Is cardiac surgery justified in patients in the ninth decade of life?

Clinical life: expectation and the double edge of medical promise

This article introduces the concept of clinical life to capture a form of life produced in the pursuit and wake of medically achieved longevity. Relying on the retrospective accounts of 28 individuals over age 70 who have undergone cardiac bypass surgery, angioplasty or a stent procedure, as well as interviews with their families and with clinicians, we examine three features of clinical life. First, patients do not distinguish between clinical possibility and clinical promise, and thus assume that life can and will be improved by medical intervention in late life. Rather than anticipating a range of potential treatment outcomes, patients therefore expect the best-case scenario: that medical procedures will reverse aging, disease and the march of time. Second, patients then assess the value of their post-procedure lives in accordance with that expectation. Norms regarding what life ‘should be like’ at particular ages are continually recalibrated to the horizon of what is clinically possible. And third, the price of living longer entails a double-edged relationship with the clinic – it generates opportunities for bodily restoration and increased self-worth but also creates ambivalence about the value of life. This latter feature of clinical life is rarely publicly acknowledged in an environment that emphasizes medical promise.

Elective hypothermic circulatory arrest to address aortic pathology is safe for the elderly

BACKGROUND

Due to assumptions of excessive risk, hypothermic circulatory arrest (HCA) has been considered prohibitive in elderly patients. However, as more elderly patients are referred for assessment of difficult aortic valve, ascending aorta, and aortic arch pathology, the risk of HCA in these patients needs to be addressed. We hypothesized that the use of HCA would not increase mortality or complications in elderly patients compared to younger counterparts.

METHODS

We retrospectively reviewed the charts of adult patients who underwent elective HCA between January 1995 and June 2007. Of 147 procedures, 45 patients were >or=75 years old. These patients were compared to their younger counterparts in terms of comorbidities, operations, and complications.

RESULTS

Comparing patients >or=75 years old to their younger counterparts revealed no significant differences in outcomes including nearly identical rates of confusion (>or=75 15% vs <75 9%, p > 0.5) and stroke (>or=75 11% vs <75 7%, p > 0.2). There was also no difference in 30-day mortality (>or=75 7% vs <75 7%, p = 0.9). Lengths of hospital stays and intensive care unit stays were longer in the older patients, but this was not statistically significant.

CONCLUSION

In this study, elderly patients faired well with HCA compared to younger patients. These data suggest that the use of HCA is safe in selected elderly patients. Elderly patients should be considered for indicated procedures of the aortic valve, ascending aorta, and aortic arch regardless of age.

Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians

BACKGROUND

Off-pump coronary artery bypass (OPCAB) surgery has been successfully used in diverse patient populations and has been postulated to be safer than conventional coronary artery bypass (CCAB) surgery in some high-risk patients, including the elderly.

OBJECTIVE

To compare the safety of OPCAB surgery versus CCAB surgery in the octogenarian population of two large southwestern Ontario cardiac surgical units.

RESULTS

Two hundred thirty-six consecutive octogenarians underwent primary isolated coronary artery bypass surgery from November 2000 to March 2005. Patients undergoing OPCAB surgery tended to have higher Parsonnet scores, while patients undergoing CCAB surgery had a greater number of emergent operations. The Canadian Cardiovascular Network predicted that mortality risk was similar in both groups. In-hospital mortality was similar between groups, as was postoperative myocardial infarction and new onset of renal dysfunction. However, in the OPCAB group, there was a decreased incidence of postoperative neurological dysfunction (2.3% in the OPCAB group versus 10.5% in the CCAB group, P=0.01), in particular cerebrovascular accidents (1.5% in the OPCAB group versus 7.6% in the CCAB group, P=0.05), and a decreased incidence of prolonged intubation (5.3% in the OPCAB group versus 13.3% in the CCAB group, P=0.04). Multivariable analysis found that cardiopulmonary bypass had no significant impact on mortality or length of stay.

CONCLUSIONS

In octogenarian patients, OPCAB surgery is as safe as CCAB surgery in terms of mortality and major morbidity. Furthermore, a significant reduction in neurological dysfunction and prolonged intubation was seen in the OPCAB group compared with the CCAB group.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.

Risk, life extension and the pursuit of medical possibility

With increasing frequency, the oldest members of US society are undergoing medical interventions aimed at prolonging life. Using cardiac care as a case study, this paper explores how a discourse of risk infuses and legitimates high-tech clinical treatments in late life. In particular, we examine how the diminishing risks associated with biomedical procedures produce a sense of medical possibility regarding life extension, and push the definition of "old age" into a receding future. Simultaneously, physicians, patients and families come to understand the management and reduction of future cardiac risks to be germane for individuals even near the end of life. Driven by the logic and language of risk, decisions to intervene are experienced as incremental and largely unremarkable, and the pursuit of an open-ended future via biomedical means is perceived as an ethical imperative, trumping deliberation or discussion of the utility of intervention and the ultimate ends being pursued. For practitioners and patients alike, the engagement of risk, the preservation of hope it facilitates and the routinisation of intervention it produces all contribute to the emerging mandate to treat at ever-older ages.

Revisiting the biomedicalization of aging: clinical trends and ethical challenges

Developments in the realms of medical innovation and geriatric clinical intervention impact our understanding of the nature of late life, the possibilities for health in advanced age, medical decision making, and family responsibility in ways that could not have been predicted 15 years ago. This essay begins to map new forms of biomedicalization in the U.S. and to underscore their emergence in a new ethical field. We suggest that a new kind of ethical knowledge is emerging through "routine" clinical care, and we offer examples from the following interventions: cardiac procedures, kidney dialysis, and kidney transplant. This new ethical knowledge is characterized by the difficulty of saying "no" to life-extending interventions, regardless of age. We explore the intensification of the biomedicalization of old age through a discussion of three features of the new ethical field: (a) the ways in which routine medical care overshadows choice; (b) the transformation of the technological imperative to a moral imperative; and (c) the coupling of hope with the normalization and routinization of life-extending interventions. We argue that societal expectations about longevity and standard medical care come together today in a shifting ethics of normalcy, with unexplored socio-cultural ramifications.

