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Rufa MI, Ursulescu A, Aktuerk D, Nagib R, Albert M, Göbel N, Shavahatli T, Franke UF. Minimally invasive strategies of surgical coronary artery revascularization for the aging population. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:534-540. [PMID: 37255493 DOI: 10.23736/s0021-9509.23.12621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients. METHODS The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%). RESULTS The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively. CONCLUSIONS MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.
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Affiliation(s)
- Magdalena I Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany -
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | | | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Nora Göbel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Tunjay Shavahatli
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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2
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Liu Z, Zang W, Zhang P, Shen Z. Prognostic implications of Global Leadership Initiative on Malnutrition-defined malnutrition in older patients who underwent cardiac surgery in China. Surgery 2023; 173:472-478. [PMID: 36494275 DOI: 10.1016/j.surg.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/04/2022] [Accepted: 11/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The proportion of older patients who are candidates for cardiac surgery is increasing. Growing evidence has shown that malnutrition is associated with a poor prognosis after cardiac surgery. The present study aimed to investigate the prognostic implications of malnutrition defined by the Global Leadership Initiative on Malnutrition in older patients who underwent cardiac surgery. METHODS From November 2015 to January 2021, 401 older patients who underwent cardiac surgery were retrospectively enrolled and evaluated using the Global Leadership Initiative on Malnutrition criteria. The perioperative characteristics and clinical outcomes were collected. The independent risk factors for postoperative complications and overall survival were analyzed. RESULTS The prevalence of Global Leadership Initiative on Malnutrition-defined malnutrition was 22.7% in this study. Patients with Global Leadership Initiative on Malnutrition-defined malnutrition had higher risks of postoperative complications (65.9% vs 49.7%, P = .006) and poor overall survival (68.1% vs 83.9%, P = .0019). Global Leadership Initiative on Malnutrition-defined malnutrition was also related to a longer postoperative hospital stay and prolonged intensive care stay. Five factors were identified as independent risk factors for overall survival: Global Leadership Initiative on Malnutrition-defined malnutrition (P = .009), chronic heart failure (P = .007), atrial fibrillation (P = .029), operative time (P < .001) and hemoglobin (P = .044). CONCLUSION We demonstrated the prognostic implications of Global Leadership Initiative on Malnutrition-defined malnutrition in older patients who underwent cardiac surgery for the first time. This study highlights the necessity of using the Global Leadership Initiative on Malnutrition assessment in the comprehensive preoperative risk assessment of cardiac surgery.
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Affiliation(s)
- Zhang Liu
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wangfu Zang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Peng Zhang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
| | - Zile Shen
- Department of Gastrointestinal Surgery, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.
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3
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Wang E, Wang Y, Li Y, Hu S, Yuan S. Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study. Front Surg 2023; 10:1117974. [PMID: 36896258 PMCID: PMC9989169 DOI: 10.3389/fsurg.2023.1117974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/03/2023] [Indexed: 02/23/2023] Open
Abstract
Background More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. Methods In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. Results The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). Conclusion We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.
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Affiliation(s)
- Enshi Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Diseases, Beijing, China
| | - Yuan Li
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shengshou Hu
- Department of Cardiovascular Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Su Yuan
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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4
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Yeşiler Fİ, Akmatov N, Nurumbetova O, Beyazpınar DS, Şahintürk H, Gedik E, Zeyneloğlu P. Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients. Cureus 2022; 14:e31602. [DOI: 10.7759/cureus.31602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
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5
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Andrew CD, Fleischer C, Charette K, Goodrum D, Chow V, Abess A, Briggs A, Deiner S. Cognitive impairment and frailty screening in older surgical patients: a rural tertiary care centre experience. BMJ Open Qual 2022; 11:bmjoq-2022-001873. [PMID: 35728865 PMCID: PMC9214386 DOI: 10.1136/bmjoq-2022-001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 06/03/2022] [Indexed: 12/02/2022] Open
Abstract
Introduction Despite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre. Methods Through stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient–provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics. Results In the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later. Conclusion We qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.
