Asian Cardiovasc Thorac Ann 2002;10:12-15
© 2002 Asia Publishing EXchange Pte Ltd
Outcome of Cardiac and Thoracic Aortic Operation in Patients Over 80 Years Old
Yoshito Kawachi, MD,
Atuhiro Nakashima, MD,
Yoshihiro Toshima, MD,
Satosi Kimura, MD,
Kouichi Arinaga, MD
|
Department of Cardiovascular Surgery Clinical Research Institute National Kyushu Medical Center Hospital Fukuoka, Japan
|
|
|
Yoshito Kawachi, MD Tel: 81 92 852 0700 Fax: 81 92 846 8485 email: kawachiy{at}qmed.hosp.go.jp Department of Cardiovascular Surgery, National Kyushu Medical Center Hospital, 1-8-1 Jigyo-hama, Chuo-ku, Fukuoka 810-8563, Japan.
|
 |
ABSTRACT
|
|---|
A retrospective analysis was performed to determine the early outcome of cardiac and thoracic aortic surgery in patients over 80 years old. Between 1994 and 2000, 41 octogenarians (mean age, 82.6 ± 2.5 years) underwent coronary artery bypass grafting (25), valve surgery (8), thoracic aortic aneurysm repair (7), or combined valve and bypass surgery (1). Overall hospital mortality was 9.8%. Mortality rates for specific procedures were 12% for coronary bypass, 0% for valve surgery, and 14% for thoracic aortic aneurysm repair. Major postoperative complications affected 27% of patients and included severe low cardiac output, respiratory failure, and acute renal failure, with a low incidence of perioperative stroke (2.4%). Cardiac and thoracic aortic operations can be performed with acceptable mortality and morbidity when appropriately applied in selected octogenarians.
|
INTRODUCTION
|
|---|
More than 41,000 patients underwent cardiac and thoracic aortic operations during 1998 in Japan.1 However, there are no data on the percentage of octogenarians or the operative mortality in this age group. People over 80 years old constituted approximately 3.6% of the Japanese population in 1999, and an 80-year-old person is expected to survive for 7.68 years if male or 10.27 years if female.2 Age is an independent risk factor for the development of cardiovascular disease. In view of the increase in life expectancy, the incidence of symptomatic cardiac and thoracic aortic disease necessitating surgical intervention in elderly patients is therefore increasing. Due to more comorbidity, surgery in elderly patients is associated with increased perioperative mortality and a higher complication rate compared to younger patients.3–5 A report from Japan of a limited number suggests that fair results of cardiac and thoracic aortic surgery can be achieved in octogenarians.6 This study was undertaken to analyze the in-hospital results of cardiac and thoracic aortic operations in octogenarians.
|
PATIENTS AND METHODS
|
|---|
Between August 1994 and December 2000, 845 patients underwent cardiac or thoracic aortic surgery at National Kyushu Medical Center Hospital. There were 41 patients aged 80 years or older (mean, 82.6 ± 2.5 years; range, 80 to 90 years). Demographic and clinical data were entered prospectively into a computerized database for analysis (Table 1
). Renal insufficiency was defined as creatinine > 15 mg•L-1 or dialysis. Operative status was classified as emergency if carried out on referral within 24 hours of suffering a cardiovascular event, and urgent if carried out unscheduled within the next 24 hours. Operative mortality was defined as death occurring within 30 days of operation or before hospital discharge. Postoperative complications are listed in Table 2. Stroke was defined as a new and focal neurologic deficit, regardless of whether it was permanent or transient. Acute renal failure was defined as a new requirement for dialysis. Severe low cardiac output state was identified by a new requirement for intraaortic balloon pumping or percutaneous cardio-pulmonary support. Postoperative outcome was defined by hospital mortality rate, complication rate, and length of postoperative hospitalization.
All except one operation were performed through a median sternotomy incision. Standard techniques of cardio-pulmonary bypass (CPB) using hollow-fiber oxygenators were employed, except in off-pump coronary artery bypass (OPCAB) procedures. Initially, moderate systemic hypo-thermia (28°C), cold crystalloid potassium cardioplegia, and topical myocardial cooling with ice slush were used for myocardial protection. Since July 1998, tepid systemic hypothermia (34°C) and cold blood cardioplegia without topical cooling were used. Retrograde cardioplegia was employed in selected patients. A venting catheter was placed into the left ventricle through the right superior pulmonary vein in the majority of patients. The use of a cell saver and administration of tranexamic acid were routinely applied as blood conservation measures.
