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.     

Cardiac surgery in octogenarians

BACKGROUND: Early and late results were studied in order to improve the indications for surgery in the elderly. METHODS: Two hundred and thirty-seven patients aged 80 years or older underwent cardiac surgery between 1987 and 2001. The mean age of patients, which included 148 men and 89 women, was 82 years. Elective operations were performed in 194 patients and urgent or emergency operations in 43. Coronary artery bypass grafting (CABG) was performed in 104 patients, valve surgery in 60, CABG plus valve in 58, and other surgery in 15. Late results were obtained in 91% of patients, and the mean follow-up period was 54 months. RESULTS: Operative mortality was 9% in total; 7% in CABG, 5% in valve, 10% in CABG plus valve. Operative mortality was significantly higher in the urgent/emergency group than in the elective group (25% vs 6%). The actuarial survival rate for hospital survivors at 60 months after surgery was 75% and the mean survival period 76 months. There were no significant differences among operations. Preoperatively 81% of the patients had been in New York Heart Association class III or IV, and 88% of survivors were in class I or II in the late period. CONCLUSIONS: Early and late results for elective surgery in octogenarians are satisfactory. However, for urgent or emergent cases, there is a marked increase in morbidity and mortality.     

Survival and length of stay following blood transfusion in octogenarians following cardiac surgery

Our aim was to assess if peri‐operative blood transfusion is an independent risk factor for mortality and morbidity in the elderly. We report the results of a cohort study of all patients aged 80 or more on the day of their emergency or elective cardiac surgery (n = 874), using routinely collected data from January 2003 to November 2007. The primary outcome was all‐cause mortality in hospital. The secondary outcomes were duration of stay in the intensive care unit (ICU) and overall hospital stay. Confounding variables were used to build up a risk model using a multivariable logistic regression analysis, and blood transfusion was added to assess whether it had additional predictive value for hospital mortality. Patients were divided into three groups: (i) transfusion of 0–2 units of red blood cells; (ii) transfusion of > 2 units of red blood cells and (iii) transfusion of red blood cells plus other clotting products. The strongest independent predictors of hospital death were logistic EuroSCORE and body mass index. After inclusion of these two variables, the odds ratio for transfusion remained significant. Relative to 0–2 units, the odds ratio for > 2 units was 6.80 (95% CI 2.46–18.8), and for other additional blood products was 14.4 (95% CI 5.34–37.3), with a p value of < 0.001. Duration of stay in the ICU was significantly associated with the amount of blood products administered (median (IQR [range]) ICU stay 1 (1‐2 [0‐15]) day if transfused 0–2 units of red blood cells, 2 (1‐6 [0‐128]) days if transfused > 2 units of red blood cells and 3 (1‐76 [0‐114]) days if other clotting products were used; p value < 0.001). Hospital stay was also associated with the amount of red cells used (p < 0.001).     

Major thoracic surgery in octogenarians

BACKGROUND: Thoracic surgery is associated with a high morbidity and mortality rate in the elderly patient population. Appropriate management of thoracic diseases is often avoided because of the inherent risks associated with the access thoracotomy. The purpose of this study was to evaluate the perioperative outcomes of octogenarians who underwent video-assisted thoracic surgery (VATS) for a variety of thoracic conditions. METHODS: A retrospective chart review was done on all patients who were between 80 and 90 years of age and underwent elective VATS between January 1995 and August 2001. RESULTS: A total of 162 consecutive VATS procedures were performed in 157 patients. Comorbid conditions consistent with their advanced age included chronic obstructive pulmonary disease, hypertension, coronary artery disease, and diabetes. The procedures included 96 lung resections (53 lobectomies, 42 wedge/segment resections), 46 pleurectomies, 8 decortications, 8 mediastinal biopsies, 3 pericardial windows, and 1 drainage of hemothorax. The pathology included 76 primary lung cancers, 35 metastatic diseases, 37 benign conditions, 9 nesotheliomas, and 3 carcinoid tumors. The average operative time and length of hospital stay after surgery were 51 min and 2.6 days, respectively. There were 3 (1.9%) mortalities, 2 from cardiac complications and 1 from pneumonia. Two (1.2%) patients required reexploration for bleeding. Four (2.5%) cases were converted to open thoracotomy thirteen (8.0%) cases had an air leak, of which 11 were managed on an outpatient basis with a Heimlich valve. They were discharged from the hospital an average of 3.3 days postoperatively. CONCLUSION: With VATS, surgical therapy can be offered to octogenarians with a low morbidity and mortality rate, as well as a short hospital stay.     

