Cardiac surgery in the elderly

Association Between the Frailty Index and Clinical Outcomes after Coronary Artery Bypass Grafting

Background

This study investigated the predictive value of the frailty index calculated using laboratory data and vital signs (FI-L) in patients who underwent coronary artery bypass grafting (CABG).

Methods

This study included 508 patients (age 67.3±9.7 years, male 78.0%) who underwent CABG between 2018 and 2021. The FI-L, which estimates patients’ frailty based on laboratory data and vital signs, was calculated as the ratio of variables outside the normal range for 32 preoperative parameters. The primary endpoints were operative and medium-term all-cause mortality. The secondary endpoints were early postoperative complications and major adverse cardiac and cerebrovascular events (MACCEs).

Results

The mean FI-L was 20.9%±10.9%. The early mortality rate was 1.6% (n=8). Postoperative complications were atrial fibrillation (n=148, 29.1%), respiratory complications (n=38, 7.5%), and acute kidney injury (n=15, 3.0%). The 1- and 3-year survival rates were 96.0% and 88.7%, and the 1- and 3-year cumulative incidence rates of MACCEs were 4.87% and 8.98%. In multivariable analyses, the FI-L showed statistically significant associations with medium-term all-cause mortality (hazard ratio [HR], 1.042; 95% confidence interval [CI], 1.010–1.076), MACCEs (subdistribution HR, 1.054; 95% CI, 1.030–1.078), atrial fibrillation (odds ratio [OR], 1.02; 95% CI, 1.002–1.039), acute kidney injury (OR, 1.06; 95% CI, 1.014–1.108), and re-operation for bleeding (OR, 1.09; 95% CI, 1.032–1.152). The minimal p-value approach showed that 32% was the best cutoff for the FI-L as a predictor of all-cause mortality post-CABG.

Conclusion

The FI-L was a significant prognostic factor related to all-cause mortality and postoperative complications in patients who underwent CABG.

Intra-aortic balloon pump postcardiac surgery: A literature review

Intra-aortic balloon pump (IABP) has been the most commonly used mechanical assist circulatory device in many postcardiotomy low output disorders for decades. Mechanism of IABP is based on its inflation in time of the diastolic pressure in the aortic root resulting increase in the blood and oxygen amount of the coronary artery and its deflation in left ventricular afterload during the systolic period. Prophylactic and postoperative application of IABP has been suggested by researchers, which has been commonly used in high-risk patients undertaking coronary artery bypass grafting surgery or percutaneous coronary intervention. Other researchers put forward the idea of the percutaneous IABP insertion throughout the left axillary artery as a reliable and relatively well-tolerated approach and also as a recovery tool to bridge patients with end-stage heart failure to heart transplantation. The current review was aimed to give further insight into routine IABP application by presenting the basic principles and trends in the incidence, management, role of IABP recovery, and long-lasting mortality outcomes in patients with cardiovascular disorders and discussing previous and current evidence.

Analysis of clinical outcomes of intra-aortic balloon pump use during coronary artery bypass surgery

AIM

The mortality rate of coronary artery bypass surgery increases with advanced patient age. This intra-aortic balloon pump (IABP) study was conducted to compare older patients (above 65 years of age) with younger patients (below 65 years of age) who had undergone coronary artery bypass surgery and had had an IABP inserted, with regard to hospital stay, clinical features, intensive care unit stay, postoperative complications, and mortality and morbidity rates.

METHODS

One hundred and ninety patients who had undergone coronary artery bypass surgery and had required IABP support were enrolled in this study. Patients younger than 65 years of age were considered younger, and the others were considered older. Ninety-two patients were in younger group and 98 patients were older group. The mortality rates, pre-operative clinical characteristics, postoperative complications, and duration of intensive care unit and hospital stay of the groups were compared. The risk factors for mortality and complications were analysed.

RESULTS

One hundred and thirty-eight of the patients were male, and the mean age was 62.7 ± 9.9 years. The mortality rate was higher in the older patient group than the younger group [34 (37.7%) and 23 (23.4 %), respectively (p = 0.043) ]. The crossclamp time, mean ejection fraction, cardiopulmonary bypass time, and length of stay in the intensive care unit were similar between the two groups (p > 0.05). Cardiopulmonary bypass time was the unique independent risk factor for mortality in both groups.

CONCLUSION

In this study, high mortality rates in the postoperative period were similar to those in prior studies regarding IABP support. The complication rates were higher in the older patient group. Prolonged cardiopulmonary bypass time and advanced age were determined to be significant risk factors for mortality.

