Laminoplasty for patients aged 75 years or older with cervical myelopathy

PURPOSE. To assess the neurological and walking status of 56 elderly patients after cervical myelopathy to determine whether the surgery was justified. METHODS. Records of 23 men and 33 women aged 75 to 86 (mean, 79) years who underwent laminoplasty for cervical myelopathy were retrospectively reviewed. They had been followed up for a mean of 3.5 (range, 0.2-8.6) years. Walking status was assessed according to long-term care insurance criteria. In 45 patients with more than 2 years of follow-up, neurological status was evaluated according to the Japanese Orthopaedic Association (JOA) score. Neurological recovery rate was classified as excellent, good, fair, poor, and worse. RESULTS. Postoperatively, of the 47 patients still living, 22 could walk independently, 22 required assistance outdoors, 2 were using a wheelchair, and one was bedridden. The mean JOA score was 9.7 preoperatively, 12.2 one year postoperatively, and 11.8 at final assessment (p<0.001). The mean neurological recovery rate was 29% at one-year follow-up and 24% at final assessment (p=0.06). CONCLUSION. Although excellent results were not expected in elderly patients, surgery to maintain independent walking status was justified in most of our patients.     

Thoracic aortic operations in patients aged 70 years or older.

Thirty-one patients over the age of 70 years (group A) and 72 patients less than 69 years (group B) underwent a variety of thoracic aortic surgical procedures. Early and long-term results and cerebral function were compared between the two groups. Preoperative and postoperative cerebral function was evaluated using mini mental state-Himeji and Wechsler adult intelligence scale tests. The operative mortality of groups A and B was 12.9% and 11.1%, respectively (not significant). There were no significant differences in postoperative complications between the two groups. The late mortality rates of groups A and B were 11.1% and 9.3%, respectively (not significant). There were no significant differences between the two groups in the mini mental state-Himeji test, digit symbol, vocabulary, and total Wechsler adult intelligence scale scores before and after operation. We conclude that thoracic aortic surgical procedures in patients over 70 years of age can be performed with acceptable mortality and morbidity risks. Most patients showed symptomatic improvement.     

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older

Objectives: Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older.Methods: To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65–74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early.Results: The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8±0.5 versus 0.3±0.5; p<0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p=0.0009), delirium in 36.7% versus 11.4%, (p=0.0004), pneumonia in 6.1% versus 0%, (p=0.0439), and intubation duration of 88.3±212.5 hours versus 37.2±92 hours (p=0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p=0.1867).Conclusion: These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.     

Thoracoabdominal and descending thoracic aortic aneurysm surgery in patients aged 79 years or older

OBJECTIVE: Advanced age has been reported as a predictor of increased morbidity and mortality in patients who undergo major cardiovascular reconstructive surgery. In this study, we evaluated the outcome of patients aged 79 years or older after thoracoabdominal and descending thoracic aortic aneurysm repair. METHODS: From February 1991 to May 2001, 854 patients underwent operation for thoracoabdominal or descending thoracic aortic aneurysm. Fifty-six patients were between the ages of 79 and 88 years at the time of surgery, and these patients were included in this study. Risk factors were analyzed for their impact on mortality and morbidity in these elderly patients with univariate analysis. RESULTS: In patients at low risk, the 30-day mortality rate was 7/42 (17%), compared with 7/14 (50%) in patients at high risk with emergency presentation, congestive heart failure, or diabetes (P <.03). Four patients (7%; 4/56) had neurologic deficits develop. No single preoperative risk factor was significantly associated with increased mortality or neurologic deficits. CONCLUSION: Thoracoabdominal and descending thoracic aortic aneurysm repair in elderly patients can be undertaken with acceptable mortality and morbidity, provided that patients are selected appropriately.     

Perioperative features of coronary artery bypass grafting in patients aged 75 years or older.

OBJECTIVES: Coronary artery bypass grafting (CABG) is well established as an effective operation to overcome ischemic heart disease; however, the number of aged patients with a high operative risk undergoing this procedure has increased in recent years. This retrospective study evaluates our experience of performing CABG in a consecutive series of patients aged 75 years or older. METHODS: To assess the hospital mortality and morbidity associated with this procedure, we retrospectively analyzed 49 patients aged 75 years or older (Elderly Group) who underwent CABG and compared the results with those of 88 patients aged 65-74 years (Control Group) who underwent CABG during the same period. Patients were examined for cerebrovascular diseases, and those with significant stenosis underwent pulsatile cardiopulmonary bypass. To avoid pulmonary complications, patients were extubated early. RESULTS: The Control Group had a significantly higher incidence of arterial grafts than the Elderly Group (0.8 +/- 0.5 versus 0.3 +/- 0.5; p < 0.0001). The Elderly Group had a significantly higher incidence of postoperative complications than the Control Group, with supraventricular arrhythmia in 57.1% versus 28.4%, (p = 0.0009), delirium in 36.7% versus 11.4%, (p = 0.0004), pneumonia in 6.1% versus 0%, (p = 0.0439), and intubation duration of 88.3 +/- 212.5 hours versus 37.2 +/- 92 hours (p = 0.0296), respectively. However, there was no significant difference in hospital mortality between the two groups, being 8.2% versus, 2.3%, in the Elderly group and Control Group, respectively (p = 0.1867). CONCLUSION: These findings indicated that when elderly patients were appropriately managed, CABG could be performed with an acceptably low risk to mortality.     

