more attention is directed toward Quality of Life (QoL) as a patient reported outcome measure.

OBJECTIVE

The purpose of this study was to explore QoL in patients one year after coronary artery bypass grafting, with special interest in the elderly patients (≥80 years).

METHODS

In a quantitative, retrospective single-center study patients with isolated coronary artery bypass grafting (eg, nonvalve) surgery aged 80 years or older and operated in 2013 were included (n = 32). A control group of patients aged younger than 80 years was selected by matching based on gender and a recalculated (for age) logistic European System for Cardiac Operative Risk Evaluation (log EuroSCORE I) during the same period (n = 48). QoL assessment by the EuroQol questionnaire (EQ-5D) and additional questions were performed at one-year follow-up.

RESULTS

QoL in elderly patients was 0.79 versus 0.90 in younger patients (P = 0.013). Overall, 54.8% of the elderly experience some or extreme problems in mobility versus 18.8% in the younger group (P = 0.001). Elderly patients also experience more problems in self care (19.3 vs 4.2%, P = 0.029). Nine of the elderly (29%) valued their postoperative health status to be worse than preoperatively versus 5 (10%) in the younger group (P = 0.028). Only patients aged 80 years or older would choose not to have surgery again (12.9%). Hospital mortality was 3.1% in the elderly group (n = 32) and 0% in the younger group (n = 48).

CONCLUSION

Not all elderly patients experience benefits in terms of QoL one year after cardiac surgery. Therefore, potential benefits and risks need to be considered and discussed by physicians and patients before making the decision to operate or not.

Isolated and Combined Valve Surgery in Elderly Patients: A Comparison of Mid-Term Results

BACKGROUND

This study examined mid-term outcomes of valve surgery in the elderly, and focused on the difference in outcomes between isolated and combined valve surgery.

METHODS

From January 2012 to June 2016, 113 consecutive patients aged 75 years and older underwent valve surgery. In all, 60 underwent isolated valve surgery (Group I), and 53 underwent combined valve surgery (Group C) involving the combination of any valve procedures or valve surgery with concurrent other procedure. Short- and mid-term outcomes were compared between the two groups.

RESULTS

There was no significant difference in length of intensive care unit stay (2.8 days in Group S vs. 4.2 days in Group C, p = 0.08), hospital stay (16.2 vs. 18.7 days, p = 0.22), and mechanical ventilation (11.2 vs. 15.0 hours, p = 0.28). Neither was there any significant difference in operative mortality (1.6% vs. 5.6%, p = 0.25) nor morbidity (8.3% vs. 9.4%, p = 0.83) between the two groups. Actuarial survival rates at 1 and 3 years were 98.3% in Group S and 92.0% in Group C (log-rank p = 0.126).

CONCLUSION

Once patients have tolerated combined surgery during the early postoperative period, good survival rates equaling those of isolated valve surgery can be expected.

Impact of post-hospital cardiac rehabilitation on the quality of life of patients after surgical treatment for coronary artery disease

INTRODUCTION

The quality of life of cardiovascular patients is worse than that of healthy individuals. Pain, dyspnea, and fatigue impair daily activities, which in turn leads to decreased life satisfaction and emotional deterioration. The objective of comprehensive treatment, including early rehabilitation, is to reduce the risk of complications, progression, and recurrence of the disease, as well as to restore, maintain, or improve all aspects of the patient's quality of life to the greatest extent possible.

AIM

To assess the quality of life of patients who underwent surgical treatment for coronary artery disease and completed the second phase of cardiac rehabilitation.

MATERIAL AND METHODS

The study enrolled 100 patients undergoing early cardiac rehabilitation in stationary conditions after coronary artery bypass grafting. The group included 21 women and 79 men; their age ranged from 40 to 75 years. The study employed a questionnaire of our own design.

RESULTS

Post-hospital cardiac rehabilitation resulted in quality of life improvements, especially with regard to psychological aspects, reducing the occurrence of anxiety from 44% to 21%. In addition, the rehabilitation program reduced the occurrence of subjective ailments such as chest pain (from 68% to 10%), fatigue (from 40% to 33%), and dyspnea (from 50% to 12%).

CONCLUSIONS

Despite the achievement of quality of life improvements among patients after surgery coronary artery by-pass grafting and early cardiac rehabilitation, the result is not fully satisfactory. Systematic treatment and education should be continued to further improve the health of patients.

Reduced Long-Term Relative Survival in Females and Younger Adults Undergoing Cardiac Surgery: A Prospective Cohort Study

OBJECTIVES

To assess long-term survival and mortality in adult cardiac surgery patients.