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Affiliation(s)
- Caroline D Andrew
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | - Kristin Charette
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Debra Goodrum
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Vinca Chow
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Alexander Abess
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Alexandra Briggs
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Stacie Deiner
- Department of Anesthesiology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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6
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Gao Y, Wang C, Wang Y, Li J, Wang J, Wang S, Tian Y, Liu J, Diao X, Zhao W. Establishment and Validation of a Nomogram to Predict Hospital-Acquired Infection in Elderly Patients After Cardiac Surgery. Clin Interv Aging 2022; 17:141-150. [PMID: 35173428 PMCID: PMC8841270 DOI: 10.2147/cia.s351226] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/16/2022] [Indexed: 12/29/2022] Open
Abstract
Background Hospital-acquired infection (HAI) after cardiac surgery is a common clinical concern associated with adverse prognosis and mortality. The objective of this study is to determine the prevalence of HAI and its associated risk factors in elderly patients following cardiac surgery and to build a nomogram as a predictive model. Methods We developed and internally validated a predictive model from a retrospective cohort of 6405 patients aged ≥70 years, who were admitted to our hospital and underwent cardiac surgery. The primary outcome was HAI. Multivariable logistic regression analysis was used to identify independent factors significantly associated with HAI. The performance of the established nomogram was assessed by calibration, discrimination, and clinical utility. Internal validation was achieved by bootstrap sampling with 1000 repetitions to reduce the overfit bias. Results Independent factors derived from the multivariable analysis to predict HAI were smoking, myocardial infarction, cardiopulmonary bypass use, intraoperative erythrocytes transfusion, extended preoperative hospitalization days and prolonged duration of mechanical ventilation postoperatively. The derivation model showed good discrimination, with a C-index of 0.706 [95% confidence interval 0.671–0.740], and good calibration [Hosmer–Lemeshow test P = 0.139]. Internal validation also maintained optimal discrimination and calibration. The decision curve analysis revealed that the nomogram was clinically useful. Conclusions We developed a predictive nomogram for postoperative HAIs based on routinely available data. This predictive tool may enable clinicians to achieve better perioperative management for elderly patients undergoing cardiac surgery but still requires further external validation.
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Affiliation(s)
- Yuchen Gao
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Chunrong Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Yuefu Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Correspondence: Yuefu Wang, Department of Anesthesiology and Surgical Intensive Care Unit, Beijing Shijitan Hospital, Capital Medical University, 10 Tieyi Road, Haidian District, Beijing, People’s Republic of China, Email
| | - Jun Li
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Jianhui Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Sudena Wang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Yu Tian
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Jia Liu
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Xiaolin Diao
- Department of Information Center, Skate Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
| | - Wei Zhao
- Department of Information Center, Skate Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China
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7
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Anand PA, Keshavamurthy S, Shelley EM, Saha S. Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting? Int J Angiol 2021; 30:202-211. [PMID: 34776820 PMCID: PMC8580610 DOI: 10.1055/s-0041-1735221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.
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Affiliation(s)
- Pavan Ashwini Anand
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ellis M. Shelley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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8
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Assessment of preoperative risk scoring systems in geriatric and non-geriatric coronary bypass surgery patients. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.744784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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9
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Takagi K, Arinaga K, Takaseya T, Otsuka H, Shojima T, Shintani Y, Zaima Y, Saku K, Oryoji A, Hiromatsu S. Aortic valve replacement with or without concomitant coronary artery bypass grafting in very elderly patients aged 85 years and older. Heart Vessels 2020; 35:1409-1418. [PMID: 32394242 DOI: 10.1007/s00380-020-01620-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/01/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan.
| | - Koichi Arinaga
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Tohru Takaseya
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Hiroyuki Otsuka
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Takahiro Shojima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yusuke Shintani
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Yasuyuki Zaima
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Kosuke Saku
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Atsunobu Oryoji
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
| | - Shinichi Hiromatsu
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine, 67 Asahimachi, Kurume, 830-0011, Japan
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Bianco V, Kilic A, Gleason TG, Aranda-Michel E, Wang Y, Navid F, Sultan I. Midterm Outcomes for Isolated Coronary Artery Bypass Grafting in Octogenarians. Ann Thorac Surg 2020; 109:1184-1193. [DOI: 10.1016/j.athoracsur.2019.07.096] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/07/2019] [Accepted: 07/29/2019] [Indexed: 10/26/2022]
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11
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Rahman IA, Kendall S. Cardiac surgery in the very elderly: it isn't all about survival. THE BRITISH JOURNAL OF CARDIOLOGY 2020; 27:05. [PMID: 35747424 PMCID: PMC8793928 DOI: 10.5837/bjc.2020.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
| | - Simon Kendall
- Consultant Cardiac Surgeon and President Elect SCTS Department of Cardiothoracic Surgery, James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW
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12
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Lorenzi E, Henao R, Heller K. Hierarchical infinite factor models for improving the prediction of surgical complications for geriatric patients. Ann Appl Stat 2019. [DOI: 10.1214/19-aoas1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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13
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McDonald SR, Heflin MT, Whitson HE, Dalton TO, Lidsky ME, Liu P, Poer CM, Sloane R, Thacker JK, White HK, Yanamadala M, Lagoo-Deenadayalan SA. Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative. JAMA Surg 2019; 153:454-462. [PMID: 29299599 DOI: 10.1001/jamasurg.2017.5513] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Importance Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients. Objective To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization. Design, Setting, and Participants Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH. Main Outcomes and Measures Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets. Results One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes. Conclusions and Relevance Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.
