Surgical outcomes for patients aged 80 and older: morbidity and mortality from major noncardiac surgery

OBJECTIVES: To gather information about surgical outcomes for patients in their 80s and 90s. DESIGN: Prospective cohort study. SETTING: Veterans Affairs Medical Centers. PARTICIPANTS: Patients (26,648 aged >/=80; 568,263 aged <80) enrolled in the Veterans Affairs National Surgical Quality Improvement Project (NSQIP) who had noncardiac surgery between 1991 and 1999. METHODS: Data were collected prospectively from medical records and healthcare providers. Detailed information was collected about patients' preoperative status, intraoperative experience, and postoperative outcomes. Postoperative outcomes were survival status at 30 days (deaths from any cause occurring during hospitalization and after hospital discharge were captured) and the occurrence of 21 selected surgical complications within 30 days postoperatively: wound complications (3 types), respiratory complications (4), urinary tract complications (3), nervous system complications (3), cardiac complications (3), and other complications (5). MEASUREMENTS: Mortality and the occurrence of 21 surgical complications within 30 days of surgery. RESULTS: Thirty-day all-cause mortality rates varied widely across operations and were higher for patients aged 80 and older than for younger patients (8% vs 3%, P<.001). Mortality rates for those aged 80 and older were less than 2% for many commonly performed operations (e.g., transurethral prostatectomy, hernia repair, knee replacement, carotid endarterectomy). Of patients aged 80 and older, 20% had one or more postoperative complications, and patients who suffered complications had higher 30-day mortality than those who did not (26% vs 4%, P<.001). For 11 of the 21 complications, mortality for patients aged 80 and older was greater than 33%. The risk factors for poor outcomes were the same for older and younger patients, and the NSQIP Mortality Risk model performed well on patients aged 80 and older (C statistic=0.83). CONCLUSION: A substantial minority of patients aged 80 and older died or suffered a complication within 30 days of surgery, but for many operations mortality rates were extremely low. Postoperative complications were associated with high 30-day mortality in patients aged 80 and older.     

Colorectal surgery in octogenarian patients—outcomes and predictors of morbidity

Introduction  Surgery for elderly patients pose a constant challenge. This study aims to review the outcome and find predictors of adverse outcome in octogenarians undergoing major colorectal resection for cancer. Methods  A review of 121 octogenarians who underwent colorectal cancer surgery between September 1992 and May 2008 was performed. Comorbidities were quantified using the weighted Charlson Comorbidity Index and ASA classification. CR-POSSUM scores and ACPGBI scores and the predicted mortality rates were calculated. Outcome measures were morbidity rates and 30-day mortality rates. Results  The patients had a mean age of 83.5 years (range, 80–99). The mean index of comorbidity was 3.1 (2–7) and 12.5% of patients were classified ASA III and above. The mean predicted mortality rate based on CR-POSSUM and ACPGBI scoring models were 11.2% and 5.4% respectively. The overall observed morbidity rate was 30.7% and 30-day mortality was 1.6. Factors found on bivariate analysis to be significantly associated with an increased risk of morbidity were tumor presenting with complication, comorbid coronary heart disease, serum urea levels, ASA classification ≥3 and comorbidity index 3 of 5 ≥ 5. Multivariate analysis revealed the latter two factors to be independent predictors of morbidity. Conclusion  Octogenarians undergoing major colorectal resection have an acceptable perioperative morbidity and mortality rate and survival rate and should not be denied surgery based on age alone. Comorbidity index scores and ASA scores are useful tools to identify poor risk patients.     

Impact of age on perioperative complications and length of stay in patients undergoing noncardiac surgery

BACKGROUND: Major surgical procedures are performed with increasing frequency in elderly persons, but the impact of age on resource use and outcomes is uncertain. OBJECTIVE: To evaluate the influence of age on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery. DESIGN: Prospective cohort study. SETTING: Urban academic medical center. PATIENTS: Consecutive sample of 4315 patients 50 years of age or older who underwent nonemergent major noncardiac procedures. MEASUREMENTS: Major perioperative complications (cardiac and noncardiac), in-hospital mortality, and length of stay. RESULTS: Major perioperative complications occurred in 4.3% (44 of 1015) of patients 59 years of age or younger, 5.7% (93 of 1646) of patients 60 to 69 years of age, 9.6% (129 of 1341) of patients 70 to 79 years of age, and 12.5% (39 of 313) of patients 80 years of age or older (P < 0.001). In-hospital mortality was significantly higher in patients 80 years of age or older than in those younger than 80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased odds ratio for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (1.8 [95% CI, 1.2 to 2.7]) and those 80 years of age or older (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Patients 80 years of age or older stayed an average of 1 day more in the hospital, after adjustment for other clinical data (P = 0.001). CONCLUSIONS: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay, but even in patients 80 years of age or older, mortality was low.     