METHODS

8,564 consecutive patients undergoing cardiac surgery in Trondheim, Norway from 2000 until censoring 31.12.2014 were prospectively followed. Observed long-term mortality following surgery was compared to the expected mortality in the Norwegian population, matched on gender, age and calendar year. This enabled assessment of relative survival (observed/expected survival rates) and relative mortality (observed/expected deaths). Long-term mortality was compared across gender, age and surgical procedure. Predictors of reduced survival were assessed with multivariate analyses of observed and relative mortality.

RESULTS

During follow-up (median 6.4 years), 2,044 patients (23.9%) died. The observed 30-day, 1-, 3- and 5-year mortality rates were 2.2%, 4.4%, 8.2% and 13.8%, respectively, and remained constant throughout the study period. Comparing observed mortality to that expected in a matched sample from the general population, patients undergoing cardiac surgery showed excellent survival throughout the first seven years of follow-up (relative survival ≥ 1). Subsequently, survival decreased, which was more pronounced in females and patients undergoing other procedures than isolated coronary artery bypass grafting (CABG). Relative mortality was higher in younger age groups, females and patients undergoing aortic valve replacement (AVR). The female survival advantage in the general population was obliterated (relative mortality ratio (RMR) 1.35 (1.19-1.54), p<0.001). Increasing observed long-term mortality seen with ageing was due to population risk, and younger age was independently associated with increased relative mortality (RMR per 5 years 0.81 (0.79-0.84), p<0.001)).

CONCLUSIONS

Cardiac surgery patients showed comparable survival to that expected in the general Norwegian population, underlining the benefits of cardiac surgery in appropriately selected patients. The beneficial effect lasted shorter in younger patients, females and patients undergoing AVR or other procedures than isolated CABG. Thus, the study identified three groups that need increased attention for further improvement of outcomes.

Heart valve disease in elderly Chinese population: effect of advanced age and comorbidities on treatment decision-making and outcomes

Background

A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes.

Methods

Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored.

Results

Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis.

Conclusions

Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.

Effects of registered nurse staffing level on hospital-acquired conditions in cardiac surgery patients: A propensity score matching analysis

BACKGROUND

The ramifications of inadequate nurse staffing may have serious consequences due to reimbursement policies.

PURPOSE

To determine the effects of registered nurse staffing on hospital-acquired conditions in cardiac surgery patients.

METHOD

Data from the 2009 to 2011 Nationwide Inpatient Sample were used to construct a propensity score-matched cohort. Multivariate regressions were performed to compare the probability, length of stay, mortality, and costs of three common hospital-acquired conditions between low- and high-staffing hospitals.

RESULTS

A total of 439,365 patients in low-staffing hospitals were 1:1 matched to patients in high-staffing hospitals. High-staffing hospitals had 10% to 25% fewer cases (adjusted odds ratio [AOR] 0.75-0.90, p < .0001), 5% to 20% lower mortality (AOR 0.80-0.95, p < .0001), and 4% to 6% shorter length of stay (coefficient -0.06 to -0.04, p < .0001). The costs for patients with hospital-acquired conditions were 13% to 17% greater in high-staffing hospitals (coefficient 0.13-0.17, p < .0001).

CONCLUSIONS

Alternatives to the current staffing and reimbursement policies should be considered to reduce hospital-acquired conditions.

Video-Assisted Thoracoscopic Surgery for Treatment of Chronic Obstructive Pulmonary Disease

The aim of this study is to evaluate the safety and efficacy of lung volume reduction surgery (LVRS) by video-assisted thoracoscopic surgery (VATS) in the treatment of chronic obstructive pulmonary disease (COPD). A total of 90 patients with COPD from 2002 to 2012 were enrolled into our study, comprising 22 who underwent conventional thoracotomies and 68 VATS. Pulmonary function testings, arterial blood gases analysis, and quality of life between these two groups were compared. VATS was found to be superior to the conventional thoracotomy in terms of length of hospital stay, intraoperative blood loss, intubation time, volume of chest tube drainage, and postoperative pain assessment (P < 0.05). However, significant differences in pulmonary function testings, arterial blood gases analysis, 6-min walking distance (6-MWD), and postoperative quality of life between the two groups were not found (P > 0.05). LVRS by VATS is a safe and reliable surgical approach for the treatment of COPD, with less invasiveness and shorter hospital recovery time.

Expectation and Quality of Life after Aortic Valve Replacement over 85 Years of Age Match those of the Contemporary General Population

Background

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS.

Methods

Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics.

Results

Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population.