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Affiliation(s)
- Shelley R McDonald
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Mitchell T Heflin
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Heather E Whitson
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Thomas O Dalton
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Michael E Lidsky
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Phillip Liu
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Cornelia M Poer
- Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Richard Sloane
- Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Julie K Thacker
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Heidi K White
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Mamata Yanamadala
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina
| | - Sandhya A Lagoo-Deenadayalan
- Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.,Department of Surgery, Duke University Medical Center, Durham, North Carolina
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14
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Demir OM, Ruparelia N, Frame A, Sen S, Mikhail GW, Fertleman M, Malik IS. Management of failing bioprosthesis in elderly patients who have undergone transcatheter aortic valve replacement. Expert Rev Med Devices 2017; 14:763-771. [DOI: 10.1080/17434440.2017.1376651] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Ozan M. Demir
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Neil Ruparelia
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Angela Frame
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Sayan Sen
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Ghada W. Mikhail
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Michael Fertleman
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
| | - Iqbal S. Malik
- Department of Cardiology, Hammersmith Hospital, Imperial NHS Healthcare Trust, London, UK
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15
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Lin CY, Yaseri M, Pakpour AH, Malm D, Broström A, Fridlund B, Burri A, Webb TL. Can a Multifaceted Intervention Including Motivational Interviewing Improve Medication Adherence, Quality of Life, and Mortality Rates in Older Patients Undergoing Coronary Artery Bypass Surgery? A Multicenter, Randomized Controlled Trial with 18-Month Follow-Up. Drugs Aging 2017; 34:143-156. [PMID: 28004259 DOI: 10.1007/s40266-016-0429-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Patients undergoing coronary artery bypass graft (CABG) surgery are required to take a complex regimen of medications for extended periods, and they may have negative outcomes because they struggle to adhere to this regimen. Designing effective interventions to promote medication adherence in this patient group is therefore important. OBJECTIVE The present study aimed to evaluate the long-term effects of a multifaceted intervention (psycho-education, motivational interviewing, and short message services) on medication adherence, quality of life (QoL), and mortality rates in older patients undergoing CABG surgery. METHODS Patients aged over 65 years from 12 centers were assigned to the intervention (EXP; n = 144) or treatment-as-usual (TAU; n = 144) groups using cluster randomization at center level. Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS), pharmacy refill rate, and lipid profile; QoL was evaluated using Short Form-36. Data were collected at baseline; 3, 6, and 18 months after intervention. Survival status was followed up at 18 months. Multi-level regressions and survival analyses for hazard ratio (HR) were used for analyses. RESULTS Compared with patients who received TAU, the MARS, pharmacy refill rate, and lipid profile of patients in the EXP group improved 6 months after surgery (p < 0.01) and remained so 18 months after surgery (p < 0.01). QoL also increased among patients in the EXP group as compared with those who received TAU at 18 months post-surgery (physical component summary score p = 0.02; mental component summary score p = 0.04). HR in the EXP group compared with the TAU group was 0.38 (p = 0.04). CONCLUSION The findings suggest that a multifaceted intervention can improve medication adherence in older patients undergoing CABG surgery, with these improvements being maintained after 18 months. QoL and survival rates increased as a function of better medication adherence. ClinicalTrials.gov NCT02109523.
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Affiliation(s)
- Chung-Ying Lin
- Department of Rehabilitation Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Amir H Pakpour
- Social Determinants of Health Research Center, Qazvin University of Medical Sciences, Shahid Bahounar BLV, Qazvin, 3419759811, Iran. .,Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden.