Benefits of cardiac surgery in octogenarians — a postoperative quality of life assessment

Objective: Assessment of postoperative quality of life in patients over 80 years after cardiac surgery including coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and combined procedures. Methods: Quality of life of n = 136 patients over 80 years at operation (82.3 ± 2.1 years), undergoing isolated CABG in 61 patients (45%), isolated AVR in 34 patients (25%) and a combination of CABG and AVR in 41 patients (30%) between January 1999 and December 2003 was reviewed. Preoperatively 66.2% presented in NYHA-class III/IV or CCS-class III/IV. Mean ejection fraction (EF) was 59.5% ± 14.0 (range 25–90%). Quality of life assessment was performed via a Seattle Angina Questionnaire. Follow-up was 100% complete for a total of 890 days (69–1853 days). Results: Five-year survival was 70% for the CABG group, 75% for the AVR group and 65% for the CABG/AVR group. Quality of life was remarkable in all of the three groups after surgery. Overall 97 patients (81%) were not or little disabled in their daily activity. One hundred and twelve patients (93%) were free or considerably less symptomatic. Seventy-eight patients or 65% reported to be very satisfied with their current quality of life and 112 patients (93%) felt very reassured to have continuous full access to medical treatment despite of their advanced age. Conclusions: A remarkable quality of life and important improvement in the functional status after cardiac surgery in patients over 80 paired with a satisfactory medium-term survival justify early intervention for heart disease in this age group. Therefore, referral practice for patients over 80 years for heart surgery should be handled liberally.     

Outcome after valve surgery in octogenarians and efficacy of early mobilization with early cardiac rehabilitation

Purpose  

This study aimed to compare postoperative complications and the surgical outcome in patients aged <80 years versus octogenarian patients. Another aim was to evaluate the safety and efficacy of early mobilization with early cardiac rehabilitation in octogenarians.     

Risk stratification models for cardiac surgery

A wide variety of risk stratification systems have been developed to quantify the risk of cardiac surgery. Generally, the focus has been on mortality; however, more recently models have been developed that allow the preoperative prediction of the incidence of morbidity, including renal failure, infection, prolonged ventilation, and neurologic deficit. Many of these risk stratification models are developed from large databases of cardiac surgical patients. Patient and surgical factors that are present preoperatively are assessed for their predictive value for postoperative complications. Risk factors that are found to be significant are assigned a specific weight in the overall summation of risk. These models have been used as tools to compare surgeon's results, institutional outcomes, individual patient risk, and within quality improvement programs. This article will focus on the European System for Cardiac Operative Risk Evaluation, the Society of Thoracic Surgeons score, the Parsonnet score, Cleveland Clinic Model, the Bayes model, and the Northern New England Score.     

Aortocoronary bypass surgery in septuagenarians and octogenarians

Six hundred and twenty-nine consecutive patients between ages 70 and 79 and 64 patients over age 80 underwent isolated aortocoronary bypass operation with cardiopulmonary bypass. Four hundred and sixty-eight men and 161 women were between ages 70 and 79 (mean 73), and 41 men and 23 women were over age 80 (mean 82). Most patients were in NYHA Functional Class III (septuagenarian 25%, octogenarian 23%) and in Class IV (septuagenarian 59%, octagenarian 72%) preoperatively. Early death was reported in 41 (6.5%) septuagenarians and in 2 (3.1%) octogenarians. Cardiac-related late mortalities were 6.4% and 6.3%, respectively. Five hundred and eighty-eight septuagenarians and 62 octogenarians were over 30-day survivors; 17.5% (sept) and 35.9% (oct) developed major postoperative complications, including bleeding, pericardial tamponade, sternal dehiscence, myocardial infarction, arrhythmia and pump failure. Mean hospital stays were 14.8 and 19 days, respectively. At follow-up (mean 38.2 months) patients had significant functional improvement by one or more classes in 80% and 60%. Mortality was adversely influenced by (1) NYHA Class IV, (2) use of intra-aortic balloon pumping, (3) postoperative hemorrhage, and (4) prolonged ischemic cross-clamp time. This experience indicates that if adequate trial of medical treatment of angina fails in the elderly patient, aortocoronary bypass surgery becomes a successful alternative.     