Echocardiographic predictors of adverse outcomes in primary pulmonary hypertension

OBJECTIVES: The aim of this study was to evaluate the relationships between echocardiographic findings and clinical outcomes in patients with severe primary pulmonary hypertension (PPH).BACKGROUND: Primary pulmonary hypertension is associated with abnormalities of right heart structure and function that contribute to the poor prognosis of the disease. Echocardiographic abnormalities associated with PPH have been described, but the prognostic significance of these findings remains poorly characterized. METHODS: Echocardiographic studies, invasive hemodynamic measurements and 6-min walk tests were performed and outcomes prospectively followed in 81 patients with severe PPH. Subjects were participants in a 12-week randomized trial examining the effects of prostacyclin plus conventional therapy compared with conventional therapy alone. RESULTS: During the mean follow-up period of 36.9 +/- 15.4 months, 20 patients died and 21 patients underwent transplantation. Pericardial effusion (p = 0.003) and indexed right atrial area (p = 0.005) were predictors of mortality. Pericardial effusion (p = 0.017), indexed right atrial area (p = 0.012) and the degree of septal shift in diastole (p = 0.004) were predictors of a composite end point of death or transplantation. In multivariable analyses incorporating clinical, hemodynamic and echocardiographic variables, pericardial effusion and an enlarged right atrium remained predictors of adverse outcomes. Six-minute walk results, mixed venous oxygen saturation and initial treatment randomization were also independently associated with a poor prognosis. CONCLUSIONS: Pericardial effusion, right atrial enlargement and septal displacement are echocardiographic abnormalities that reflect the severity of right heart failure and predict adverse outcomes in patients with severe PPH. These characteristics may help identify patients appropriate for more intensive medical therapy or earlier transplantation.     

Helical CT pulmonary angiography predictors of in-hospital morbidity and mortality in patients with acute pulmonary embolism

PURPOSE: To determine if CT variables predict in-hospital morbidity and mortality in patients with pulmonary embolism (PE). MATERIALS AND METHODS: CT scans and charts of 173 patients with CT scans positive for PE were reviewed. CT scans were reviewed for leftward ventricular septal bowing, increased right ventricle (RV) to left ventricle (LV) diameter ratio, clot burden, increased pulmonary artery to aorta diameter ratio, and oligemia. Charts were reviewed for severe morbidity and mortality outcomes: death from pulmonary emboli or any cause, and cardiac arrest. Charts were also reviewed for milder morbidity outcomes: intubation, vasopressor use, or admission to an intensive care unit (ICU) and for multiple comorbidities. RESULTS: No CT predictor was significantly associated with severe morbidity or mortality outcomes. Ventricular septal bowing and increased RV/LV diameter ratio were both associated with subsequent admission to an ICU (P = 0.004 and P = 0.025, respectively). Oligemia (either lung) was associated with subsequent intubation; right lung oligemia was associated with the subsequent use of vasopressors. After controlling for history of congestive heart failure, ischemic heart disease, and pulmonary disease, both septal bowing and an increased RV/LV diameter ratio remained associated with admission to an ICU. CONCLUSION: No CT variables predicted severe in-hospital morbidity and mortality (death from pulmonary embolism, death from any cause, or cardiac arrest) in patients with PE. However, ventricular septal bowing and increased RV/LV diameter ratio were both strongly predictive of less severe morbidity, namely, subsequent ICU admission, and oligemia was associated with subsequent intubation and vasopressor use.     

Determinants of perioperative morbidity and mortality after pneumonectomy

BACKGROUND: Pneumonectomy remains a relatively high-risk procedure. However, the underlying mechanism is still unknown. Thus, the effort to find out predisposing factors for surgical risks continues. We investigated the effect of both water-load control and sampling lymphadenectomy technique on perioperative morbidity and mortality after pneumonectomy. MATERIAL AND METHODS: A hundred and three consecutive patients undergoing simple pneumonectomy were included in the prospective study. Pneumonectomy was performed for lung cancer in 92 patients and for benign diseases in 11 cases; 81 patients were male and 22 female, and the mean age was 53.4 +/- 11.4 years. Both sampling and completion lymphadenectomy techniques were used randomly. Water-load was carefully limited to values as low as possible, depending on stable hemodynamics during and after operation. RESULTS: There were no deaths, and none of the patients needed postoperative mechanical ventilation. Major complications included dyspnea in 9 patients and supraventricular arrhythmias in 13 patients. Completion lymphadenectomy increased morbidity in both right and left pneumonectomy. CONCLUSIONS: Both water-load limitation and sampling lymphadenectomy technique may decrease morbidity and mortality after pneumonectomy.     