| | - Dan Malm
- Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden.,Department of Internal Medicine, Country Hospital Ryhov, Jönköping, Sweden
| | - Anders Broström
- Department of Nursing, School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Bengt Fridlund
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Andrea Burri
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand.,Department of Anaesthesia and Perioperative Medicine, Waitemata Pain Service, North Shore Hospital, Auckland, New Zealand
| | - Thomas L Webb
- Department of Psychology, The University of Sheffield, Sheffield, UK
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16
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Raja SG. Off-pump coronary artery bypass grafting in octogenarians. J Thorac Dis 2016; 8:S799-S807. [PMID: 27942398 PMCID: PMC5124585 DOI: 10.21037/jtd.2016.10.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 08/29/2016] [Indexed: 11/06/2022]
Abstract
Enhanced life expectancy has confronted cardiac surgery with a rapidly growing population of octogenarians needing coronary artery bypass grafting (CABG). Octogenarians are deemed a high-risk patient population with increased postoperative morbidity and mortality following conventional CABG using cardiopulmonary bypass (CPB). In such patients reducing the invasiveness of the surgical procedure by avoiding CPB may be tried in an attempt to improve outcomes. The increasing performance of off-pump coronary artery bypass (OPCAB) grafting within certain centers reflects surgeon preference to avoid the inherent risks of CPB and cardioplegic arrest including hemodilution, nonpulsatile arterial flow, global myocardial ischemia, atherosclerotic embolization from aortic manipulation, and systemic inflammatory response. Although OPCAB grafting is a well-established surgical myocardial revascularization strategy, its actual benefits in terms of morbidity and mortality remain questionable in the general population. In the higher risk octogenarian patients, however, there is a potential for more tangible clinical benefits when CPB is avoided. This review article provides an overview of the impact of OPCAB grafting on postoperative mortality and morbidity in octogenarians.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK
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17
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Ruparelia N, Prendergast BD. Transcatheter aortic valve implantation - what the general physician needs to know. Clin Med (Lond) 2015; 15:420-5. [PMID: 26430178 PMCID: PMC4953224 DOI: 10.7861/clinmedicine.15-5-420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
With an increasingly elderly population, the incidence of aortic stenosis (AS) is rising. While surgical aortic valve replacement remains the gold standard treatment for patients with severe symptomatic AS, transcatheter aortic valve implantation (TAVI) has emerged as the treatment of choice for patients who are inoperable or high surgical risk. TAVI has been shown to be associated with a clear mortality benefit when compared with medical therapy and to be at least as good as surgical aortic valve replacement in this patient group. The last few years have seen rapid development in this revolutionary technology in conjunction with increasing centre and operator experience, and indications for the procedure are swiftly expanding. In this review, we summarise the current evidence base and discuss factors that need to be considered by the general physician when contemplating TAVI as a treatment option, including practical aspects, emerging indications and future directions.
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Affiliation(s)
- Neil Ruparelia
- Hammersmith Hospital, Imperial College, London, UK, and Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
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18
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Mangieri A, Regazzoli D, Ruparelia N, Colombo A, Latib A. Recent advances in transcatheter aortic valve replacement for high-risk patients. Expert Rev Cardiovasc Ther 2015; 13:1237-49. [PMID: 26414888 DOI: 10.1586/14779072.2015.1093935] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Aortic stenosis is the most common valvular heart disease of old age. Patients with severe aortic stenosis who develop symptoms have a very poor prognosis without valve intervention. Surgical aortic valve replacement has historically been the only treatment option for these patients. However a significant minority are considered inoperable or at high surgical risk and therefore are refused or decline surgery. In recent years, transcatheter aortic valve replacement has emerged as an alternative treatment option in these high-risk patients. The aim of this review is to summarize the current role of transcatheter aortic valve replacement in contemporary clinical practice including recent advances in technological and procedural aspects and then discuss future directions.
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Affiliation(s)
- Antonio Mangieri
- a 1 Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Damiano Regazzoli
- a 1 Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Neil Ruparelia
- a 1 Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy.,b 2 Imperial College, London, UK.,c 3 Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Antonio Colombo
- a 1 Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy.,c 3 Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
| | - Azeem Latib
- a 1 Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy.,c 3 Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy
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19
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Affiliation(s)
- Neil Ruparelia
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK Hammersmith Hospital, London, UK
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20
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Coronary artery bypass grafting in the octogenarians: should we intervene, or leave them be? JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:147-52. [PMID: 25870618 PMCID: PMC4394330 DOI: 10.11909/j.issn.1671-5411.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 01/07/2015] [Accepted: 01/16/2015] [Indexed: 11/21/2022]
Abstract
Objective Coronary artery bypass grafting (CABG) is gradually increasing in the elderly population. We aimed to investigate the risk factors and the results of CABG along with the long term survival in patients at an age of 80 and older. Methods Between January 2002 and December 2011, a total of 101 consecutive patients at an age of 80 and older who underwent CABG in our hospital were included in the study. The patients were followed and the long-term survival was estimated. Results The mean age of the patients was 82.98 ± 2.27 years. Sixty-four (63.4%) were males and 37 (36.6%) were females. Emergency surgery, duration of cardiopulmonary bypass, the intensive care unit (ICU) stay, inotropic support, intra aortic balloon pulsation application, amount of erythrocyte transfusion and fresh frozen plasma transfusion and ventilation period were significantly higher in the patients who died in the hospital. The duration of cardiopulmonary bypass (CPB) was found to be an independent predictor of mortality (OR: 1.18, 95% CI 1.01−1.38, P = 0.034). The in-hospital mortality was 16.8%. Kaplan-Meier analyses revealed a survival ratio of 91.3% at one year, 82.9% at three years and 69.0% at five years. Conclusions Patients at the age of 80 and older can be candidates for the CABG procedure bearing in mind that they may have a longer ventilation period and intensive care unit stay. The morbidity and mortality of this age group is considered within an acceptable range. Approaches to minimize CPB, or the choice of off-pump surgery, may be a preventive method to lower the incidence of mortality. Hence, CABG may be performed in this age group with a satisfactory survival ratio.