Outcomes of cardiac surgery in the elderly

The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.

The hidden risks of advancing age and concomitant ischemic heart disease after aortic valve replacement

BACKGROUND

Despite an increasing patient risk profile, in-hospital mortality after aortic valve replacement (AVR) has declined.

HYPOTHESIS

Advanced age, concomitant coronary artery bypass grafting (CABG), and increasing comorbidity negatively affect outcomes after AVR and do so particularly in the early months after hospital discharge, where results compare much less favorably with mortality during the first 30 days.

METHODS

The study population consisted of all patients undergoing elective AVR by a single surgeon, with and without CABG, in the decade of 2000-2009. Age, logistic EuroSCORE, diabetes, type of operation, and 30-day and 1-year mortality were recorded.

RESULTS

One hundred ninety-one patients underwent isolated AVR; 133 underwent AVR + CABG. The average age increased by 5.7 years, octogenarians by 50%, logistic EuroSCORE by 18%, and the proportion of diabetics from 4% to 25.5%. Concomitant CABG surgery increased from 36% to 49%. Overall mortality for isolated AVR was zero in the first 30 days and 1.6% in the next 11 months. For AVR and CABG, mortality was 3.75% and 9%, respectively. For octogenarians, mortality was zero and 5.9% for AVR and 4.76% and 14.29% for AVR and CABG at 30 days and in the next 11 months, respectively.

CONCLUSIONS

Thirty-day mortality in all age groups remained low but was much higher in the short term after discharge from hospital, particularly in octogenarians and those with concomitant ischemic heart disease. This should inform the consent process (which traditionally concentrates on in-hospital mortality) and there should be greater awareness of the frailty and particular requirements of the elderly after discharge.

Morbidity and mortality of nonagenarians undergoing CoreValve implantation

Background

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

Methods

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

Results

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

Conclusion

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

Coronary bypass surgery in a 105-year-old patient with cardiopulmonary bypass

Coronary artery bypass grafting is one of the routine daily surgical procedures in the current era. Parallel to the increasing life expectancy, cardiac surgery is commonly performed in octogenarians. However, literature consists of only seldom reports of coronary artery bypass grafting in patients above 90 years of age. In this report, we present our management strategy in a 105-year-old patient who underwent coronary artery bypass grafting at our institution.

Vascular access site complications after percutaneous transfemoral aortic valve implantation

BACKGROUND AND PURPOSE

Transcatheter aortic valve implantation (TAVI) is a rapidly emerging treatment option for patients with aortic valve stenosis and high surgical risk. Different access routes have been proposed for TAVI including transapical, transsubclavian and transfemoral, with percutaneous transfemoral being the preferred because least invasive and nonsurgical. However, vascular access site complications due to the large-bore delivery catheters remain an important clinical issue, particularly with respect to the elderly patient collective typically considered for TAVI. In the study, the authors analyzed their 4-year TAVI experience with respect to vascular complications and their management in patients undergoing completely percutaneous transfemoral TAVI procedures.

PATIENTS AND METHODS

Since 2006, TAVI was performed in 101 consecutive patients at the West German Heart Center Essen. 33 patients underwent transapical TAVI, eight patients transfemoral TAVI with surgical access or closure, and 60 patients percutaneous transfemoral TAVI using two commercially available prosthetic valve devices.

RESULTS

Completely percutaneous TAVI was technically successful in all but one patient with malpositioning in the aortic arch during valve retrieval. There was no intraprocedural death and 30-day mortality was 12% (7/60). Vascular access site complications occurred in 19 patients (32%), necessitating surgical repair in six of them (10%). Complications included retroperitoneal hematoma (n = 2), iliac or femoral artery dissection (n = 10), (pseudo)aneurysm formation (n = 3), and closure device-induced vessel stenosis/ occlusion (n = 6). Of these, 13 cases could be managed either conservatively (n = 5) or by contralateral endovascular treatment (n = 8).

CONCLUSION

Completely percutaneous TAVI has a high acute success rate with low intraprocedural and 30-day mortality. The patient collective appears to be prone to vascular complications which remain an important limitation of this novel technique. Although conservative or endovascular management is possible in the majority of cases, further technological developments are obliged to reduce the vascular complication rate.

