Cost-effectiveness of minimally invasive coronary artery bypass surgery.

BACKGROUND: Coronary artery bypass grafting without cardiopulmonary bypass is gaining popularity as an alternative to conventional on-pump technique for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off-pump (OPCAB) methods. These two approaches should be evaluated for financial and clinical appropriateness. METHODS: Records of patients who had single or double bypass (internal mammary artery and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed. These included 44 MIDCAB, 62 OPCAB, and 243 conventional coronary artery bypass (CCAB) patients. Univariate analysis was applied to pre, intra, and postoperative variables, comparing MIDCAB and OPCAB to the CCAB group. Procedural cost information was obtained from participating institutions. RESULTS: MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4+/-11 versus 2.3+/-2.8, p = 0.012) and OPCAB patients had a predicted risk of 5.3+/-7.8. MIDCAB and OPCAB procedures required less operating room time and blood utilization. Observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6%, and CCAB 2.8% (not significant). Mean hospital costs were CCAB at $19,000, OPCAB at $15,000, and $17,000 for MIDCAB. CONCLUSIONS: Off pump procedures currently reflect acute episode-of-care cost savings over CCAB.     

Isolated coronary artery bypass grafting in octogenarians

We evaluate the outcomes of isolated coronary artery bypass grafting (CABG) in high-risk octogenarians. There are 20 cases in 5 years, which contain 1 re-operation case, and 10 emergency cases. Nineteen cases were performed off-pump CABG (OPCAB), and conventional CABG was performed for only 1 case because of unstable hemodynamics with intraaortic balloon pumping (IABP). We generally performed CABG with aorta no-touch technique. There is no death case, and no serious complication like stroke. We used 23 artery and 11 vein grafts for CABG, and mean number of grafts per patient was 1.8+/-0.7. And "hybrid therapy" with percutaneous transluminal coronary angioplasty (PTCA) was done for 5 cases. Octogenarians are at increased risk for perioperative morbidity and mortality after CABG, but we have performed OPCAB for them and have had good results. And we think that aorta no-touch technique, proper selection and use of graft are important.     

Off-pump coronary artery bypass grafting in octogenarians

Objectives: Off-pump coronary artery bypass grafting (CABG) has become accepted for myocardial revascularization because it reduces perioperative morbidity. We assessed the safety and efficacy of bypass surgery on the beating heart in elderly patients. Methods: Off-pump CABG was done in 25 patients aged 80 years or older between February 1996 and February 2001. We retrospectively compared clinical results for these patients to those of 18 consecutive age-matched patients undergoing on-pump CABG during the same period. Results: Mean patient age in both groups was similar −82.2±2.3 years in the off-pump group vs 81.9±2.0 years in the on-pump group (p=0.66). Preoperative risk was similar in both groups, but significantly more patients in the on-pump group had triple-vessel disease. Distal anastomoses were significantly fewer in the off-pump group than in the on-pump group at 2.0±1.0 vs 2.8±0.5 (p<0.01). The off-pump group had a shorter postoperative ventilation −13.4±17.2 hours vs 45.2±52.8 hours (p<0.05)—, and less blood transfused −16% vs 89% (p<0.01)—than the on-pump group. Mean postoperative hospitalization and intensive care unit stay were 18.6 days and 3.2 days in the off-pump group, versus 37.1 days and 9.4 days in the on-pump group (p<0.05). No difference was seen in the incidence of major postoperative complications between groups. No hospital deaths occurred in the off-pump group. Conclusion: Off-pump CABG is thus a safe and effective for myocardial revascularization in the elderly.     

Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians.

OBJECTIVE: To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. METHODS: Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged > or =80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. RESULTS: There were more females (47% vs 26%, p<0.0001) among octogenarians (n=383, median age 82 years) than among younger patients (n=6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p<0.0001). Operative procedures differed between octogenarians and younger patients (p<0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR+CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p<0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age > or =80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89-4.21, p<0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56-3.18, p<0.0001), AVR+CABG (OR 2.92, 95% CI 1.60-5.33, p<0.0001) and MVR+CABG (OR 4.77, 95% CI 2.10-10.85, p<0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p<0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p=0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56-8.32, p=0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47-39.70, p=0.02). CONCLUSION: Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.     

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass

BACKGROUND: Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians. METHODS: Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared. RESULTS: The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant). CONCLUSIONS: This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.     

Short-term and long-term outcomes of octogenarians after off-pump coronary artery bypass surgery

Purpose  

Off-pump coronary artery bypass has been reported to be associated with reduced morbidity and mortality after surgical coronary revascularization, especially in high-risk patients. The aim of this study was to clarify the efficacy of off-pump coronary artery bypass for the very elderly patients.     