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21
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St-Louis E, Sudarshan M, Al-Habboubi M, El-Husseini Hassan M, Deckelbaum DL, Razek TS, Feldman LS, Khwaja K. The outcomes of the elderly in acute care general surgery. Eur J Trauma Emerg Surg 2015; 42:107-13. [PMID: 26038035 DOI: 10.1007/s00068-015-0517-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/11/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Elderly patients form a growing subset of the acute care surgery (ACS) population. Older age may be associated with poorer outcomes for some elective procedures, but there are few studies focusing on outcomes for the elderly ACS population. Our objective is to characterize differences in mortality and morbidity for acute care surgery patients >80 years old. METHODS A retrospective review of all ACS admissions at a large teaching hospital over 1 year was conducted. Patients were classified into non-elderly (<80 years old) and elderly (≥80 years old). In addition to demographic differences, outcomes including care efficiency, mortality, postoperative complications, and length of stay were studied. Data analysis was completed with the Student's t test for continuous variables and Fisher's exact test for categorical variables using STATA 12 (College Station, TX, USA). RESULTS We identified 467 non-elderly and 60 elderly patients with a mean age-adjusted Charlson score of 3.2 and 7.2, respectively (p < 0.001) and a mortality risk of 1.9 and 11.7 %, respectively (p < 0.001). The elderly were at risk of longer duration (>4 days) hospital stay (p = 0.05), increased postoperative complications (p = 0.002), admission to the ICU (p = 0.002), and were more likely to receive a non-operative procedure (p = 0.003). No difference was found (p = NS) for patient flow factors such as time to consult general surgery, time to see consult by general surgery, and time to operative management and disposition. CONCLUSIONS Compared to younger patients admitted to an acute care surgery service, patients over 80 years old have a higher risk of complications, are more likely to require ICU admission, and stay longer in the hospital.
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Affiliation(s)
- E St-Louis
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M Sudarshan
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M Al-Habboubi
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - M El-Husseini Hassan
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - D L Deckelbaum
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - T S Razek
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - L S Feldman
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - K Khwaja
- Division of General Surgery, Montreal General Hospital, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
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22
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Ruparelia N, Prendergast BD. Indications for transcatheter aortic valve implantation--now and next? MINIM INVASIV THER 2015; 24:264-73. [PMID: 25827477 DOI: 10.3109/13645706.2015.1031680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Aortic stenosis (AS) is the most common valvular pathology and its prevalence is expected to increase rapidly in coming decades as a consequence of the increasingly elderly population. Without treatment, severe symptomatic AS has a very poor prognosis with a mortality of 50% at two years. Whilst surgical aortic valve replacement is the gold standard treatment, a significant minority of patients are deemed inoperable and declined surgery due to prohibitively high risk. The advent of transcatheter aortic valve implantation (TAVI) has revolutionised their treatment. In this review, we discuss current indications for TAVI, other applications of this technology and future indications.
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Affiliation(s)
- Neil Ruparelia
- a 1Oxford Heart Centre, John Radcliffe Hospital , Oxford, UK
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23
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Horne A, Reineck EA, Hasan RK, Resar JR, Chacko M. Transcatheter aortic valve replacement: historical perspectives, current evidence, and future directions. Am Heart J 2014; 168:414-23. [PMID: 25262249 DOI: 10.1016/j.ahj.2014.07.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 07/11/2014] [Indexed: 11/30/2022]
Abstract
Severe aortic stenosis (AS) results in considerable morbidity and mortality without aortic valve replacement and is expected to increase in prevalence with the aging population. Because AS primarily affects the elderly, many patients with comorbidities are poor candidates for surgical aortic valve replacement (SAVR) and may not be referred. Transcatheter aortic valve replacement (TAVR) has emerged as transformative technology for the management of AS over the past decade. Randomized trials have established the safety and efficacy of TAVR with improved mortality and quality of life compared with medical therapy in inoperable patients, while demonstrating noninferiority and even superiority to SAVR among high-risk operative candidates. However, early studies demonstrated an early penalty of stroke and vascular complications with TAVR as well as increased paravalvular leak as compared with SAVR. Two device platforms have been evaluated and approved for use in the United States: the Edwards SAPIEN and the Medtronic CoreValve. Early studies also suggest cost-effectiveness for TAVR. Ongoing studies are evaluating new iterations of the aforementioned TAVR devices, novel device designs, and applications of TAVR in expanded populations of patients including those with lower risk profiles as well as those with comorbidities that were excluded from early clinical trials. Future improvements in TAVR technology will likely reduce periprocedural and long-term complications. Further studies are needed to confirm device durability over long-term follow-up and explore the applicability of TAVR to broader AS patient populations.