Is urgent coronary artery bypass grafting a safe option in octogenarians? A developing country perspective

Life expectancy has increased during recent decades leading to a growing number of older population. The objective of this study was to evaluate the outcomes of coronary artery bypass grafting (CABG) in octogenarians and to compare the outcomes of the emergent CABG with elective surgery. Prospectively collected data from 31 consecutive octogenarian patients who underwent CABG between 1 January 2006 and 31 December 2008 were analyzed. Main outcomes of interest included mortality, length of ICU stay, length of hospital stay, priority of surgery, postoperative complications and functional status on follow-up. Fifteen patients were operated on an urgent basis. Patients operated on an urgent basis were in NYHA class III or IV preoperatively (P=0.0016). There were no significant differences in operative and postoperative variables. There were three in-hospital deaths and 23 patients (82%) were alive on follow-up and 19 were in functional class I or II. Quality of life assessment was performed using Seattle Angina Questionnaire and patients reported remarkable improvement in quality of life. Overall, 90% patients were not or slightly disabled in their daily activity. Satisfaction with their current quality of life was reported by 95% of patients. CABG may be performed in octogenarians with remarkable outcomes and improvement in quality of life.

Long term results and functional outcomes following cardiac surgery in octogenarians

OBJECTIVE

Cardiac surgery for patients >80 years has seen a dramatic increase in the last decade. The aim was to assess the long term survival and quality of life in this patient population.

METHOD

Patients who underwent cardiac surgery between 1995 and 2007 were identified and case notes reviewed. Follow-up was undertaken by personal interview with the patient or the nearest kin to complete a pre-planned questionnaire.

RESULTS

Sixty six (M:F; 45:21) octogenarians had Coronary artery bypass grafting (CABG) only (55%), Aortic valve replacement (AVR) only (12%), Mitral valve replacement (MVR) only (3%), Valve and CABG (25%) and complex procedures (5%). Fifty-eight percent were elective procedures. Operative mortality was 8% (n = 5). Multivariate analysis identified complex procedures, prolonged bypass time and re-do/emergency surgery as predictors of death (p < 0.05). Median Intensive care unit (ICU) stay was 206 h (range 43-1176 h), with >70% leaving ICU in 72 h. Late mortality involved five patients (8%) who died at 10 yr; 7 yr; 3 yr; 1 yr; and 8 months; and 2 yr and 7 months, respectively. Survival by Kaplan-Meir was 8.8 yr (Standard Error (SE) = 0.66, Confidence interval (CI) 7.6-10.1), median survival was 10 yr and mean Barthel's index 17.7 (min 0, max 20).

CONCLUSIONS

Cardiac surgery can be accomplished in octogenarians with good long-term survival and quality of life. However, complex procedures, prolonged bypass and re-do/emergency surgery contribute significantly to mortality.

A modified "preclosure" technique after percutaneous aortic valve replacement

OBJECTIVES

To evaluate the feasibility, safety and efficacy of suture-mediated closure devices using a modified "preclosure" technique for access site management after percutaneous aortic valve replacement (PAVR).

BACKGROUND

PAVR using a retrograde transfemoral approach has recently evolved to an endovascular alternative to open surgery in high-risk patients. However, large-bore femoral artery access is required, commonly demanding surgical closure and general anesthesia. A truly percutaneous intervention would be desirable to reduce procedural complexity and diminish the need of vascular surgery and general anaesthesia.

METHODS

After direct puncture of the common femoral artery, three conventional suture-mediated closure devices (6F Perclose) were deployed. The preloaded sutures were tied at the end of the procedure. If no immediate hemostasis was achieved, an additional device was deployed thereafter.

RESULTS

PAVR with percutaneous access site closure was attempted in 15 consecutive patients and could successfully be achieved in all patients allowing conscious sedation in all but three cases. Following complications occurred: one retroperitoneal bleeding caused by removal of the valve delivery sheath requiring surgical repair, as well as two cases of femoral and iliac artery dissection caused by delivery sheath introduction and treated by stenting and vascular surgery, respectively. Vascular surgery became only necessary due to total vessel occlusion after suture closure and remains the only closure-related complication. However, treatment led to recovery in all patients.

CONCLUSIONS

The modified "preclosure" technique is a feasible and safe method for hemostasis after PAVR improving procedural management and diminishing the need for general anesthesia.

Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: impact of patient's choice of refusing aortic valve replacement on survival

BACKGROUND

Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80.

AIM

To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR.

DESIGN

Cohort study.