Early and late surgical outcomes of acute type A aortic dissection in patients aged 75 years and older

BACKGROUND: With the general increase in human lifespan, aortic surgeons are faced with an increasing prevalence of acute type A aortic dissection in the elderly. In this study, we reviewed early and late surgical outcomes of acute type A dissection (operation within 48 hours after onset) in patients aged 75 years and older. METHODS: Between 1990 and 1999, 109 patients underwent emergency operation for acute type A dissection at Omiya Medical Center. Twenty-three patients were aged 75 years and older (elderly group, mean age, 79.1 +/- 4.7 years) and 86 were younger than 75 years old (younger group, mean age, 58.7 +/- 10.8 years). Early and late outcomes of both groups were compared. RESULTS: The hospital mortality rates were 13.0% (3 of 23) in the elderly group and 10.5% (9 of 86) in the younger group (p = 0.71). In the elderly, actuarial survival rate (including the operative mortality rate) at 1, 3, and 5 years was 78% +/- 9% for each point. In the younger group, the rates were 88% +/- 4% at 1 year, 83% +/- 4% at 3 years, and 81% +/- 5% at 5 years (p = 0.57). Actuarial event-free rates were 84% +/- 8% at 1 year, 77% +/- 11% at 3 years, and 77% +/- 11% at 5 years in the elderly group. In the younger group, the rates were 96% +/- 2% at 1 year, 88% +/- 4% at 3 years, and 81% +/- 7% at 5 years (p = 0.27). CONCLUSIONS: No significant differences in the hospital mortality, actuarial survival, or event-free rates were observed between the two groups. Operation for type A acute aortic dissection in patients aged 75 years or older can be performed with acceptable risk of death, and long-term results are satisfactory.     

Late incidence and predictors of persistent or recurrent heart failure in patients with aortic prosthetic valves

BACKGROUND: We examined factors associated with persistent or recurrent congestive heart failure after aortic valve replacement. METHODS: Patients who underwent aortic valve replacement with contemporary prostheses (n = 1563) were followed up with annual clinical assessment and echocardiography. The effect of demographic, comorbid, and valve-related variables on the composite outcome of New York Heart Association class III or IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models, and logistic regression. Factors associated with all-cause death were also examined. Prediction models were bootstrapped 1000 times. RESULTS: Total follow-up was 6768 patient-years (mean, 4.3 +/- 3.3 years; range, 60 days to 17.1 years). Freedom from congestive heart failure or congestive heart failure death was 98.6% +/- 0.3%, 88.6% +/- 1.0%, 73.9% +/- 2.3%, and 45.2% +/- 8.5% at 1, 5, 10, and 15 years, respectively. Age, preoperative New York Heart Association class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo status predicted congestive heart failure after surgery (all P <.05). Larger prosthesis size and effective orifice area, both absolute and indexed for body surface area, were independently associated with freedom from congestive heart failure. Increased transprosthesis gradients were predicted by prosthesis-patient mismatch and were associated with congestive heart failure after surgery. Mismatch defined as an effective orifice area/body surface area of 0.80 cm(2)/m(2) or less was a significant predictor of congestive heart failure events after surgery, but mismatch defined as an effective orifice area/body surface area of 0.85 cm(2)/m(2) or less was not. Small prosthesis size and mismatch were not significantly associated with all-cause mortality. CONCLUSIONS: These analyses identify independent predictors of congestive heart failure symptoms and congestive heart failure death late after aortic valve replacement and indicate that prosthesis size has a significant effect on this cardiac end point, but not on overall survival after aortic valve replacement.     