Conclusions

Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

Early and long-term results of cardiosurgical treatment of coronary artery disease and aortic stenosis in patients over 80 years old

Background

In recent years, patients over 80 years of age have been a growing group of individuals referred to cardiac surgeons. They pose a serious challenge and usually require a multidisciplinary approach.

Aim

The aim of this study was to evaluate the early and late outcomes of cardiosurgical treatment of patients over 80 years of age suffering from coronary artery disease and aortic stenosis.

Material and methods

The study involved 96 patients aged over 80 years treated between January, 2004 and December, 2012. The mortality and morbidity in the early postoperative period, as well as throughout the follow-up period, were analyzed.

Results

The majority of patients underwent isolated coronary artery bypass grafting (CABG) (58.3%; Group I), while 29.2% of them underwent an isolated aortic valve replacement (AVR) (Group II). Combined procedures (CABG + AVR) were carried out in 12.5% of patients (Group III). The mean operational risk calculated according to the logistic EuroSCORE was 11.6%, 11.9%, and 9.5%, respectively in Group I, Group II and in Group III. In the early postoperative period, 4 patients died (all from Group I). The 30-day mortality rate was 4.2% and the morbidity rate was 56.3%. During the post-discharge follow-up period that lasted from 1 to 100 months, 4 patients died (2 from Group I and 2 from Group III). The 2-year probability of survival was 91.9 ± 3.0%. During the last follow-up clinical assessment, half of the patients were asymptomatic.

Conclusions

The perioperative mortality of the patients is acceptably and markedly lower than that predicted by the logistic EuroSCORE calculator. However, the complication rate, particularly in the early postoperative period, is relatively high.

Quality of Life in Patients of Different Age Groups before and after Coronary Artery By-Pass Surgery

PURPOSE

The study evaluates the changes in quality of life (QOL) six months after coronary artery bypass grafting (CABG) related to the patients' age.

METHODS

The total of 243 consecutive patients completed the Nottingham Health Profile Questionnaire part 1 before and six months after CABG. Postoperative questionnaire was completed by 226 patients. Patients were divided into four examined groups (<50, 50-59, 60-69 and ≥70 years), according to their age.

RESULTS

Six months after CABG, the quality of life in different sections has been significantly improved in most patients.The analysis of the relation between the age and the changes in QOL of patients six months after CABG showed a significant correlation among the patients' age and the improvement of QOL in the sections of physical mobility (r = 0.18, p = 0.008), social isolation (r = 0.17, p = 0.01) and energy ( r = 0.21, p = 0.002). The most prominent improvement was found in older patients. The age was not an independent predictor of QOL deterioration after CABG.

CONCLUSIONS

The most noticeable improvement of QOL six months after CABG was found in older patients. Age is not the independent predictor of deterioration of QOL after CABG.

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.

Causes of death and mortality and evaluation of prognostic factors in patients with severe aortic stenosis in an aging society

BACKGROUND

Severe aortic stenosis (AS) is now predominantly a disease of the elderly, with significant mortality and morbidity. In order to investigate the burden of severe AS in the current population, we assessed mortality, causes of death, clinical event rates, and prognostic factors of patients diagnosed with severe AS.

METHODS

A total of 519 consecutive patients (mean age, 78±9 years) with severe AS (aortic valve area <1.0 cm(2)) were retrospectively analyzed. All-cause mortality and clinical events including aortic valve replacement, heart failure requiring admission, acute coronary syndrome, and syncope were measured as main outcome.

RESULTS

During a median follow-up of 3.5 years, 167 patients (32%) died. Overall survival rates at 1 and 3 years were 86% and 70%, respectively. Of all deaths, 101 (61%) were cardiovascular-related and 56 (33%) were non-cardiovascular. Syncope occurred in only 18 (4%) patients, while heart failure requiring admission occurred in 188 (43%) patients as the most frequent event. Male, severe symptoms (New York Heart Association functional class, III/IV), inactive state, previous history of heart failure, renal insufficiency, hemodialysis treatment, peripheral vascular disease, malignancy, and statin use at enrollment were significantly and independently associated with death among the patients.

CONCLUSIONS

Among the one-third of severe AS patients who died during follow-up, 61% of deaths were cardiovascular-related. Cardiovascular death may be the leading, but not the only, cause of death for contemporary severe AS patients. Factors such as severe symptomatic status, lower daily activity level, and chronic kidney diseases were strong predictive factors of worse survival in this population.

Association between older age and outcome after cardiac surgery: a population-based cohort study

Objective

Octogenarians (aged ≥ 80 years) are increasingly being referred for cardiac surgery. We aimed to describe the morbidity, mortality, and health services utilization of octogenarians undergoing elective cardiac surgery.