METHODS

Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of medical records and telephone interviews. The primary endpoint was all-cause mortality.

RESULTS

A total of 103 patients (86.0 +/- 4.2 years, 41% male) were identified and no patient was lost during follow-up. In Group A (n = 17), all 15 patients who underwent AVR were alive after 3.6 +/- 1.4 years follow-up and 2 died whilst awaiting AVR. Seventy-four percent of Group B (n = 24) and 76% of Group C (n = 62) died during follow-up. Group A had significantly better survival than B and C. (P < 0.01) Amongst patients fit for AVR with similar operative risks (Groups A and B), refusal to undergo surgery (hazard ratio 12.61, P = 0.001) was the only predictor of mortality in a multivariate model.

CONCLUSION

For elderly AS patients fit for surgery, the patient's decision to refuse AVR is associated with a >12-fold increase in mortality risk. These findings have significant implications for informed decision-making when managing the fit, elderly patient with AS.

Permanent pacemaker implantation after isolated aortic valve replacement: incidence, indications, and predictors

BACKGROUND

Conducting system defects are common in patients with aortic valve disease. Aortic valve replacement may result in further conduction abnormalities and necessitate permanent pacemaker implantation (PPM). We sought to identify the contemporary incidence and predictors for early postoperative PPM in patients undergoing isolated aortic valve replacement.

METHODS

Data were analyzed from 354 consecutive patients undergoing isolated aortic valve replacement at a referral cardiac unit during a 30-month period; data were unavailable on 4 patients and a further 8 had undergone preoperative PPM. Results for the remaining 342 patients (97%; mean age, 67 +/- 14 years), of whom 212 were males, are presented. The major indications for aortic valve replacement were valvular stenosis (n = 224), regurgitation (n = 70), or infective endocarditis (n = 25). Preoperative conducting system disease was present in 26% of patients.

RESULTS

In-hospital mortality was 1.8% (6 of 342 patients). Postoperatively 29 patients (8.5%) required early PPM, of which 26 were during the index admission. Patients with preoperative conducting system disease (16% versus 6%; p = 0.004) and valvular regurgitation (16% versus 7%; p = 0.01) were more likely to require PPM as opposed to those without. Preoperative conducting system disease was the only independent predictor of PPM (p < 0.01); the relative risk of PPM requirement in this group was 2.88 (95% confidence interval, 1.31 to 6.33).

CONCLUSIONS

Permanent pacemaker implantation requirement after aortic valve replacement is a common occurrence, and should be discussed as part of the preoperative consent process. Preexisting conducting disease and preoperative aortic regurgitation were predictors of PPM requirement.

Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis

BACKGROUND

Percutaneous aortic valve replacement represents an endovascular alternative to conventional open heart surgery without the need for sternotomy, aortotomy, or cardiopulmonary bypass.

METHODS AND RESULTS

Transcatheter implantation of a balloon-expandable stent valve using a femoral arterial approach was attempted in 50 symptomatic patients with severe aortic stenosis in whom there was a consensus that the risks of conventional open heart surgery were very high. Valve implantation was successful in 86% of patients. Intraprocedural mortality was 2%. Discharge home occurred at a median of 5 days (interquartile range, 4 to 13). Mortality at 30 days was 12% in patients in whom the logistic European System for Cardiac Operative Risk Evaluation risk score was 28%. With experience, procedural success increased from 76% in the first 25 patients to 96% in the second 25 (P=0.10), and 30-day mortality fell from 16% to 8% (P=0.67). Successful valve replacement was associated with an increase in echocardiographic valve area from 0.6+/-0.2 to 1.7+/-0.4 cm2. Mild paravalvular regurgitation was common but was well tolerated. After valve insertion, there was a significant improvement in left ventricular ejection fraction (P<0.0001), mitral regurgitation (P=0.01), and functional class (P<0.0001). Improvement was maintained at 1 year. Structural valve deterioration was not observed with a median follow-up of 359 days.

CONCLUSIONS

Percutaneous valve replacement may be an alternative to conventional open heart surgery in selected high-risk patients with severe symptomatic aortic stenosis.

Cirugía cardíaca en el anciano: nuevas perspectivas para una población en crecimiento

Improvement in socioeconomic and sanitary conditions during last 2 decades has lead to 4 year-life expectancy increasing in Spanish population. Increasing in age-related cardiovascular pathologies makes more necessary cardiac surgery in the elderly. Analysis of current characteristics of elderly population, cardiac surgery indications in this group, as well as morbimortality published results and future expectations, constitute the topic of this review.

