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.     

Outcome after aortic valve replacement in octogenarians

Background

The advancing age of the population in the western world and improvements in surgical techniques and postoperative care have resulted in an increasing number of very elderly patients undergoing cardiac operations. Therefore, the aim of this study is to evaluate the surgical outcome in 115 octogenarians after aortic valve replacement.

Methods

We retrospectively identified 115 patients (47 men, 68 women) aged 82.3 ± 2.1 years (mean, 80 to 92 years) who underwent aortic valve replacement alone (71 patients, 62.1%) or in combination with coronary artery bypass grafting (44 patients, 37.9%), between January 1992 and April 2003. These patients had significant severe aortic stenosis with a mean valve area of 0.62 ± 0.15 cm² and a mean gradient of 88.62 ± 24.06 mm Hg.

Results

The in-hospital mortality rate was 8.5%. The late follow-up was 100% complete. Actuarial survival at 1 and 5 years was 86.4% and 69.4%, respectively. Predictors of late mortality were ejection fraction (p < 0.01), preoperative heart failure (p < 0.03), and the type of prosthesis (p < 0.03).

Conclusions

The outcome after aortic valve replacement in octogenarians is excellent; the operative risk is acceptable and the late survival rate is good. Therefore, cardiac surgery should not be withheld on the basis of age alone.     

Functional rehabilitation after cardiac valve surgery

Functional rehabilitation after cardiac valve surgery was evaluated in a series of 267 patients operated upon during the years 1963 through 1970. All but a few were in N.Y.H.A. Functional Class III or IV prior to operation. Hospital mortality was 14%, and the late mortality was 26%. During the last four years (1967–1970), when only current-model Starr-Edwards valves were used, hospital mortality was reduced to 8% (5.4% for single- or double-valve replacement), but late mortality (15% within two years) was unchanged. The reduction in hospital mortality was due to improvements in surgical technique and postoperative care rather than to improved valve design.Although more than 70% of the survivors were in Functional Class I or II postoperatively, fewer than 20% returned to work and only 24% were asymptomatic. These findings did not improve during 1967–1970. Multivariable computer analysis failed to reveal specific preoperative factors that correlated with late mortality or functional results. Isolated mitral stenosis was associated with the lowest late mortality, and isolated mitral regurgitation had the highest late mortality. Long-standing congestive heart failure also carried a poor prognosis. Complications related to the prosthetic valve were reduced with current-model prostheses, but valve-related causes accounted for less than 12% of deaths, and late mortality due to progressive cardiac disease was unchanged. It is suggested that correction of cardiac valve lesions is performed too late in the course of the disease to significantly influence rehabilitation of most patients.     

Marked mixed venous desaturation during early mobilization after aortic valve surgery

We investigated the physiological reaction to mobilization the first and second day after aortic valve replacement in an open, prospective study. Hemodynamic and oxygenation variables were recorded in 15 patients using a pulmonary artery oximetry catheter and bench oximetry. Serious intraoperative events occurred in 3 patients, but all patients began mobilization on the first postoperative day and mobilization was accomplished without clinical problems. Mixed venous oxygen saturation (SvO(2)) at rest was 58.0 +/- 7.7% (mean +/- SD) on the first postoperative day and 58.0 +/- 6.2% on the second day (NS). During mobilization, oxygen consumption increased by 64 +/- 41% and 58 +/- 33% on the first and second days (P < 0.01; NS between days). No compensatory increase in cardiac index and oxygen delivery was seen. Oxygen extraction increased, resulting in SvO(2) values during exercise of 35.7 +/- 6.8% on the first day and 36.7 +/- 7.7% on the second day (P < 0.01; NS between days), whereas mixed venous oxygen partial pressure was 3.0 +/- 0.4 kPa on both days. The lowest recorded value for SvO(2) was 10%. The marked and consistent mixed venous desaturation during early mobilization has not been described before and the clinical consequences and underlying mechanism require further investigation. IMPLICATIONS: During early mobilization after aortic valve replacement, a marked and consistent reduction in mixed venous oxygen saturation to 35% and mixed venous oxygen partial pressure to 3 kPa was observed.     

Outcome of early active mobilization after extensor tendon repair

Background:

Traditionally the repaired extensor tendons have been treated postoperatively in static splints for several weeks, leading to formation of adhesions and prolonged rehabilitation. Early mobilization using dynamic splints is common, but associated with many shortcomings. We attempted to study the results of early active mobilization, using a simple static splint, and easy-to-follow rehabilitation plan.

Materials and Methods:

In a prospective study 26 cases of cut extensor tendons in Zone V to VIII were treated with primary or delayed primary repair. Following this, early active mobilization was undertaken, using an easy-to-follow rehabilitation plan. The results were assessed according to the criteria of Dargan at six weeks and one year.

Results:

All the 26 patients were followed up for one year. 20 out of 26 patients were below 30 years of age, involving the dominant hand more commonly (16 patients, 62%). Agriculture instruments were the most common mode of injury (13 patients, 50%). The common site for injury was extensor zone VI (42%, n = 11).

Conclusion:

Rehabilitation done for repaired extensor tendon injuries by active mobilization plan using a simple static splint has shown good results.     

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.     