Quality-of-Life measures as predictors of mortality and morbidity

Poor quality of life assessed singly, using an instrument designed to assess quality of life, or variously, using assessments of job stress, depression, anxiety, hostility, anger, or life events, seems to be predictive of poor cardiovascular health and attendant morbidity and mortality. Since risk factors appear to cluster together, new studies may benefit from concentrating on assessing quality of life and health in multivariate domains, including both psychological and behavioral aspects of life, and validating instruments for use as predictive tools in the future. However, single questions on energy also appear useful as predictors.     

Predictive value of preoperative electrocardiography for perioperative cardiovascular outcomes in patients undergoing noncardiac, nonvascular surgery

Background:

The utility of routine preoperative electrocardiography (ECG) for assessing perioperative cardiovascular risk in patients undergoing noncardiac, nonvascular surgery (NCNVS) is unclear.

Hypothesis:

There would be an association between preoperative ECG and perioperative cardiovascular outcomes in patients undergoing NCNVS.

Methods:

A total of 660 patients undergoing NCNVS were prospectively evaluated. Patients age >18 years who underwent an elective, nonday case, open surgical procedure were enrolled. Troponin I concentrations and 12‐lead ECG were evaluated the day before surgery, immediately after surgery, and on the first 5 postoperative days. Preoperative ECG showing atrial fibrillation, left or right bundle branch block, left ventricular hypertrophy, frequent premature ventricular complexes, pacemaker rhythm, Q‐wave, ST‐segment changes, or sinus tachycardia or bradycardia were classified as abnormal. The patients were followed up during hospitalization and were evaluated for the presence of perioperative cardiovascular events (PCE).

Results:

Eighty patients (12.1%) experienced PCE. Patients with abnormal ECG findings had a greater incidence of PCE than those with normal ECG results (16% vs 6.4%; P < 0.001). Mean QTc interval was significantly longer in the patients who had PCE (436.6 ± 31.4 vs 413.3 ± 16.7 ms; P < 0.001). Univariate analysis showed a significant association between preoperative atrial fibrillation, pacemaker rhythm, ST‐segment changes, QTc prolongation, and in‐hospital PCE. However, only QTc prolongation (odds ratio: 1.15, 95% confidence interval: 1.06‐1.2, P < 0.001) was an independent predictor of PCE according to the multivariate analysis. Every 10‐ms increase in QTc interval was related to a 13% increase for PCE.

Conclusions:

Prolongation of the QTc interval on the preoperative ECG was related with PCE in patients undergoing NCNVS. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Increased preoperative glucose levels are associated with perioperative mortality in patients undergoing noncardiac, nonvascular surgery

OBJECTIVE: To determine the relationship between preoperative glucose levels and perioperative mortality in noncardiac, nonvascular surgery. RESEARCH DESIGN AND METHODS: We performed a case-control study in a cohort of 108 593 patients who underwent noncardiac surgery at the Erasmus MC during 1991-2001. Cases were 989 patients who underwent elective noncardiac, nonvascular surgery and died within 30 days during hospital stay. From the remaining patients, 1879 matched controls (age, sex, calendar year, and type of surgery) were selected. Information was obtained regarding the presence of cardiac risk factors, medication, and preoperative laboratory results. Preoperative random glucose levels <5.6 mmol/l (110 mg/dl) were normal. Impaired glucose levels in the range of 5.6-11.1 mmol/l were prediabetes. Glucose levels >or=11.1 mmol/l (200 mg/dl) were diabetes. RESULTS: Preoperative glucose levels were available in 904 cases and 1247 controls. A cardiovascular complication was the primary cause of death in 207 (23%) cases. Prediabetes glucose levels were associated with a 1.7-fold increased mortality risk compared with normoglycemic levels (adjusted odds ratio (OR) 1.7 and 95% confidence interval (CI) 1.4-2.1; P<0.001). Diabetes glucose levels were associated with a 2.1-fold increased risk (adjusted OR 2.1 and 95% CI 1.3-3.5; P<0.001). In cases with cardiovascular death, prediabetes glucose levels had a threefold increased cardiovascular mortality risk (adjusted OR 3.0 and 95% CI 1.7-5.1) and diabetes glucose levels had a fourfold increased cardiovascular mortality risk (OR 4.0 and 95% CI 1.3-12). CONCLUSIONS: Preoperative hyperglycemia is associated with increased (cardiovascular) mortality in patients undergoing noncardiac, nonvascular surgery.     