Liver resections in over-75-year-old patients: surgical hazard or current practice?

OBJECTIVES

To assess the safety of hepatic resections in the very old patient by comparing the outcome in patients younger and older than 75 years.

METHODS

Thirty-two resections in 31 patients > or =75 years (Over-75 Group) were compared with 164 resections in 162 patients <75 years (Control Group). Indications for resection, concomitant diseases, previous abdominal surgery, type of resection, associated surgical procedures, use/length of portal clamping, intra-operative blood losses and transfusions, and length of operation were preliminarily compared. The outcome was evaluated in terms of post-operative mortality, morbidity, transfusions, and postoperative hospitalization.

RESULTS

Mean age was 76.0 +/- 2.3 years (range 75-83) in the Over-75 Group and 58.4 +/- 10.7 years (range 23-74) in the Control Group. The over-75 group included more hepatomas (43.8% vs. 26.8%, P = 0.09), chronic liver disease (31.3% vs. 28.7%, P = 0.03) and concomitant diseases (62.5% vs. 32.9%, P = 0.002). The two groups were comparable (P = n.s.) when evaluated for all other variables. The 30-day mortality rate was 3.6% in the Control Group and none in the Over-75 Group. Postoperative surgical complications occurred in 37 patients (22.6%) in the Control Group and 1 patient (3.1%) in the Over-75 Group, with statistically significant differences (P = 0.01), and incidence of medical complications was 13.4% in the Control Group and 3.1% in the Over-75 Group. Median postoperative hospitalization and transfusions were not statistically different.

CONCLUSIONS

Hepatic resections in over-75-year-old patients are not a surgical hazard and may be carried out relatively safely as long as an accurate selection of the patient is performed.

Quality of Life in the Elderly After Coronary Bypass Surgery

In addition to the clinical outcome, a patient's perspective and satisfaction with their health status have become important indicators. One of the most common measures to assess the quality of life is Short Form (SF)-36. The objective of the present study was to measure the functional status of elderly patients who had undergone coronary bypass surgery and to evaluate the impact of that surgery on their quality of life. The study involved 120 nonsmoking patients who underwent coronary bypass surgery between January 1, 2001 and January 1, 2003 at the Sevket Demirel Heart Center. Assessments were made using physical, clinical, and laboratory findings. We used the Turkish version of the Short Form (SF)-36 preoperatively and 18 months after surgery. The paired t test, two-tailed correlation, and variant analysis were used for statistical analysis. Of the 120 patients, 108 could be followed during the study period. Significant physical and mental improvements were seen in all areas, especially in the items of vitality and mental health. Females seemed to benefit from surgery more than males. Cardiac surgery substantially improved the quality of life of our patients. The findings allowed us to determine the patient's perspective of his or her outcome. With this knowledge, health care workers can provide information to the patient regarding functional limitations after cardiac surgery.

Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?

AIMS

To analyse decision-making in elderly patients with severe, symptomatic aortic stenosis (AS).

METHODS AND RESULTS

In the Euro Heart Survey on valvular heart disease, 216 patients aged > or =75 had severe AS (valve area < or =0.6 cm(2)/m(2) body surface area or mean gradient > or =50 mmHg) and angina or New York Heart Association class III or IV. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 72 patients (33%). In multivariable analysis, left ventricular (LV) ejection fraction [OR = 2.27, 95% CI (1.32-3.97) for ejection fraction 30-50, OR = 5.15, 95% CI (1.73-15.35) for ejection fraction < or =30 vs. >50%, P = 0.003] and age [OR = 1.84, 95% CI (1.18-2.89) for 80-85 years, OR=3.38, 95% CI (1.38-8.27) for > or =85 vs. 75-80 years, P = 0.008] were significantly associated with the decision not to operate; however, the Charlson comorbidity index was not [OR = 1.72, 95% CI (0.83-3.50), P = 0.14 for index > or =2 vs. <2]. Neurological dysfunction was the only comorbidity significantly linked with the decision not to operate.

CONCLUSION

Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.