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.

Cost, outcome, and functional status in octogenarians and septuagenarians after cardiac surgery

STUDY OBJECTIVES

To evaluate cost, outcome, and functional status of octogenarians and septuagenarians after cardiac surgery.

DESIGN

Observational case control study. Retrospective analysis of hospital cost and outcome. Prospective analysis of functional status at 1 to 2 years.

PATIENTS

One hundred three consecutive octogenarians and 103 randomly selected septuagenarians who underwent cardiac surgery.

SETTING

A university-affiliated tertiary care center.

MEASUREMENTS AND RESULTS

Compared to septuagenarians, octogenarians were more likely to be widowed (p < or = 0.001) and to have had preoperative strokes (p < or = 0.05) but were less likely to have diabetes mellitus (p < or = 0.001). They were less likely to have undergone mitral valve surgery (p < or = 0.01) but were more likely to have undergone coronary artery bypass graft surgery without cardiopulmonary bypass (p < or = 0.001). The hospital mortality rate was 6% in the younger group and 9% in the older group (odds ratio, 1.5; 95% confidence interval [CI], 0.5 to 4.5; p > 0.05). In patients undergoing isolated CABG, the mortality rate was 1.4% in the septuagenarians and 8.2% in the octogenarians (odds ratio, 6.2; 95% CI, 0.7 to 52.7; p = 0.12). Despite similar ICU, postoperative, and total lengths of stay, the median hospital direct variable cost was 35% higher for the octogenarians. At late follow-up, octogenarians had lower levels of physical functioning and general health but otherwise had levels of function that were similar to those of septuagenarians.

CONCLUSION

Cardiac surgery can be performed in the elderly with good hospital and late functional results, but at a higher hospital cost than that for younger patients.

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.

Is aortic surgery using hypothermic circulatory arrest in octogenarians justifiable?

OBJECTIVE

This study was undertaken to analyze the risk of mortality and neurological complications after aortic surgery requiring hypothermic circulatory arrest (HCA) in octogenarians.

METHODS

All patients of >80 years at the time of aortic surgery requiring HCA since 1988 were examined. Of 51 patients, 23 were male; the median age was 83. Twenty-six (51%) had proximal repair; the arch was replaced in eight (16%), and 17 (33%) had descending aorta repair. Eleven (22%) were emergencies. Multivariate analysis was carried out to determine the risk factors for in-hospital mortality and/or stroke (adverse outcome) using variables with P<0.1 after univariate analysis.

RESULTS

The hospital mortality was 16%. Five patients suffered strokes (9.8%): only one survived >6 months, and three died before discharge. The overall adverse outcome was 22%, but elective operation was associated with much better results, with an adverse outcome of only 3.6% after operations via a median sternotomy. Adverse outcome was strikingly higher with more distal resections via a left thoracotomy: 47 vs. 8.8% for ascending aorta/arch resections (P=0.003). Emergency operation via a lateral thoracotomy was associated with a prohibitively high adverse outcome. Twenty-nine patients (73%) had temporary neurological dysfunction (TND). Multivariate analysis revealed emergency operation (P=0.01; odds ratio (OR), 10.6) and operations via a lateral thoracotomy (P=0.008; OR, 11) as independent preoperative predictors of adverse outcome. The overall survival was 66% at 2 years and 39% at 5 years, compared with 85 and 52% among age- and sex-matched controls.

CONCLUSIONS

Aortic surgery utilizing HCA in octogenarians can be performed with an acceptable risk of mortality and stroke. From the evidence in this study, it seems that elective aneurysm repair via a median sternotomy can be undertaken for the usual indications, even in octogenarians. However, the enhanced vulnerability of the brain in the elderly is reflected by a high early mortality following stroke, and a high incidence of TND. Emergency operations increase the possibility of adverse outcome dramatically, and patients who require a lateral thoracotomy are at significantly higher risk than those operated via a median sternotomy.

Target vessel revascularization without cardiopulmonary bypass in elderly high-risk patients

BACKGROUND

Coronary artery bypass grafting in patients over 75 years is associated with high operative risk. Target vessel revascularization without cardiopulmonary bypass is a promising option for highly selected, older patients. However, the outcome remains uncertain.

METHODS

We investigated 44 patients over 75 years, matched for preoperative risk and left ventricular function, who underwent coronary artery bypass grafting either with or without cardiopulmonary bypass (CPB). We analyzed patients characteristics, Parsonnet score, EuroSCORE, short as well as midterm outcome and quality of life (freedom from recurrence of angina, anti-anginal therapy, sf36 test).

RESULTS

Perioperative mortality was higher in the patient group operated with CPB (15.9) as compared to patients operated without CPB (4.5%, p = 0.0226). Patients operated with cardiopulmonary bypass received more grafts (3.1 +/- 0.1) than patients operated without cardiopulmonary bypass (1.6 +/- 0.1, p = 0.0001) and and were more likely to undergo complete revascularization (with CPB 100%, without CPB 63.6%, p = 0.0010). Perioperative complications were more frequent and midterm survival was worse in the patient group operated with CPB (log rank p = 0.0228). Quality of life was comparable in both groups.

CONCLUSIONS

The concept of incomplete target vessel revascularization of the culprit lesion seems to be a promising option for selected high-risk patients, predominantly due to lower perioperative mortality.