Risk management of minimally invasive cardiac surgery

Since the initiation of port-access minimally invasive cardiac surgery (MICS) in 1998, 350 patients have undergone the operations in our institute. With development of new instruments, the operation of mitral valve diseases and simple congenital defect has become easier. At present, it is the procedure of choice in operation of these lesions. Its weakness, however, is the limitation of visual field and working space. In order to maintain the same operative quality as median sternotomy and avoid any perioperative risk, cooperation of the anesthesiologist and the medical engineering technologist is indispensable. This paper reports on latest surgical procedure and risk management of the port-access MICS.     

601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups.

BACKGROUND: Cardiac valve replacement and coronary artery bypass graft surgery (CABG) are being applied with increasing frequency in patients 80 years of age and older. METHODS: Six hundred one consecutive patients older than 80 years, undergoing cardiac surgery between 1976 and 1994 (CABG with saphenous vein graft, 329 [54.7%]; CABG with left internal mammary artery, 101 [16.8%]; CABG + valve, 80 [13.3%]; isolated aortic valve replacement, 71 [11.8%]; isolated mitral valve replacement, 18 [3.0%]), were studied retrospectively to assess short- and long-term survival. They were compared with 11,386 patients aged 60 to 69 years and 5,698 patients aged 70 to 79 years undergoing similar procedures during the same time interval. RESULTS: In comparison with patients 60 to 69 years old, more octogenarians were women (44.4% versus 25.6%, p<0.0001), had class IV angina (54.1% versus 38.9%, p<0.0001), and had congestive heart failure class IV (4.9% versus 3.0%, p = 0.0001). In-hospital death rates (9.1% versus 3.4%, p<0.0001) and stroke (5.7% versus 2.6%, p<0.0001) reflected these adverse clinical risk factors. However, Q-wave infarction tended to be less frequent (1.5% versus 2.6%, p = 0.102). Interestingly, hospital mortality (9.1% versus 6.7%, p = 0.028) was only slightly increased, and stroke (5.7% versus 4.7%, p = 0.286) was not more common in octogenarians than in patients 70 to 79 years old. Late-survival curves have similar slopes for the first 5 years in all clinical subgroups. However, after 5 years there is a more rapid decline in octogenarians than in younger age groups. Median 5-year survival was 55% for patients older than 80 years, 69% for patients 70 to 79 years, and 81% for patients 60 to 69 years old. CONCLUSIONS: When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and excellent 5-year survival.     

Risk stratification for adverse outcome in cardiac surgery

Risk-adjusted outcome prediction is mainly important in two separate fields. The first is quality monitoring: measuring actual versus predicted mortality in an institution allows assessment of the clinical surgical and anaesthesia performance while adjusting for the risk profile of the patients. Without risk stratification, surgeons and hospitals treating high-risk patients will appear to have worse results than others. This may prejudice referral patterns, affect the allocation of resources and even discourage the treatment of high-risk patients. The second field is that of informed consent and clinical decision-making. Risk-adjusted predicted mortality should form an important part of patient and surgeon decisions on whether or not to proceed with surgery. Clearly, no 'perfect' model can be produced as some aspects of mortality will always be related to risk factors not included in the model (e.g. the quality of the distal coronary artery vessels in coronary artery surgery) or due to chance happenings not related to preoperative patient characteristics (such as surgical error). An individual patient will either survive or die after cardiac surgery. Clearly, no scoring system will predict the specific outcome for every patient. However, risk stratification will inform patients and clinicians of the likely risk of death for a group of patients with a similar risk profile undergoing the proposed operation. This information is useful and should form part of the basis on which the patient and surgeon decide whether to proceed.     