Rapid recovery following cardiac surgery: a nursing perspective

Fast track or rapid-recovery pathways following cardiac surgery are becoming common practice in many cardiac units in order to maximize use of scarce critical care resources. Within the UK, rapid recovery generally describes same-day discharge from the initial intensive care facility to a lower-dependency unit. There are no nationally agreed protocols to help guide this practice. In a London teaching hospital a nurse-led audit was undertaken to identify which patients were selected for rapid recovery and to evaluate safety (length of hospital stay and incidences of postoperative complications) compared to a conventional recovery pathway. The study also sought to gain insight into the patients' views on rapid recovery. Data were collected on 104 patients, all patients (n = 56) who followed a rapid-recovery pathway were included. A comparison group (n = 48) was selected from patients who followed a conventional recovery but who were eligible for rapid recovery. The primary outcome, median length of hospital stay was 6 days for both groups, but the rapid-recovery group experienced significantly fewer postoperative complications. Rapid recovery as currently practised on this unit is safe for carefully selected cardiac surgical patients but barriers to rapid recovery need to be explored.

Impact of Age on the Outcome of Liver Resections

The purpose of this study was to evaluate the influence of age on the outcome of liver resections. One hundred five consecutive hepatic resections were divided into two groups: ≥65 years old [old group (O-group)] and <65 years old [young group (Y-group)]. The two groups were first compared to evaluate the distribution of the variables potentially affecting the postoperative course, including primary diagnosis, concomitant diseases, previous upper abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of hepatic resections in the two groups was comparatively evaluated in terms of postoperative mortality, morbidity, transfusions, and length of postoperative hospitalization. The Y-group included 61 resections in 60 patients, mean age 52 ± 10 years (mean ± SD), range 23–64 years, whereas the O-group included 44 resections in 43 patients, mean age 71 ± 4 years (mean ± SD), range 65–82 years. The O-group included more hepatocellular carcinomas (45.4% vs 18.0%, P = 0.002) and chronic liver diseases (40.9% vs 18.7%, P = 0.017); the median length of operation was slightly higher in the Y-group (300 minutes vs 270 minutes, P = 0.003). Both O-group and Y-group were comparable ( P = n.s.) when evaluated for all other listed variables. As far as concerns the outcome of hepatic resections in the two groups, the length of postoperative hospitalization was identical (median 9 days, 5–60 days), whereas transfusions of packed red cells (O-group vs Y-group: 25.0% vs 16.3%, P = 0.30) or fresh frozen plasma (O-group vs Y-group: 13.6% vs 6.5%, P = 0.053) were not statistically different. Postoperative mortality included one case among young patients whereas no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (31.5% vs 20.5%, P = 0.59). The age factor does not negatively affect the outcome of liver resections.

Cardiac surgery for octogenarians: is it an informed decision?

BACKGROUND

Cardiac surgery is frequently performed to palliate cardiovascular symptoms in patients who are octogenarians, without controlled clinical trials to support its benefits. We hypothesized that death or discharge to a nursing care facility after cardiac surgery is similar in patients who are octogenarians and younger patients.

METHODS

We conducted an inception cohort study in a tertiary care teaching hospital in patients who had undergone coronary grafting, valve surgery, or both over 36 months before. We collected data on preoperative disease, operation characteristics, postoperative complications, and outcome at hospital discharge.

RESULTS

Of 783 patients who had cardiac surgery, 96 were octogenarians. Female sex, pulmonary hypertension, previous malignancy, cerebral vascular disease, valvular heart disease, and congestive heart failure were more frequent in patients who were octogenarians than in younger patients. Operative characteristics were similar in both age groups, except there were more frequent valve or combined with coronary grafts surgery and surgical re-exploration in octogenarians. The rate of postoperative complications including cardiovascular, neurological, renal, and nosocomial infections were higher in patients who were octogenarians than younger patients. Death or discharge to a nursing care facility was more frequent in patients who were octogenarians than younger patients (53% vs 14%, P <.002). Age > or =80 years, female sex, congestive heart failure, and surgical re-exploration were independent predictors for death or discharge to a nursing care facility after cardiac surgery.

CONCLUSIONS

The rate of death or discharge to nursing care facility after cardiac surgery was high among patients who were octogenarians. Current operative outcome end points do not reflect such important differences between patients who are octogenarians and younger patients. Informed discussion of treatment options, potential for discharge to a nursing care facility, and quality of life expectations should precede a decision to undergo cardiac surgery in patients who are octogenarians. Randomized clinical trials of medical versus surgical palliation of cardiovascular symptoms in patients who are octogenarians are needed to justify cost-effectiveness and guide better use of relatively scarce Medicare resources.

Age does not limit quality of life improvement in cardiac valve surgery

OBJECTIVES

We sought to determine the association of age with the change in quality of life (QOL) after valve surgery.