Morbidity and mortality after coronary artery bypass in octogenarians

One hundred fifty seven consecutive octogenarians (mean age +/- standard deviation, 82.4 +/- 1.9 years) underwent coronary artery bypass grafting with hypothermia (mean temperature, 21.8 degrees +/- 1.8 degrees C), hyperkalemic cardioplegia, and cardiopulmonary bypass in a 9-year period. Sixty-six percent were male. Preoperatively, 115 patients (73%) were in New York Heart Association functional class IV, with the remainder being in either class III (23%) or class II (4%). Twenty percent of the patients had major complications including postoperative hemorrhage (15), sepsis (9), cerebrovascular accident (6), third-degree heart block (5), renal failure requiring dialysis (1), and pulmonary embolism (1). The 30-day or in-hospital mortality rate was 7.0%. Mean total hospital stay was 26.1 +/- 17.9 days. One-year and 5-year actuarial survival rates were 85% and 62%, respectively. Higher mortality was seen to be associated with New York Heart Association class IV, left ventricular ejection fraction less than 0.40, and lesser values for cardiac output and cardiac index. At the 6-month postoperative follow-up, 73% of the survivors reported that their general health had improved as compared with before operation. This experience demonstrates that for select octogenarians with unmanageable angina pectoris, coronary artery bypass grafting is an effective therapeutic option.     

Off-pump versus conventional coronary artery bypass grafting in octogenarians

Coronary artery bypass grafting (CABG) in elderly patients is becoming increasingly common. From January 1996 to February 2002, 836 patients underwent CABG in our hospital, of whom 33 patients (3.9%) were aged 80 years or older. We evaluated the clinical and short-term results of 7 cases of off-pump CABG (OPCAB) and 26 cases of conventional CABG (C-CABG). Mean patient age and preoperative risk factors were similar in both groups. The OPCAB group had significantly decreased operation time (218 versus 281 minutes, p<0.05), and the number of distal anastomoses was significantly fewer in the OPCAB group than in the C-CABG group (1.9 versus 3.8, p<0.05). The frequency of complete revascularization in C-CABG was significantly higher than that of the OPCAB group (84.6% versus 42.9%, p<0.05), and there were no differences in the incidence of major postoperative complications between the groups. There was no hospital death in either group. Cumulative cardiac event free rates were 75% at 1 year and 75% at 3 years in the OPCAB group and 100% at 1 year and 84.6% at 3 years in the C-CABG group (p<0.05). In conclusion, CABG is safe and effective for myocardial revascularization in octogenarians. Except for high-risk cases, complete revascularization with OPCAB or C-CABG should be performed, because favorable outcomes can be expected even in the elderly patients.     

Coronary artery bypass grafting in octogenarians.

The aging of the Japanese population and improvements in surgical techniques have resulted in an increasing number of elderly patients undergoing coronary artery bypass grafting (CABG). We reviewed the records of 11 patients 80 years of age or older (mean age 82+/-0.38 years, range, 80 to 85 years) who had undergone a CABG at our institution between August 1989 and February 1999. Eight patients were males and 3 were females. Preoperatively, 4 of 11 patients were categorized as New York Heart Association class II, 4 as class III, 3 as class II. The operations were elective in 8 cases, and emergent in 3. Three patients presented with neck and cerebrovascular disease. One patient experienced chronic renal failure. No patients died within 30 postoperative days and no in-hospital deaths occurred. A total of 11 were followed up for an average of 35+/-11 months (range, 1 to 105 months). One patient died due to unknown causes. There was a significant decrease in overall anginal symptoms after CABG among the survivors, with the average decrease being from NYHA class 3.1 to 1.5. In conclusion, CABG is a safe and effective surgical procedure in the treatment of octogenarians with heart disease.     

Results and predictors of early and late outcomes of coronary artery bypass graft surgery in octogenarians

OBJECTIVES: The aim of this study was to investigate early and late outcomes of coronary artery bypass graft (CABG) surgery in a large cohort of octogenarian patients. The results were compared with 2 other age groups including septuagenarians and patients <70 years old. DESIGN: A retrospective study of consecutive patients undergoing CABG surgery using a computerized database based on the New York State Department of Health registry. Data collection was performed prospectively. Setting: A university hospital (single institution). PARTICIPANTS: Two thousand nine hundred eighty-five patients undergoing CABG surgery including 282 (9.4%) octogenarians, 852 (28.6%) septuagenarians, and 1851 (62%) patients younger than 70 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, hospital mortality, morbidity, length of stay, and long-term survival were analyzed. Octogenarians were more likely female and presented significantly more often with comorbidities such as heart failure, an ejection fraction <30%, peripheral vascular disease, and aortic calcification. Crude hospital mortality was 4.6% (n = 13) in octogenarians compared with 2.2% (n = 19) in septuagenarians and 2.4% (n = 44) in patients <70 years old (p = 0.067). Respiratory failure and gastrointestinal complications occurred more frequently in octogenarians. The stroke rate was 1.6% and similar in the 3 age groups. In multivariate logistic regression analysis, age >80 years was not a predictor of hospital mortality. The length of stay was significantly higher in octogenarians compared with nonoctogenarians (16 +/- 24 days v 10 +/- 13 days, p < 0.001). Five-year survival was 63% +/- 4% in octogenarians and was similar to that of an age- and sex-matched general US population. CONCLUSIONS: Excellent results after CABG surgery can be expected in octogenarians, with a minimal increase in postoperative mortality and acceptable postoperative morbidity. Respiratory failure is the main postoperative complication in octogenarians. Recent advances in operative techniques and perioperative management have contributed in improving surgical outcome in these patients compared with historic reports.     

