Cardiac surgery in octogenarians--The Green Lane Hospital Experience 1995-1998

OUTCOME AND QUALITY OF LIFE AFTER CARDIAC SURGERY IN OCTOGENARIANS

BACKGROUND

Cardiac surgery is being performed with increasing frequency in octogenarians. The purpose of the present study was to determine the outcome and quality of life of octogenarians after cardiac surgery in a single surgeon series and in a newly established cardiac surgery unit.

METHODS

Prospective data collection and analysis were undertaken of octogenarians having cardiac surgery from 1997 to 2003 by a single surgeon in a single institution. The outcome was compared to septuagenarians operated on by the same surgeon in the same time frame, specifically to see if there were any significant differences in outcomes between these two close age groups. Follow up was conducted by sending a questionnaire, interviewing patients or their general practitioner.

RESULTS

There were significantly less octogenarians with airway disease but more with class III and IV New York Heart Association heart failure. There were no significant differences in the incidence of left main disease, urgent operations, renal impairment and cerebrovascular disease between the two groups. There was a trend towards increased operative mortality in octogenarians when the group was taken as a whole (8%vs 2%, P = 0.052). They also had a significantly higher incidence of respiratory failure (6%vs 2%, P = 0.029). The incidence of stroke, renal failure and low cardiac output was not significantly different between the two groups. Blood product usage was significantly higher in octogenarians (19%vs 9%, P = 0.042), but re-operation for bleeding was not significantly different (3%vs 4%). Intensive care unit median length of stay was significantly longer in the case of Octogenarians (1.0 vs 0.9 days, P = 0.039), but the duration of hospital stay was similar (6.5 vs 6.4 days, P = 0.165). Follow up was 94.5% complete, 85% of the octogenarians responded to the questionnaire sent to them. All patients were free of angina, 98% of them had improved by at least one New York Heart Association heart failure class and 86.7% felt that they were less dependent on others after cardiac surgery. In retrospect, 94.2% said that they would have the procedure again.

CONCLUSION

Octogenarians can be operated on with acceptable mortality and morbidity to achieve significant improvement in quality of life. The outcome of surgery in these patients in a new unit is comparable with established units.

Outcomes of cardiac surgery in nonagenarians: a 10-year experience

BACKGROUND

With an increasing awareness of health issues and greater emphasis on preventive medicine, the general population is living longer and healthier lives than ever before. Physicians are taking care of older patients, many of whom may require cardiac surgical procedures. Improving cardiopulmonary bypass technology allows for safer procedures with reduced morbidity and mortality even in older patients.

METHODS

We have performed a retrospective analysis of 42 consecutive nonagenarian patients who underwent open-heart procedures over a 10-year period (1993 to 2002) at our institution. Their demographic profiles, operative data, perioperative results, and long-term outcomes were recorded and analyzed.

RESULTS

Twenty-two women and 20 men with an age range of 90 to 97 years (mean, 91.4 years) had open-heart surgery over the study period. The complication rate was 67% overall, consisting of 7% respiratory (pneumonia, respiratory failure, reintubation), 7% hemorrhagic or embolic (postoperative bleeding, cerebral vascular accident), 12% infectious (wound infection, sepsis), and 31% new arrhythmia (atrial fibrillation, atrial flutter, ventricular tachycardia, ventricular fibrillation). Despite these complication rates, average hospital stay was 17.5 days (median, 11 days), with an intensive care unit stay of 12.0 days (median, 5 days). Thirty-day survival was 95% and survival to discharge was 93% (three deaths total; one cardiac arrest at hospital day 134 and two perioperative deaths; one ventricular arrhythmia, one cerebral vascular accident). The only statistically significant risk factor of mortality was emergency surgery. Currently, 81% are still alive an average of 2.53 years since surgery (range, 0.16 to 7.1 years).

CONCLUSIONS

With improving techniques and greater attention to detail, the select nonagenarian can safely undergo cardiac surgery.

Predictors of postoperative complications in high-risk octogenarians undergoing cardiac operations

BACKGROUND

Cardiac operations in octogenarians are currently reserved for selected patients with severe symptoms and low extracardiac comorbidity; early and midterm results are satisfactory. We evaluated the outcome of high-risk octogenarians undergoing cardiac operations and investigated the predictors of postoperative complications.

METHODS

Between June 1998 and March 2001, 73 consecutive octogenarians (mean age = 83.1 +/- 3.0 years) hospitalized and awaiting operation in our Department were analyzed for postoperative complications. We recorded the main risk factors for cardiovascular disease, symptoms of heart failure, previous myocardial infarction, reoperation, left ventricular ejection fraction, use of intraaortic balloon pump, surgical priority, and operative risk. Cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal failure were the preoperative extracardiac comorbidities considered. We adopted a multidisciplinary approach to perioperative management.

RESULTS

Surgical procedures included coronary artery bypass grafting in 36 patients (49.3%), valve procedures in 20 (27.4%), and combined coronary artery bypass grafting and valve procedures in 17 patients (23.3%). In-hospital death occurred in 6 patients (8.2%). Twenty-one patients (28.8%) had major postoperative complications including renal failure (15.1%), respiratory failure (8.2%), and myocardial infarction (8.2%). The main predictors of postoperative complications were New York Heart Association functional class IV, Canadian Cardiovascular Society angina class 4, and prolonged aortic cross-clamping time.

CONCLUSIONS

Cardiac operations can achieve satisfactory results even in high-risk octogenarians. Early surgical intervention before severe symptoms appear, and a multidisciplinary approach to perioperative management, may reduce postoperative complications.