BACKGROUND

Improvement in QOL is one of the principal goals of valve surgery. These procedures are being done with increasing frequency for older patients.

METHODS

We prospectively studied 148 patients with aortic valve procedures and 72 patients with mitral valve procedures. Patients' QOL was measured at baseline and at 18 months using the Medical Outcomes Trust Short Form 36-Item (SF-36) Health Survey (response rate 90%). The association of age with change in QOL was measured by multiple regression analysis and based on two meta-scores of the SF-36: the Mental Component Summary (MCS) and the Physical Component Summary (PCS).

RESULTS

Overall improvement in most domains of the SF-36, including the MCS and the PCS scores, was substantial. Improvement in the MCS score was not influenced by age in either aortic (0.09 score point improvement per 10-year age increments; p = 0.9) or mitral (0.90 score point improvement per 10-year age increments; p = 0.3) patients. Similarly, improvement in the PCS score did not vary by age in aortic patients (-1.00 score points per 10-year age increments; p = 0.2) and only slightly varied by age in mitral patients (-1.90 score points per 10-year age increments, p = 0.02). In the latter, despite statistical significance, the association was not substantial or clinically important.

CONCLUSIONS

Among patients referred for cardiac valve surgery, age does not appear to limit the QOL benefits of surgery.

Impact of advanced age on the outcome of liver resection

The aim of this retrospective study was to evaluate the influence of age on the outcome of liver resection. A total of 129 consecutive liver resections were divided into two groups: > or = 70 years old [old group (O-group)] and < 70 years old [young group (Y-group)]. The two groups were first compared for the variables potentially affecting the postoperative course, including diagnosis, concomitant diseases, previous abdominal surgery, type of operation (major or minor resection), associated procedures, presence and length of portal clamping, intraoperative blood losses and transfusions, and length of operation. The outcome of liver resections was evaluated in terms of postoperative mortality, morbidity, transfusions, and length of hospitalization. The Y-group included 97 resections in 95 patients, aged 55.9 +/- 10.5 years (mean +/- SD; range: 23-69 years), and the O-group included 32 resections in 32 patients, aged 73.7 +/- 3.2 years (mean +/- SD; range: 70-82 years. The O-group included more hepatocellular carcinomas (46.9% versus 20.6%, p = 0.002) and cardiovascular diseases (15.2% versus 1.0%, p = 0.004). The two groups were comparable (p > 0.05) when evaluated for all other listed variables. As regards the postoperative outcome, the length of hospitalization was similar (median, range: 9.5 days, 5-60 days in the Y-group and 9 days, 5-48 days in the O-group) and the need for postoperative transfusions were not statistically different. Mortality included one case among young patients, while no deaths were recorded among elderly patients. Postoperative morbidity was higher in Y-group than in O-group (21.6% versus 9.4%, p = 0.2). In conclusion, the age factor does not negatively affect the outcome of liver resections.

The elderly: health status benefits and recovery of function one year after coronary artery bypass surgery

OBJECTIVES

The purpose of this study was to describe the health status (symptoms, function, and quality of life) changes of elderly patients undergoing coronary artery bypass grafting (CABG) and compare these to younger patients.

BACKGROUND

Despite increasing use of CABG in the elderly, few data exist about elderly patients' health status benefits from CABG.

METHODS

A total of 690 consecutive patients (n = 156, >75 years of age; n = 534, <or=75 years of age) from a single center were administered the Seattle Angina Questionnaire (SAQ) at baseline and at one year. The first 224 patients were also given monthly questionnaires for six months after CABG.

RESULTS

Although peri-operative mortality was similar (2.6% vs. 2.2%, p = NS), one-year mortality was greater in older patients (11.5% vs. 5.4%, p = 0.008). Among survivors, similar health status benefits were observed one year after surgery (SAQ change scores for Physical Function 21.5 +/- 27.0 vs. 19.7 +/- 27.0, p = 0.67; Angina Frequency 30.1 +/- 25.7 vs. 24.6 +/- 25.6, p = 0.07; and Quality of Life 37.7 +/- 21.8 vs. 33.6 +/- 25.2, p = 0.16). In 224 patients assessed monthly, elderly patients' physical function scores were significantly lower than the younger group until one year. The age-time interaction term was significant (p = 0.003), confirming a slower recovery of physical function. In contrast, angina relief and quality of life improvement did not differ by age.