Risk evaluation of cardiac surgery in octogenarians

OBJECTIVE: To assess the predictive value of risk factors in the European System for Cardiac Operative Risk Evaluation (EuroSCORE) for cardiac surgery on octogenarians. DESIGN: An observational study of octogenarians undergoing cardiac surgery and average-aged controls matched according to the cardiac surgical procedure. SETTING: A university hospital. PARTICIPANTS: One hundred sixty-two consecutive patients 80 years or older who underwent cardiac surgery between January 1, 2001, and June 30, 2003, and 162 average-aged controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Risk factors according to the EuroSCORE (The European System for Cardiac Risk Evaluation) model and EuroScore algorithm without an age component (EuroSCOREex) were evaluated. The EuroSCORE model and EuroSCOREex predicted mortality (odds ratio 1.4) and morbidity (odds ratio 1.2 and 1.3, respectively) equally well in both age groups. Adding age group information into the EuroSCOREex model in combined data, the odds ratio estimate was 3.5 for age group. The 30-day mortality of octogenarians was 8.6% versus 1.9% in controls (p < 0.01). Incidences of organ-related complications were comparable. Octogenarians spent more days in the hospital's intensive care unit and surgical ward than did controls (3.4 +/- 3.3 days v 2.7 +/- 3.1 days, p < 0.01; 9.9 +/- 5.8 days v 8.6 +/- 3.8 days, p = 0.02). Only 31 (19.1%) octogenarians were discharged home, whereas the corresponding number was 66 (40.7%) in controls (p < 0.01). CONCLUSIONS: Risk factors other than age were not higher in octogenarians, and the EuroSCORE model predicted mortality and morbidity. Age was an important single risk factor predicting mortality.     

心脏术后患者ICU早期康复锻炼的最佳证据总结

目的 提取并总结心脏术后患者ICU早期康复锻炼的最佳证据,为临床早期康复的开展提供参考.方法 计算机检索Med-line、Up To Date、PubMed、Cochrane Library、CINAHL、JBI循证卫生保健数据库及万方、知网、医脉通数据库,根据纳排标准选取临床指南、专家共识、最佳证据总结、系统评价等,由2名研究人员进行文献质量评价后提取证据.结果 共纳入12篇文献,从组建多学科团队、康复前评估、制订康复计划、心脏早期康复方案、康复过程动态评估、康复后评估、心理干预、健康教育8个方面对心脏术后患者早期康复进行总结,共34条证据.结论 本证据可为临床医护人员制订ICU心脏术后患者早期康复方案提供参考,建议证据转化时,应结合我国的医疗文化背景和证据应用场所,以及患者的需求和意愿.     

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.     

高龄短节段腰椎融合患者术后早期功能康复的安全性及有效性

目的：评估高龄患者（年龄≥75岁）短节段腰椎融合手术后早期功能康复的安全性和有效性。方法 ：回顾性分析2018年1月～2021年4月在我院接受单/双节段腰椎融合手术的高龄患者,患者均在完成充分的术前评估后接受手术治疗。2019年7月开始对腰椎融合术后的高龄患者进行早期功能康复,即术后当日在康复医师指导下开始行规范床上康复锻炼,2d内下床活动,纳入早期康复组。2019年7月之前接受手术治疗的高龄患者术后采用传统康复措施,拔除引流管后开始下床活动,术后进行自主康复锻炼,纳入对照组。收集两组患者的临床资料,包括患者的基本信息[年龄、性别比、疾病种类、术前腰腿痛视觉模拟（VAS）评分、Oswestry功能障碍指数（ODI）、合并症、手术史和烟酒史]、手术相关资料（手术时间、术中出血量、手术节段）和结局指标（下床时间、拔除引流管时间、术后90d内的并发症情况、再入院率、术后住院时间以及术后额外的阿片类药物的使用情况）。结果：共纳入188例患者,早期康复组94例,对照组94例。早期康复组患者合并下肢静脉瓣膜功能不全及既往手术史比率较对照组高（46%vs 22%,P<0.01;72%vs 55...     

目标导向早期活动在心脏大血管术后患者中的应用

目的 探讨目标导向早期活动在心脏大血管术后患者中的应用效果.方法 将2019年1～8月心脏大血管术后患者38例作为对照组,实施心脏术后常规活动护理;2019年9月至2020年4月心脏大血管术后患者42例作为干预组,实施目标导向早期活动.结果 干预后7d,干预组肌力、生活自理能力、活动能力显著优于对照组(均P＜0.01)...     

Achilles tendon rupture: effect of early mobilization in rehabilitation after surgical repair

BACKGROUND: Surgical and nonsurgical treatments of Achilles tendon ruptures are available. Nonsurgical treatment using immobilization does not have the varying degrees of infection as seen with surgical procedures, but it frequently is linked to muscle atrophy, weakness, and higher rates of rerupture than surgical treatment. This study reports the results of 64 patients with Achilles tendon ruptures treated surgically and with early mobilization. METHODS: Surgery of the ruptured tendon involved dividing the proximal stump into two separate strands and the distal stump into a single strand. The repair was advanced to a V-Y formation, and nonabsorbable sutures were used for repair. After wound closure, an early mobilization rehabilitation program was initiated, which consisted of wearing a moveable ankle brace for 4 to 6 weeks in 0 to 15 degrees of dorsiflexion and 10 weeks of regular exercises. RESULTS: All 64 patients resumed normal activities in an average of 3.3 months regardless of whether the rupture was acute or chronic. Tendons healed with no reruptures. There were 13 complications, all wound infections, which healed when treated with antibiotics. The infection rate dropped markedly when wounds were inspected and dressings changed 1 week postoperatively, instead of at 2 weeks. CONCLUSION: Surgery combined with early mobilization reduces range of motion loss, increases blood supply, and reduces the degree of muscle atrophy that typically occurs after Achilles tendon rupture, thereby decreasing the time to resumption of normal activities. Applying tension to the tendon also improved strength of the calf muscles and improved ankle movement. The main concern with early mobilization is rerupture, but this was lessened by patients carefully following the weightbearing and early mobilization protocols. The results of this study strengthen the argument to employ early mobilization rehabilitation after surgical repair.