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Affiliation(s)
- Aaron Horne
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elizabeth A Reineck
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rani K Hasan
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jon R Resar
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthews Chacko
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD.
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24
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Bessho R, Ishii Y, Nishina D, Kawase Y. Thoracic aortic aneurysms in octogenarians: the results of open surgical repair using hypothermic circulatory arrest with antegrade selective cerebral perfusion. J NIPPON MED SCH 2014; 81:12-8. [PMID: 24614390 DOI: 10.1272/jnms.81.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Ryuzo Bessho
- Department of Cardiothoracic Surgery, Nippon Medical School Chiba Hokusoh Hospital
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25
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Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol 2013; 4:228. [PMID: 24009586 PMCID: PMC3755226 DOI: 10.3389/fphys.2013.00228] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/05/2013] [Indexed: 12/16/2022] Open
Abstract
Despite surgical proficiency and innovation driving low mortality rates in cardiac surgery, the disease severity, comorbidity rate, and operative procedural difficulty have increased. Today's cardiac surgery patient is older, has a "sicker" heart and often presents with multiple comorbidities; a scenario that was relatively rare 20 years ago. The global challenge has been to find new ways to make surgery safer for the patient and more predictable for the surgeon. A confounding factor that may influence clinical outcome is high K(+) cardioplegia. For over 40 years, potassium depolarization has been linked to transmembrane ionic imbalances, arrhythmias and conduction disturbances, vasoconstriction, coronary spasm, contractile stunning, and low output syndrome. Other than inducing rapid electrochemical arrest, high K(+) cardioplegia offers little or no inherent protection to adult or pediatric patients. This review provides a brief history of high K(+) cardioplegia, five areas of increasing concern with prolonged membrane K(+) depolarization, and the basic science and clinical data underpinning a new normokalemic, "polarizing" cardioplegia comprising adenosine and lidocaine (AL) with magnesium (Mg(2+)) (ALM™). We argue that improved cardioprotection, better outcomes, faster recoveries and lower healthcare costs are achievable and, despite the early predictions from the stent industry and cardiology, the "cath lab" may not be the place where the new wave of high-risk morbid patients are best served.
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Affiliation(s)
- Geoffrey P. Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook UniversityTownsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Jakob Vinten-Johansen
- Cardiothoracic Research Laboratory of Emory University Hospital Midtown, Carlyle Fraser Heart CenterAtlanta, GA, USA
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26
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Stolker JM, Patel AY, Lim MJ, Hauptman PJ. Estimating the adoption of transcatheter aortic valve replacement by US interventional cardiologists and clinical trialists. Clin Cardiol 2013; 36:691-7. [PMID: 24038119 DOI: 10.1002/clc.22202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 07/25/2013] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Despite extensive attention dedicated to transcatheter aortic valve replacement (TAVR) in both the medical literature and lay press, little is known about the anticipated utilization of TAVR by the US cardiology community. HYPOTHESIS TAVR use is likely to outstrip its initial clinical indications. METHODS Four days after approval of the first TAVR device in November 2011 by the US Food and Drug Administration, we emailed an online questionnaire to 201 authors of major TAVR clinical trials (trialists) and 461 recent members of an interventional cardiology professional society (clinicians). Responses were compared using χ(2) , t tests, and analysis of variance. RESULTS Of 205 surveys received (response rate 31%; 114 clinicians, 91 trialists), the majority of respondents were interventionalists (86%) working in academic practices (72%). Although most physicians anticipated referring <25% of their patients with severe aortic stenosis for TAVR, 68% believed that TAVR is equally efficacious as open-heart surgery, and 11% believed that moderate-surgical risk patients should also be considered for TAVR. More clinicians (98%) than trialists (81%) expected to routinely refer patients for TAVR (P < 0.001). Furthermore, the clinicians were anticipating less operator training and lower annual volume requirements for performing TAVR, when compared with the trialists (P ≤ 0.001). CONCLUSIONS Our findings suggest optimism for TAVR acceptance in the United States., with more conservative expectations regarding training, procedural volume requirements, and anticipated referral patterns among TAVR trialists than clinical interventionalists.
