Non-elective cardiac surgery in octogenarians: Do these patients benefit in terms of clinical outcomes and quality of life?

Living Longer or Better-Patient's Choice in Cardiac Surgery Is Gender-Dependent-A Multicenter Study

In view of the increasing age of cardiac surgery patients, questions arise about the expected postoperative quality of life and the hoped-for prolonged life expectancy. Little is known so far about how these, respectively, are weighted by the patients concerned. This study aims to obtain information on the patients' preferences. Between 2015 and 2017, data were analyzed from 1349 consecutive patients undergoing cardiac surgery at seven heart centers in Germany. Baseline data regarding the patient's situation as well as a questionnaire regarding quality of life versus lifespan were taken preoperatively. Patients were divided by age into four groups: below 60, 60-70, 70-80, and above 80 years. As a result, when asked to decide between quality of life and length of life, about 60% of the male patients opted for quality of life, independent of their age. On the other hand, female patients' preference for quality of life increased significantly with age, from 51% in the group below sixty to 76% in the group above eighty years. This finding suggests that female patients adapt their preferences with age, whereas male patients do not. This should impact further the treatment decisions of elderly patients in cardiac surgery within a shared decision-making process.

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

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

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

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

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

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†

OBJECTIVES

With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period.

METHODS

Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes.

RESULTS

There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk.

CONCLUSIONS

The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.

Successful extracorporeal membrane oxygenation assisted revascularisation in a high-risk elderly patient refused surgical treatment

Management of high-risk elderly patients requiring revascularisation remains a clinical challenge. We report a case of extracorporeal membrane oxygenation (ECMO) assisted complex percutaneous coronary intervention in a  high-risk octogenarian. An 83-year-old female with signs of worsening heart failure was admitted to the emergency department of a tertiary care facility. Transthoracic echocardiography revealed a  decreased left ventricular ejection fraction of 20% with severe mitral regurgitation and mild aortic and tricuspid valve insufficiency. Three-vessel disease was found during coronary angiography. Due to the patient's frailty, a high-risk surgery decision to proceed with ECMO assisted percutaneous coronary intervention was made during a heart team meeting. Following initiation of mechanical support, coronary lesions were treated with three drug-eluting stents. After the procedure, the patient was transferred to the ICU on ECMO support, where she was successfully weaned from the device 9 h later. Her ICU stay was four days. She was successfully discharged from the hospital after uneventful recovery. At one-year's follow-up, the patient was clinically stable in an overall state of general well-being and with complete participation in routine activities; she had good exercise tolerance and no signs of ischemia. This report highlights the possibility of use of ECMO during PCI in high-risk elderly patients.

Survival, quality of life and impact of right heart failure in patients with acute cardiogenic shock treated with ECMO

BACKGROUND

Mechanical circulatory support is increasingly used in acute cardiogenic shock.

OBJECTIVE

To assess treatment strategies for cardiogenic shock.

METHODS

Data of 57 patients in acute intrinsic cardiogenic shock treated with ECMO were analyzed. Different subsequent strategies (weaning, VAD, transplantation) were followed.​

RESULTS

Overall 1, 2, and 4-year survival was 36.8 ± 6.4%, 32.2 ± 6.4%, 29.8 ± 6.3%. Elevated lactate and hemorrhagic complications (all p in patients with right heart failure prior to ECMO implantation, BVAD therapy showed a trend (p=0.058) towards superior survival compared with LVAD therapy. Seven of the BVAD patients received successful transplantation, with a 1-year survival of 71%. Among survivors Short Form 36 reported significantly lower combined physical scores (p=0.004).

CONCLUSIONS

Right heart assessment prior to ECMO implantation may be beneficial to provide tailored therapy if ECMO weaning fails. Survival after cardiogenic shock requiring ECMO seems to be associated with impaired long-term quality of life.