Delirium after coronary artery bypass surgery.

The incidence of postoperative delirium following coronary artery bypass surgery was 28%. This rate is comparable to that after open-heart surgery. However, of those variables which were previously found to correlate with delirium in the open-heart group, only severity of postoperative illness in the recovery room significantly correlated with delirium in patients having bypass. The relationship between personality type and delirium, previously found to be signficant, was suggestively associated in these patients. A history of myocardial infarction prior to surgery was significantly associated with delirium.     

Significance of interferon-gamma in coronary artery bypass surgery.

BACKGROUND: Gamma interferon (IFN-gamma) is produced by activated natural killer and T cells under pathologic circumstances. The objective of our study was to compare the level of IFN-gamma in open and endoscopic methods of vein harvesting for coronary artery bypass surgery (CABG). METHOD: Ninety samples of human saphenous veins harvested from patients prepared for CABG. Pre- and post-procedure sera of the patients, in addition to supernatants of 3-day endothelial cell culture, were analyzed for IFN-gamma. RESULTS: The mean preoperative IFN-gamma level (0.09+/-0.03 pg/mL) and that for postoperative sera (0.08+/-0.02 pg/mL) were not significantly different (P = 0.2). The mean IFN-gamma level in endothelial cell culture from the endoscopic (0.18+/-0.21 pg/mL) and the open method (0.19+/-0.39 pg/mL) were not significant (P = 0.89). CONCLUSION: We recommend the endoscopic method of vein harvesting because of its lower morbidity and earlier hospital discharge.     

80岁以上冠心病病人行冠状动脉旁路移植术21例

目的 探讨80岁以上冠心病病人行冠状动脉旁路移植术(CABG)的可行性和临床效果.方法 2004年6月至2007年3月80岁以上行冠状动脉旁路移植术者21例,男16例,女5例;年龄80～89岁.均行非体外循环不停跳下CABG(OPCAB).结果 术后出现低心排出量综合征2例,呼吸功能衰竭、多脏器衰竭、胸骨哆开各1例.死亡3例.平均住院29d.术后1例应用主动脉内球囊反搏,1例应用左心辅助装置(BVS5000),1例术后3 d再次行OPpcABG术.结论 CABG手术治疗高龄冠心病者有效.全身脏器功能衰退是高龄围术期并发症发生率和病死率上升的主要原因.采用OPCAB可有效地降低围术期并发症发生率和病死率.     

Coronary artery bypass grafting in octogenarians

Preoperative profiles, postoperative complications, and the early and late results in 32 patients 80 yrs. of age and older (elderly group) who underwent coronary artery bypass grafting were compared with those in patients under 80 yrs. of age (control group). In the elderly group, the prevalence of patients with preoperative creatinine clearance (Ccr.) <50 l/day (34.4%), unstable angina pectoris (78.1%) and left main trunk disease (40.1%) was significantly higher than those in the control group. The incidences of arrhythmia and intensive care unit(ICU) syndrome were also significantly higher in the elderly group than in the control group, however, there was no death due to these complications. In the elderly group, one patient (3.1%) died in the hospital due to low cardiac output syndrome (LOS), while three patients (2.4%) of the control group died in the hospital. As for the long-term results, the 5-yr. survival rates for the elderly group and the control group were 82.6% and 85.2%, respectively, and the effectiveness of surgery was remarkable, with improved postoperative activity in 96.9% of the elderly group. These findings indicate that although the elderly patients have higher risks by undergoing surgery and have a disadvantage in the rate of postoperative complications, the postoperative improvement in activity and survival rate can be similar to those in the younger patients.     

Anaesthetic management for coronary artery bypass surgery.

The principles and practice of aneasthesia for patients having coronary bypass grafts are discussed. The essential basic principle is to restrict myocardial oxygen requirement while maintaining oxygen supply. The pathophysiology of coronary artery disease and the pharmacological principles for successful management of the cardiac patient through operation and whole body perfusion for coronary bypass grafts are summarized.