Impact of post-capillary pulmonary hypertension on mortality in interstitial lung disease

BackgroundPulmonary hypertension (PH) influences mortality in patients with interstitial lung disease (ILD). Almost all studies on patients with ILD, have focused on the clinical impact of pre-capillary PH on survival. Therefore, little is known about the influence of post-capillary PH. We aimed to assess the prevalence of post-capillary PH and its clinical impact on survival in patients with ILD, followed by comparison with pre-capillary PH.MethodsThis retrospective study enrolled 1152 patients with ILD who were diagnosed with PH using right heart catheterization between May 2007 and December 2015. We analyzed the demographics and composite outcomes (defined as death from any cause or lung transplantation) of patients with post-capillary PH and compared them with patients with pre-capillary PH.ResultsThirty-two (20%) of the 157 patients with ILD-PH were diagnosed with post-capillary PH. Patients with post-capillary PH had significantly lower modified Medical Research Council scores, higher diffusion capacity for carbon monoxide, higher resting PaO₂, lower pulmonary vascular resistance (PVR), and higher lowest oxygen saturation during the 6-min walk test compared to those with pre-capillary PH. Cardiovascular diseases were associated with a higher risk of mortality in patients with post-capillary PH. Multivariate Cox proportional hazards analysis demonstrated no significant difference between the composite outcomes in pre-capillary and post-capillary PH, while PVR and the ILD Gender-Age-Physiology Index were significantly associated with the composite outcome.ConclusionsWe found that approximately one-fifth of patients with ILD-PH were diagnosed with post-capillary PH, and that PVR and not post-capillary PH was associated with mortality.     

Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay

PURPOSE: To determine the relation between cardiac and noncardiac complications and their effects on length of stay in patients undergoing noncardiac surgery. METHODS: We collected detailed information from the history, physical examination, and preoperative tests of 3970 patients aged > or =50 years who were undergoing major noncardiac procedures. Serial electrocardiograms and cardiac enzyme measurements were performed perioperatively, and cardiac and noncardiac complications were recorded prospectively. Multivariate logistic regression analysis was used to determine the association between cardiac and noncardiac complications, and linear regression was used to assess their effects on length of stay. RESULTS: Cardiac complications occurred in 84 patients (2%), and noncardiac complications developed in 510 patients (13%). Both types of complications occurred in 40 patients (1%). The most common cardiac complications were pulmonary edema (n = 42) and myocardial infarction (n = 41). The most common noncardiac complications were wound infection (n = 291), confusion (n = 87), respiratory failure requiring intubation (n = 62), deep venous thrombosis (n = 48), and bacterial pneumonia (n = 46). Patients with cardiac complications were more likely to suffer a noncardiac complication than were those without cardiac complications, even after adjustment for preoperative clinical factors (odds ratio = 6.4; 95% confidence interval [CI]: 3.9 to 10.6). Mean length of stay was markedly increased in patients who experienced cardiac (11 days; 95% CI: 9 to 12 days) or noncardiac (11 days; 95% CI: 10 to 12 days) complications, or both (15 days; 95% CI: 12 to 18 days), as compared with patients without complications (4 days; 95% CI: 3 to 4 days), even after adjustment for procedure type and clinical factors. CONCLUSION: Cardiac and noncardiac complications were strongly linked in patients undergoing noncardiac surgery. Patients who experienced one type of complication were at increased risk of developing the other type of complication as well as prolonged perioperative length of stay.     