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Affiliation(s)
- Joshua M Stolker
- Center for Comprehensive Cardiovascular Care, Saint Louis University School of Medicine, St. Louis Missouri
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27
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Caceres M, Cheng W, De Robertis M, Mirocha JM, Czer L, Esmailian F, Khoynezhad A, Ramzy D, Kass R, Trento A. Survival and Quality of Life for Nonagenarians After Cardiac Surgery. Ann Thorac Surg 2013; 95:1598-602. [DOI: 10.1016/j.athoracsur.2013.02.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 02/14/2013] [Accepted: 02/25/2013] [Indexed: 11/16/2022]
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Abel N, Rogal G, Burns P, Saunders C, Chamberlain R. Aortic Valve Replacement with and without Coronary Artery Bypass Graft Surgery in Octogenarians: Is It Safe and Feasible? Cardiology 2013; 124:163-73. [DOI: 10.1159/000346153] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 11/14/2012] [Indexed: 11/19/2022]
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29
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Limited Blood Transfusion Does Not Impact Survival in Octogenarians Undergoing Cardiac Operations. Ann Thorac Surg 2012; 94:2038-45. [DOI: 10.1016/j.athoracsur.2012.06.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/19/2012] [Accepted: 06/20/2012] [Indexed: 11/23/2022]
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30
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Lidsky ME, Thacker JKM, Lagoo-Deenadayalan SA, Scarborough JE. Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis. Surgery 2012; 152:465-72. [PMID: 22938905 DOI: 10.1016/j.surg.2012.06.038] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Accepted: 06/29/2012] [Indexed: 01/28/2023]
Abstract
BACKGROUND The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients. METHODS All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors. RESULTS We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure. CONCLUSION Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.
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Affiliation(s)
- Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
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Harris I, Madan A, Naylor J, Chong S. Mortality rates after surgery in New South Wales. ANZ J Surg 2012; 82:871-7. [DOI: 10.1111/j.1445-2197.2012.06319.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2012] [Indexed: 12/17/2022]
Affiliation(s)
| | - Aman Madan
- Liverpool Hospital; South Western Sydney Clinical School, University of New South Wales; Liverpool; New South Wales; Australia
| | | | - Shanley Chong
- South Western Sydney Local Health District; Liverpool Hospital; Centre for Research; Evidence Management and Surveillance; Liverpool; New South Wales; Australia
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Sengstock D, Vaitkevicius P, Salama A, Mentzer RM. Under-prescribing and non-adherence to medications after coronary bypass surgery in older adults: strategies to improve adherence. Drugs Aging 2012; 29:93-103. [PMID: 22239673 DOI: 10.2165/11598500-000000000-00000] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The focus for this clinical review is under-prescribing and non-adherence to medication guidelines in older adults after coronary artery bypass grafting (CABG) surgery. Non-adherence occurs in all age groups, but older adults have a unique set of challenges including difficulty hearing, comprehending, and remembering instructions; acquiring and managing multiple medications; and tolerating drug-drug and drug-disease interactions. Still, non-adherence leads to increased morbidity, mortality, and costs to the healthcare system. Factors contributing to non-adherence include failure to initiate therapy before hospital discharge; poor education about the importance of each medication by hospital staff; poor education about medication side effects; polypharmacy; multiple daily dosing; excessive cost; and the physician's lack of knowledge of clinical indicators for use of medications. To improve adherence, healthcare systems must ensure that (i) all patients are prescribed the appropriate medications at discharge; (ii) patients fill and take these medications post-operatively; and (iii) patients continue long-term use of these medications. Interventions must target central administrative policies within healthcare institutions, the difficulties facing providers, as well as the concerns of patients. Corrective efforts need to be started early during the hospitalization and involve practitioners who can follow patients after the date on which surgical care is no longer needed. A solid, ongoing relationship between patients and their primary-care physicians and cardiologists is essential. This review summarizes the post-operative medication guidelines for CABG surgery, describes barriers that limit the adherence to these guidelines, and suggests possible avenues to improve medication adherence in older cardiac surgery patients.
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Affiliation(s)
- David Sengstock
- Wayne State University, Department of Medicine, Detroit, MI 48124, USA.