Methods

Retrospective population-based cohort study of adult patients receiving elective cardiac surgery between January 1 2004 and December 31 2009. Primary exposure was age ≥80 years. Outcomes were 30-day, 1- and 5-year mortality, post-operative complications, and ICU/hospital lengths of stay. Multi-variable logistic and Cox regression analyses were used to explore the association between older age and outcome.

Results

Of 6,843 patients receiving cardiac surgery, 544 (7.9%) were octogenarians. There was an increasing trend in the proportion of octogenarians undergoing surgery during the study period (0.3% per year, P = 0.073). Octogenarians were more likely to have combined procedures (valve plus coronary artery bypass or multiple valves) compared with younger strata (p < 0.001). Crude 30-day, 1-year and 5-year mortality for octogenarians were 3.7%, 10.8% and 29.0%, respectively. Compared to younger strata, octogenarians had higher adjusted 30-day (OR 4.83, 95%CI 1.30-17.92; P = 0.018) and 1-year mortality (OR 4.92; 95% CI, 2.32-10.46. P<0.001). Post-operative complications were more likely among octogenarians. Octogenarians had longer post-operative stays in ICU and hospital, and higher rates of ICU readmission (P < 0.001 for all). After multi-variable adjustment, age ≧ 80 years was an independent predictor of death at 30-days and 1 year.

Conclusions

Octogenarians are increasingly referred for elective cardiac surgery with more combined procedures. Compared to younger patients, octogenarians have a higher risk of post-operative complications, consume greater resources, and have worse but acceptable short and long-term survival.

Electronic supplementary material

The online version of this article (doi:10.1186/s13019-014-0177-6) contains supplementary material, which is available to authorized users.

Longitudinal functional recovery after geriatric cardiac surgery

BACKGROUND

Impaired functional and cognitive status is an important outcome for older adults undergoing major cardiac surgery. We conducted this pilot study to gauge feasibility of assessing these outcomes longitudinally, from preoperatively up to two time points postoperatively to assess for recovery.

METHODS

We interviewed patients aged ≥ 65 y preoperatively and repeated functional and cognitive assessments at 4-6 wk and 4-6 mo postoperatively. Simple unadjusted linear regression was used to test whether baseline measures changed at each follow-up time point. Then we used a longitudinal model to predict postoperative recovery overall, adjusting for comorbidity.

RESULTS

A total of 62 patients (age 74.7 ± 5.9) underwent scheduled cardiac surgery. Preoperative activities of daily living (ADL) impairment was associated with poorer functional recovery at 4-6 wk postoperatively with each baseline ADL impairment conferring recovery of 0.5 fewer ADLs (P < 0.05). By 4-6 mo, we could no longer detect a difference in recovery. Preoperative cognition and physical activity were not associated with postoperative changes in these domains.

CONCLUSIONS

A preoperative and postoperative evaluation of function and cognition was integrated into the surgical care of older patients. Preoperative impairments in ADLs may be a means to identify patients who might benefit from careful postoperative planning, especially in terms of assistance with self-care during the first 4-6 wk after cardiac surgery.

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.

Feasibility of a nursing intervention to prepare frail older patients for cardiac surgery: a mixed-methods study

BACKGROUND

Given the growing number of vulnerable, older cardiac surgery patients, the preadmission PREvention Decline in Older Cardiac Surgery patients (PREDOCS) programme was developed to reduce the incidence of postoperative complications. Before the clinical effects of such a complex multicomponent intervention can be evaluated, the feasibility needs to be determined to detect possible problems with the acceptability, compliance and delivery.

AIM

The purpose of this study was to test the PREDOCS programme on its feasibility and estimate theoretical cost savings.

METHODS

In a mixed-methods multicentre study, the Medical Research Council (MRC) guidelines concerning testing feasibility were followed, and theoretical cost savings were calculated. We used data from interviews and the continuous data registry at three hospitals. The results were reported following the criteria for reporting the feasibility of complex interventions (CReDECI).

RESULTS

Twenty-one females and 49 males out of 114 eligible patients completed the intervention and provided full data. Patients were equally satisfied with the usual care and the PREDOCS programme (satisfaction rate respectively standard deviation (SD): 7.5 (95% confidence interval (CI): 6.4-8.7) and 7.6 (6.6-8.6)). The involved nurses were satisfied with the tools for guiding patients to reduce their risk of postoperative complications and considered the PREDOCS programme as complementary to usual care. Integrating PREDOCS into current hospital structures appeared to be difficult. Both patients and nurses indicated that the additional consult was tiresome for the patient. The PREDOCS programme will be cost-effective when postoperative complications are prevented in six to sixteen of 1000 cardiac surgery patients.