Thromboembolic events after aortic valve replacement in elderly patients with a Carpentier-Edwards Perimount pericardial bioprosthesis

OBJECTIVES: Thromboembolic events after aortic valve replacement with a bioprosthesis were the most frequently occurring complications in elderly patients. Whether this was valve related or dependent on other factors needed further exploration. METHODS: Five hundred patients with a median age of 73 years were followed retrospectively after aortic valve replacement with a pericardial prosthesis for occurrence of thromboembolism. Of these, 348 also underwent coronary artery bypass grafting. Twenty-five factors were investigated for their potential effect by using univariate and multivariate analysis. RESULTS: Univariate analysis revealed 6 significant factors: preoperative endocarditis (P =.0001), preoperative cerebrovascular accident (P =.002), use of postoperative warfarin sodium (Coumadin, DuPont Merck; P =.006), arterial hypertension (P =.023), size of valve prosthesis of 27 mm or larger (P =.023), and hospital thromboembolism (P =.040). There was a trend toward increased fatal thromboembolism in patients without medication. With a multivariate analysis, 4 factors remained significant: preoperative cerebrovascular accident (risk ratio, 4.8; P =.0016), warfarin sodium (risk ratio, 3.0; P =.0028), preoperative endocarditis (risk ratio, 5.6; P =.006), and hospital thromboembolism (risk ratio, 6.1; P =.016). Hypertension had a borderline effect. Age, sex, diabetes, 4 coronary artery factors, 3 other valvular factors, atrial fibrillation, and carotid artery disease had no significant effect. CONCLUSIONS: Some emboli seemed triggered by the valve prosthesis. A proper anticoagulant protocol but also a treatment of hypertension is important in the prevention of thromboembolism after aortic valve replacement with a bioprosthesis. We did not find a significant role of atrial fibrillation and carotid artery disease.     

Percutaneous nephrolithotomy in patients aged 60 years or older

PURPOSE: To assess the safety and efficacy of percutaneous nephrolithotomy in patients more than 60 years old. PATIENTS AND METHODS: We retrospectively evaluated and compared the data of 28 percutaneous nephrolithotomies (PCNL) performed on 27 patients aged 60 years and older (mean 65.8) with the data of the remaining 178 PCNL procedures on 166 patients performed in our clinic between December 1997 and December 1999. RESULTS: Although staghorn stones seemed to be more common in the elderly group (25% v 22%), no statistical significance was demonstrated (P = 0.715), and the stone burden was similar for the two groups (P = 0.112). The only interesting finding in terms of patient characteristics was a significantly higher incidence of solitary kidney in patients aged 60 years or older (29% v 7%; P = 0.003). The success rates (stone-free patients and patients with residual stones <4 mm) were similar, being 89% for the elderly group and 92% for the younger patients (P = 0.718). Transfusion rates were also similar (21.4% in the elderly v 18% in the younger group; P = 0.662). No significant complication was observed in this elderly group, and no renal deterioration has been detected even in the follow-up of patients with a solitary kidney. CONCLUSIONS: Despite the somewhat higher stone burden in the elderly patients (1077.92 mm2 v 920.85 mm2), the stone-free rate was similar to that obtained in the younger patients, without any higher rates of complications or blood transfusions or longer hospital stay. Percutaneous nephrolithotomy is a safe and effective method of stone treatment in the elderly, even if they have a solitary kidney or complex calculi.     

Stability of total hip arthroplasty in patients 75 years or older

Increasing patient age (> 75 years) is a known risk factor for dislocation of total hip arthroplasty. This is a study of total hip arthroplasties by one surgeon in patients 75 years or older to determine the prevalence of dislocation and a review of the surgical options for prevention and treatment of instability in this population. Of 140 primary total hip arthroplasties done in patients 75 years or older who were followed up for at least 1 year, the preoperative diagnosis was osteoarthritis in 82% and the mean followup time was 4 years. The acetabular component was cementless: modular in 121 arthroplasties and cemented in 19 arthroplasties. There were five dislocations (3.5%), but only two were recurrent and the patients were treated successfully by modular component exchange. Bipolar arthroplasty has a lower rate of dislocation, but there are problems with residual pain and high rates of reoperation, wear, and osteolysis. Constrained components may be indicated in older patients with dementia, abductor insufficiency, or failure of modular exchange. Large femoral heads, to increase the range of motion before dislocation occurs, may be used with highly cross-linked acetabular liners. Modular cementless acetabular components are preferable in patients who are 75 years or older. A 28-mm or 32-mm femoral head is recommended, but larger femoral heads should be considered in patients with fractures and for the treatment of recurrent dislocation.     