Risk factors for mediastinitis after cardiac surgery

BACKGROUND: Postoperative mediastinitis is one of the most feared complications in patients who undergo cardiac surgery because in addition to a high mortality rate (10% to 47%), there are increases in the length of hospital stay and in hospital costs. The purpose of the present study is to assess the risk factors for mediastinitis after cardiac surgery, the mediastinitis rate, and the mortality rate in our institution. METHODS: To determine the risk factors, a matched case-control study was carried out, with 39 cases and 78 controls, among the patients who underwent cardiac surgery at the Dante Pazzanese Cardiology Institute, S?o Paulo, Brazil. RESULTS: In the period of the study, 9,136 cardiac surgeries were performed and the mediastinitis rate was 0.5%. In the multivariate analysis, the independent risk factors found were obesity (odds ratio, 6.49; 95% confidence interval, 2.24 to 18.78), smoking (odds ratio, 3.27; 95% confidence interval, 1.04 to 10.20), intensive care unit stay more than 2 days (odds ratio, 4.50; 95% confidence interval, 1.57 to 12.90), and infection at another site (odds ratio, 8.86; 95% confidence interval, 1.86 to 42.27). The mortality rate was 23% among the patients with mediastinitis. CONCLUSIONS: We observed two independent risk factors related to patients' antecedents (obesity and smoking) and two risk factors related to problems in the postoperative period (length of intensive care unit stay and infection at another site). Efforts should be concentrated so that patients lose weight and stop smoking before elective surgeries. There should also be a prevention program against hospital infection directed to, and intensified for, at-risk patients.     

Abdominal aortic aneurysm surgery for octogenarians

Purpose  To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians. Methods  We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006. Results  Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B. Conclusions  We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.     

Is mitral valve surgery safe in octogenarians?

OBJECTIVE: To evaluate the outcomes of mitral valve surgery in octogenarians. METHODS: Data were collected prospectively from January 1996 to March 2004 at two surgical centers. Of 1386 consecutive patients with mitral valve surgery, 58 (4.2%) were aged > or = 80 years. Survival data were analyzed using Cox proportional hazards modeling and Kaplan-Meier actuarial log rank statistics. RESULTS: Octogenarians were similar to younger patients for the presence of pre-operative hypertension, hyperlipidemia, diabetes mellitus, and smoking history. Octogenarians had a higher incidence of cerebrovascular disease (19.0 versus 7.8%, P = 0.003), urgent in-hospital surgery (55.2 versus 28.6%, P < 0.001), and presence of ischemic disease requiring combined mitral valve plus revascularization surgery (72.4 versus 41.0%, P < 0.001). Mitral valve repair was performed in a similar proportion of octogenarians and younger patients (44.8 versus 45.6%). Thirty-day mortality for octogenarians was significantly higher than younger patients (15.5 versus 5.6%, P = 0.002), and actuarial survival of octogenarians was significantly decreased (P = 0.009). However, 52.3% of the octogenarians were alive at 7-years following surgery. Independent predictors of mortality from multivariate risk adjusted modeling of the entire cohort were: emergency surgery (hazards ratio [HR] = 2.94, P < 0.001), combined mitral valve plus revascularization surgery (HR = 2.27, P < 0.001), mitral valve replacement (HR = 1.85, P < 0.01), and age > or = 80 years (HR = 1.80, P = 0.02). CONCLUSIONS: Octogenarians undergoing mitral valve surgery have significantly greater incidence of urgent surgery, ischemic disease requiring combined revascularization surgery, and have decreased rates of survival. While caution is required when operating on these higher risk elderly patients, overall 52.3% of the octogenarians are alive at 7-years following surgery, which is greater than the survival of octogenarians in the community. The greatest survival benefit within octogenarians occurred when mitral valve repair was possible over replacement. Further study will more clearly define subgroups of octogenarians with potentially greater benefit from mitral valve surgery.