CONCLUSIONS

Despite a slower rate of physical recovery, older patients derived similar health status benefits from CABG compared with younger patients. These data should assist physicians in counseling elderly patients and suggest that age alone should not be a deterrent for recommending bypass surgery.

Outcomes in nonagenarians after heart valve replacement operation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cause of late death after cardiac surgery in the very elderly: a single institution experience

OBJECTIVES

The referrals of elderly for cardiac surgery are increasing. The aim of this retrospective study is to review the long-term survival and to identify causes of late death in elderly after cardiac surgery.

DESIGN

Between 1990 and 1993, 130 octogenarians underwent cardiac surgery in our department. A majority (88%) had elective surgery. One hundred and nine patients (84%) were in New York Heart Association functional class III or IV, preoperatively. Mean follow-up time was 5.4 +/- 2.5 years (range 0-10 years). Follow-up was 100% complete.

RESULTS

Hospital mortality was 3.8% (5/130). Actuarial survival at 1 and 5 years were 90.0 +/- 2.6% (n = 117) and 62.3 +/- 4.3% (n = 81), respectively. Forty-six operative survivors died from cardiac-related death during follow-up. Multivariate predictors of postoperative death were higher age, poor left ventricular ejection fraction, preoperative renal insufficiency and combined surgical procedures.

CONCLUSION

Our results in this paper indicate that cardiac-related mortality represents the majority of late deaths after cardiac surgery in octogenarians.

Long-term results of the bioprosthesis in elderly patients: impact on quality of life

BACKGROUND

A wealth of data exists on acceptable mortality and morbidity for valve operations in older patients, yet information documenting quality of life is lacking.

METHODS

From October 1974 to May 1998, 2,075 patients aged 65 years and older underwent valve replacement using a porcine bioprosthesis. There were 1,126 men (54.3%) and 949 women (45.7%) with a mean age of 73.9 years (range 65 to 104 years).

RESULTS

The elective hospital mortality was 8.5% (158 patients), and urgent/emergent/salvage mortality was 25.8% (54 patients). Follow-up was completed for 1,863 patients (98.2%) and extended from 1 month to 23.0 years (mean 60.8 months) with a cumulative follow-up of 9,442.1 patient-years. At follow-up, surviving patients (n = 849) completed the Short Form-36 Quality of Life Survey. Results showed patients had a more favorable quality of life compared with control subjects matched for age and sex. Functional improvement was significant with 96.3% in New York Heart Association functional class I or II at follow-up. There were 74 valves that failed from all causes (33 aortic and 41 mitral valves). Actuarial freedom from valve failure at 9 years was 94.4%+/-1.1% and at 18 years was 83.7%+/-2.4%.

CONCLUSIONS

Valve replacement in older patients provides excellent functional improvement, reduces late cardiac events, and enhances quality of life.

Coronary artery bypass grafting in the elderly

BACKGROUND AND METHODS

The incidence of coronary artery bypass grafting (CABG) in elderly patients has been increasing. We retrospectively analyzed the results of CABG performed at Shin-Tokyo Hospital between January 1, 1991, and December 31, 1998. Preoperative, perioperative, and follow-up data of patients > or = 75 years old (group E, n = 190) were collected, and compared with those of patients < 75 years old (group Y, n = 1,380).

RESULTS

Female gender, emergent CABG, preoperative balloon pumping use, cardiogenic shock, hypertension, and preoperative cerebral vascular accident were significantly more frequent in group E (p < 0.05). CABG was completed without any significant differences, except for less frequent use of the bilateral internal mammary artery (p < 0.01), more frequent use of the saphenous vein (p < 0.005), and a greater incidence of blood transfusion in group E (p < 0.0001). The postoperative course required longer intubation, ICU stay, and postoperative hospital stay in group E (p < 0.001), and was more frequently associated with major complication (p < 0.0001) and in-hospital death (p < 0.05). During the mean follow-up of 2.7 years (maximum 6.9 years), the actuarial 5-year survival of groups E and Y were 84.3% and 92.5% (p < 0.01), respectively, excluding in-hospital mortality. The actuarial 5-year cardiac event-free rates were 79.9% in group E and 79.7% in group Y, showing no significant difference.

CONCLUSIONS

CABG in the elderly carries certain surgical risks. However, the long-term cardiac event-free rate after CABG in the elderly was almost the same as that of younger patients. Inferior long-term survival in the elderly was most likely due to the biological nature of aging.