Anesthetic management of elderly patients aged 90 years or older

The authors experienced 55 cases of anesthetic management in 52 elderly surgical patients, 14 men and 38 women, aged 90 to 101 years with an average of 92.1 +/- 2.1 years for the past ten years. Surgical procedures included 38 cases of orthopedic, 14 cases of general surgical and 3 cases of ophthalmic operations. Thirteen cases out of them were emergency. General, epidural, spinal, and local anesthesia were applied in 34 cases, 18 cases, 2 cases, and one case out of these elderly patients, respectively. These general anesthesia consisted of total intravenous anesthesia with propopol, fentanyl and ketamine in 27 cases, sevoflurane with nitrous oxide in 4 cases, isoflurane with nitrous oxide or air in 2 cases, and thiopental anesthesia in one case. The elderly patients had past history of heart disease, dementia, hypertension, cerebral infarction/hemorrhage, diabetes mellitus and others. Their preoperative examinations revealed anemia, hypoproteinemia, renal hypofunction, serum electrolytes imbalance, and others. Vasopessors were given to 42% of the patients during anesthesia and surgery. Their postoperative complications included myocardial infarction, paroxysmal atrial fibrillation, hypotension following anemia, transient hemiparesis, delirium and so on. Two patients developed myocardial infarction postoperatively and died thereafter. The authors suggest that appropriate anesthetic management for elderly patients aged 90 years or older requires proper preoperative evaluation, sufficient vigilance of hemodynamics with direct arterial pressure measurement, reliable preparation of medical agents, and awareness of impairment of circulatory function and others by aging.     

Clinical pulmonary autograft valves: pathologic evidence of adaptive remodeling in the aortic site

OBJECTIVE: We studied the pathologic features, cellular phenotypes, and matrix remodeling of clinical pulmonary-to-aortic valve transplants functioning up to 6 years. METHODS: Nine autografts and associated vascular walls early (2-10 weeks) and late (3-6 years) postoperatively were examined by using routine morphologic methods and immunohistochemistry. In 4 cases autograft and homograft cusps were obtained from the same patients. RESULTS: Autografts had near-normal trilaminar cuspal structure and collagen architecture and viable valvular interstitial and endothelial cells throughout the time course. In contrast, cusps of homografts used to replace the pulmonary valves in the same patients were devitalized. In early autograft explants, 19.3% +/- 2.4% of cuspal interstitial cells were myofibroblasts expressing alpha-actin. In contrast, myofibroblasts comprised only 6.0% +/- 1.1% of cells in late explants and 2.5% +/- 0.4% and 4.6% +/- 0.8% of cells in normal pulmonary and aortic valves, respectively (P <.05). In early autografts only 12.0% +/- 4.6% of endothelial cells expressed the systemic arterial endothelial cell marker EphrinB2, whereas later explants had 85.6% +/- 5.4% of endothelial cells expressing EphrinB2 (P <.05). In early autografts 43.8% +/- 8.8% of interstitial cells expressed metalloproteinase 13, whereas late autografts had 11.4% +/- 2.7% of interstitial cells expressing matrix metalloproteinase 13 (P <.05). Collagen content in autografts was comparable with that of normal valves and was higher than that seen in homograft valves (P <.005). However, autograft walls were damaged, with granulation tissue (early) and scarring, with focal loss of normal smooth muscle cells, elastin, and collagen (late). CONCLUSIONS: The structure of pulmonary valves transplanted to the systemic circulation evolved toward that of normal aortic valves. Key processes in this remodeling included onset of a systemic endothelial cell phenotype and reversible plasticity of fibroblast-like valvular interstitial cells to myofibroblasts.     

Long term results of cardiac valve replacement in patients aged 75 years and older.

From June 1978 to December 1989, 158 patients over 75 years of age (mean: 78 years; range 75 to 86 years) underwent 164 valve replacements: 134 in the aortic, 18 in the mitral and 6 in double mitral and aortic positions. One hundred and seven of these valves (66%) were bioprostheses, 93 aortic and 14 mitral and 57 valves (34%) were mechanical prostheses; 47 aortic and 10 mitral. Hospital mortality (less than or equal to 30 days) was 7% (11 patients, all in NYHA class III or IV) but was higher in patients who had undergone associated procedures (9.8%; 6/61 patients) or in patients who had mitral valve replacements (11%) and in double valve replacement (16.6%). Because of a minimal delay of one year, long term follow-up information (100%) was only obtained from the first 110 patients discharged from hospital. Late mortality has been 13.6% and actuarial survival at 11 years was 71.5% +/- 5. Therefore, despite a hospital mortality of more than twice that of patients operated upon under 75 years of age (3.3%), an actuarial survival at 11 years, similar to that of patients under 75 years (77 +/- 5%) and the functional improvement obtained (95% of survivors are NYHA class I or II) certainly justify surgery in these patients. Because of the incidence of anticoagulant related hemorrhages in these patients (1.7% patient year) and since, structural deterioration of the bioprostheses was non existent in this series, a bioprosthesis appears to be the best valvular substitute in patients over 75 years of age.