Major adverse noncardiac events after PCI as predictors of long-term mortality

Background: Studies of percutaneous coronary intervention (PCI) routinely report major adverse cardiovascular events (MACE), but not major adverse noncardiac events (MANE) after PCI. MANE, such as post‐PCI bleeding and contrast nephropathy, adversely influence survival, but are not recognized as a standard composite of complications. We assessed the feasibility and prognostic utility of deriving a composite of MANE. Methods: In 985 consecutive patients who underwent PCI, we estimated the incidence and prognostic impact of in‐hospital MACE (myocardial infarction [MI] target vessel revascularization, or stroke) and MANE (defined as thrombolysis in myocardial infarction [TIMI], bleeding [major or minor], or contrast nephropathy) and their impact on long‐term survival. Results: The incidence of MANE was >6‐fold greater than MACE (9.5% vs 1.5%). Independent correlates of MANE included age, female gender, peripheral vascular disease, lower left ventricular ejection fraction, and use of an intraaortic balloon pump (IABP) during PCI. Of 973 patients who survived the index hospitalization, death occurred in 169 (17%) at a median follow‐up of 4.0 years. MANE (but not MACE) showed a significant relation with survival; 34 of 85 patients with MANE compared to 135 of 888 patients without MANE died during follow‐up (40% vs 15%, log‐rank P < 0.0001). After adjustment for several baseline clinical features, the occurrence of MANE was independently associated with a significant increase in long‐term mortality (adjusted hazards ratio [HR]= 1.72, CI = 1.05–2.83) and myocardial infarction (adjusted HR = 3.43, CI = 1.55–7.58). Conclusions: After PCI, MANE are common and carry grave long‐term prognostic significance. Our findings emphasize the need to monitor and report MANE, in addition to MACE, in PCI‐related trials.     

N-terminal pro-brain natriuretic peptide and renal insufficiency as predictors of mortality in pulmonary hypertension

BACKGROUND: N-terminal pro-brain natriuretic peptide (NT-proBNP) is a byproduct of the brain natriuretic peptide (BNP) that was shown to be of prognostic value in pulmonary hypertension (PH). The role of NT-proBNP in PH has to be determined, especially under the influence of renal impairment that might lead to an accumulation of the peptide, and may be a sign of increased mortality per se. METHODS: We assessed NT-proBNP, BNP, renal function, and hemodynamic parameters (during right-heart catheterization) in 118 consecutive patients with isolated PH, excluding left-heart disease. Depending on the calculated creatinine clearance, patients were classified into different groups of renal function. Correlation analysis was performed on all key parameters. Results were then compared between the levels of renal function. The prognostic value of each parameter was assessed during a mean follow-up period of 10 months. RESULTS: Twenty-two patients (approximately 19%) had significantly impaired renal function (creatinine clearance < 60 mL/min). Although the overall levels of NT-proBNP were correlated with hemodynamics, we observed no correlation in the group with significant renal dysfunction. Moreover, NT-proBNP was related to creatinine clearance. Finally, NT-proBNP and renal insufficiency were independent predictors of death during univariate and multivariate analysis, whereas BNP only predicted mortality in univariate analysis. CONCLUSIONS: The diagnostic accuracy of NT-proBNP as a parameter of the hemodynamic status is diminished by renal function. However, NT-proBNP could be superior to BNP as a survival parameter in PH because it integrates hemodynamic impairment and renal insufficiency, which serves as a sign of increased mortality per se.     

Catastrophic outcomes of noncardiac surgery soon after coronary stenting

OBJECTIVES: To assess the clinical course of patients who have undergone coronary stent placement less than six weeks before noncardiac surgery. BACKGROUND: Surgical and percutaneous transluminal coronary angioplasty revascularization performed before high-risk noncardiac surgery is expected to reduce perioperative cardiac morbidity and mortality. Perioperative and postoperative complications in patients who have undergone coronary stenting before a noncardiac surgery have not been studied. METHODS: Forty patients who underwent coronary stent placement less than six weeks before noncardiac surgery requiring a general anesthesia were included in the study (1-39 days, average: 13 days). The records were screened for the occurrence of adverse clinical events, including myocardial infarction, stent thrombosis, peri- and postoperative bleeding and death. RESULTS: In 40 consecutive patients meeting the study criteria, there were seven myocardial infarctions (MIs), 11 major bleeding episodes and eight deaths. All deaths and MIs, as well as 8/11 bleeding episodes, occurred in patients subjected to surgery fewer than 14 days from stenting. Four patients expired after undergoing surgery one day after stenting. Based on electrocardiogram, enzymatic and angiographic evidence, stent thrombosis accounted for most of the fatal events. The time between stenting and surgery appeared to be the main determinant of outcome. CONCLUSIONS: Postponing elective noncardiac surgery for two to four weeks after coronary stenting should permit completion of the mandatory antiplatelet regimen, thereby reducing the risk of stent thrombosis and bleeding complications.