CONCLUSIONS

The PREDOCS programme is acceptable for patients and nurses but should be built into the hospital's cardiac surgery pathway or applied in home care.

Thoracic aortic aneurysms in octogenarians: the results of open surgical repair using hypothermic circulatory arrest with antegrade selective cerebral perfusion

OBJECTIVE

Although recent progress has expanded the indications for thoracic aortic surgery to include elderly patients, the procedure remains extremely invasive. We performed a chart review to determine the early and late outcomes of thoracic aortic surgery using hypothermic circulatory arrest (HCA) and antegrade selective cerebral perfusion (ASCP) in octogenarians.

MATERIALS AND METHODS

Of 79 patients who underwent surgery for thoracic aortic aneurysms from April 2007 through December 2012, 8 patients 80 years or older were selected for analysis. Mean age at the time of surgery was 84.3±1.39 years. The diagnoses were aortic dissection in 5 patients and degenerative thoracic aneurysm in 3 patients. All patients underwent surgery with HCA. The lowest body temperature was 25℃ ASCP was used as an additional brain-protection technique. Emergency operations were performed in 5 patients (62.5%).

RESULTS

The mean duration of HCA was 60.4±19.7 minutes, that of aortic cross-clamping time was 143.0±30.4 minutes, and mean pump time was 207.8±44.4 minutes. The hospital mortality rate was 0%. Major postoperative complications occurred in 3 (37.5%) patients: stroke, temporary neurologic dysfunction, and paraparesis in 1 patient each. No patients required temporary dialysis for new-onset renal dysfunction. There were no deaths during the 65-month follow-up period.

CONCLUSION

The early and late outcomes after thoracic aortic surgery at our hospital using HCA with ASCP in octogenarians are acceptable. The operations are performed with an acceptable operative risk, even under emergency situations, including acute aortic dissection.

The changing face of cardiac surgery: practice patterns and outcomes 2001-2010

BACKGROUND

Advances in cardiac surgical care have allowed for successful surgery in high-risk elderly patients. Advances in percutaneous coronary intervention (PCI) techniques and expanded indications for PCI have resulted in a decrease in referrals for coronary artery bypass grafting (CABG). Our objective was to document changes in practice patterns and outcomes in a single tertiary cardiac surgery centre serving a large geographic area.

METHODS

For all cardiac surgery cases performed from 2001-2010 we examined its use, patient clinical characteristics, and outcomes. Frailty was assessed using a measure we have previously demonstrated to be associated with adverse outcomes.

RESULTS

During the study period, annual case volume decreased by 13%. The number of isolated CABG cases declined, and valve surgery and other complex procedures increased. The proportion of patients aged ≥ 80 years rose from 7%-12%, and the proportion of frail patients increased from 4%-10%. Although unadjusted in-hospital mortality remained relatively unchanged, intensive care unit (ICU) stays and prolonged institutional care increased. Older age and frailty were associated with mortality, prolonged ICU stays, prolonged institutional care, and a composite of mortality and major morbidities.

CONCLUSIONS

Our findings showed a decline in CABG, an increase in more complex operations, and an increase in prolonged ICU stays and prolonged institutional care. The proportion of frail and elderly patients increased over time and these patient groups were at higher risk of adverse postoperative outcomes. Particular attention is required in the decision for surgery and perioperative management of these patients.

Development of a nursing intervention to prepare frail older patients for cardiac surgery (the PREDOCS programme), following phase one of the guidelines of the Medical Research Council

Background:

In older patients undergoing elective cardiac surgery, the timely identification and preparation of patients at risk for frequent postoperative hospital complications provide opportunities to reduce the risk of these complications.

Aims:

We developed an evidence-based, multi-component nursing intervention (Prevention of Decline in Older Cardiac Surgery Patients; the PREDOCS programme) for application in the preadmission period to improve patients’ physical and psychosocial condition to reduce their risk of postoperative complications. This paper describes in detail the process used to design and develop this multi-component intervention.

Methods:

In a team of researchers, experts, cardiac surgeons, registered cardiac surgery nurses, and patients, the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed, including identifying existing evidence, identifying and developing theory and modelling the process and outcomes. Additionally, the criteria for reporting the development of complex interventions in healthcare (CReDECI) were followed.

Results:

The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients, a second part in which patients with an increased risk are identified, and a third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk.

Conclusions:

Following the MRC guidelines, an extended, stepwise, multi-method procedure was used to develop the multi-component nursing intervention to prepare older patients for cardiac surgery, creating transparency in the assumed working mechanisms. Additionally, a detailed description of the intervention is provided.