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Badhwar V, Peterson ED, Jacobs JP, He X, Brennan JM, O'Brien SM, Dokholyan RS, George KM, Bolling SF, Shahian DM, Grover FL, Edwards FH, Gammie JS. Longitudinal outcome of isolated mitral repair in older patients: results from 14,604 procedures performed from 1991 to 2007. Ann Thorac Surg 2012; 94:1870-7; discussion 1877-9. [PMID: 22858278 DOI: 10.1016/j.athoracsur.2012.05.105] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Revised: 05/18/2012] [Accepted: 05/25/2012] [Indexed: 12/23/2022]
Abstract
BACKGROUND Mitral valve (MV) repair is performed with less frequency than MV replacement in older persons, with referral often delayed until symptoms are severe. Surgical practice in this population remains inconsistent in the absence of national MV repair outcomes. The goal of this study was to assess durability and longitudinal outcomes after isolated primary MV repair in patients aged 65 years or more. METHODS We linked clinical data from The Society of Thoracic Surgeons adult cardiac surgery database (STS) to longitudinal claims data from the Centers for Medicare and Medicaid Services (CMS). Between January 1991 and December 2007, we identified 14,604 isolated nonemergent primary MV repair operations in STS-CMS data. These were longitudinally examined for mortality, mitral reoperation, and readmissions for heart failure, bleeding, and stroke. Predictors of 5-year death after MV repair were identified using Cox proportional hazard modeling. RESULTS The study cohort had a mean age of 73.3±5.5 years, ejection fraction 54.0%±12.9%; 55.8% (8,148 of 14,604) were female; and 8.4% (1,233 of 14,604) were non-Caucasian. Operative mortality was 2.59% (378 of 14,604). Mean follow-up was 5.9±3.9 years (range, 1.0 to 18.0). Survival during follow-up was 74.9% (10,934 of 14,604). The number of observed events for mitral reoperation, heart failure, bleeding, and stroke were 552 of 14,604 (3.7%), 2,681 of 14,604 (18.4%), 1,051 of 14,604 (7.2%), and 1,131 of 14,604 (7.7%), respectively. The 10-year Kaplan-Meier event rates for mitral reoperation, heart failure, bleeding, and stroke were 6.2%, 30.1%, 15.3%, and 16.4%, respectively. The 10-year actuarial survival of 57.4% was equivalent to the matched US population. CONCLUSIONS Utilizing linked STS and CMS databases, we demonstrate that MV repair is a safe and durable long-term option for older patients. Survival restored to the normal population suggests repair may suppress the longitudinal impact of mitral regurgitation in the elderly and that the practice of delayed referral should be reevaluated. These data provide a contemporary longitudinal benchmark of MV repair outcomes.
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Affiliation(s)
- Vinay Badhwar
- University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Oliveira SM, Correia AS, Paiva M, Gonçalves A, Pereira M, Alves E, Dias P, Almeida R, Abreu A, Pinho P. Long-term survival, autonomy, and quality of life of elderly patients undergoing aortic valve replacement. J Card Surg 2011; 27:20-3. [PMID: 22211277 DOI: 10.1111/j.1540-8191.2011.01360.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS We reviewed the long-term survival, autonomy, and quality of life (QoL) of elderly patients undergoing aortic valve replacement (AVR). METHODS Records of patients ≥75 years old that underwent AVR from 2002 to 2006 were retrospectively analyzed. Functional status was classified with Barthel Index (BI). QoL was presumed as the self-perception of well-being after AVR. Independent predictors of mortality were identified using the Cox proportional hazards model. RESULTS We included 114 patients, with a mean age of 78.5 ± 2.5 years. Seventy (59.8%) patients were females. Mean additive and logistic EuroSCORE were 7 ± 2 and 9 ± 7, respectively. Follow-up on vital status was achieved for 113 (99.1%) patients after a mean period of 47.2 ± 23.4 months. Twenty-seven (23.7%) patients died (including three operative deaths). Survival up to one, three, and five years of follow-up was 94.4%, 86.7%, and 76.1%, respectively. Multivariate analysis showed that pulmonary hypertension and diabetes were independent predictors of all-cause mortality. Information on BI score and QoL was obtained for 77 (89.5%) and patients. Among those, 69 (89.6%) were autonomous according to BI and 72 (93.5%) considered having had an improvement in QoL. CONCLUSION Patients ≥75 years old undergoing AVR presented good medium-term survival. Predictors of an adverse outcome were significant pulmonary hypertension and diabetes. At follow-up, most achieved improvement of QoL and remained autonomous. These results stress that excellent long-term outcomes with AVR can be achieved in appropriately selected elderly patients.
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Mächler H, Salaymeh L, Zirngast B, Anelli-Monti M, Oberwalder P, Yates A, Knez I, Huber S, Streinu C, Ovcina I, Malliga D, Keeling I, Beran E, Mircic A, Meszaros K, Hetterle R, Rieger K, Curcic P, Vötsch A, Marte W, Toller W, Quehenberger F, Dacar D. There is no significant difference in the operative risk between octogenarians compared with patients younger than 60 years in cardiac surgery*. Eur Surg 2011. [DOI: 10.1007/s10353-011-0054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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