Continuous data were expressed as the mean ± standard deviation, and categorical variables were expressed as percentages. Statistical analysis was performed with the StatView version 5.0 statistical software package (SAS Institute Inc., Cary, NC, USA). Comparison of two groups was performed for categorical variables with the chi-squared test with 2 x 2 contingency tables or Fisher's exact test, as appropriate. Variables were found to be significant at a level of p < 0.05.
|
RESULTS
|
|---|
Preoperative clinical problems were noted in 71% of patients (Table 1
). The severity and previous treatment of these coexisting diseases were variable. Mean left ventricular ejection fraction was 66% ± 13% (range, 19% to 84%). Operative procedures are summarized in Table 3. Twenty-five patients had coronary artery bypass grafting (CABG) only, of whom 24 had a left and/or right internal thoracic artery graft (almost always in conjunction with a saphenous vein graft). Eleven patients underwent OPCAB of at least one target vessel (the left anterior descending artery) using a left internal thoracic artery graft. Valve surgery comprised aortic valve replacement (4), mitral valvuloplasty (2), aortic and mitral valve replacement (1), and aortic valve replacement and mitral valvuloplasty (1); 1 patient had CABG concomitant with aortic valve replacement. The CPB and aortic crossclamp times were 154 ± 76 minutes and 92 ± 41 minutes, respectively.
There were 4 hospital deaths (9.8%) overall, between 19 and 89 days postoperatively. Among the 25 patients undergoing CABG, there were 3 hospital deaths (12%); 2 had undergone conventional CABG electively, and one had urgent OPCAB. All 7 patients with a thoracic aortic aneurysm (TAA) underwent surgery on an emergency basis for acute Stanford type A aortic dissection (4) or ruptured aortic aneurysm (3); there was one hospital death (14%) in this group. Hospital death did not reflect the preoperative adverse clinical risk factors (Table 1). There was no statistical difference in mortality between elective and urgent operation. All 4 hospital deaths were cardiac-related; 3 patients needed intraaortic balloon or percutaneous cardiopulmonary support for low cardiac output syndrome, and one suffered recurrent ventricular fibrillation and flutter, acute renal failure, and multiorgan failure. Major postoperative complications occurred in 27% of patients (Table 2). Postoperative new requirement for intraaortic balloon or percutaneous cardiopulmonary support, prolonged ventilator dependence, and dialysis had the highest incidences. However, the rate of stroke (2.4%) was low. The mean postoperative hospital stay of the survivors was 27 ± 16 days.
|
DISCUSSION
|
|---|
Cardiac and TAA surgery is currently being performed frequently in patients aged 80 years or older.3–5,7–15 Of the 41 octogenarians in this study, 78% were treated during the last 3 years. They accounted for 4.9% of the patients receiving cardiac and thoracic aortic operation in the study period. Overall hospital mortality (9.8%) compared favorably with other reports (8% to 27%).3,4,6,7,10,11,13,15 There have been several recent series suggesting that surgery may be an effective and safe treatment for symptomatic coronary and valvular heart disease in octogenarians.3–5,7–11,13–15 Our hospital mortality rate of 12% for isolated CABG is comparable with the reported range of 5.8% to 14.1%, although incomplete revascularization is more frequent with the OPCAB procedure.3–7,10,11,13–15 The concept of complete surgical revascularization of all diseased vessels is the gold standard for the ischemic heart. Recently, some have suggested that target-vessel revascularization without CPB in very old and high-risk patients might lead to a significant reduction of in-hospital mortality and major postoperative complications.16 There was no mortality from isolated valve surgery, indicating that advanced age alone is not associated with an excessive operative risk from CPB, and that these operative procedures can be safely per-formed in selected octogenarians with correctable lesions.
Generally, TAA repair is reported separately from cardiac disease because of its higher operative mortality. Neri and colleagues12 reported 83% hospital mortality in operations for acute type A aortic dissection in octogenarians. Okita and colleagues17 had a hospital mortality of 27% after surgery for TAA in patients 75 years or older. Data for TAA repair was included in this report because it is among the operations performed under CPB; the operative mortality for TAA was relatively low at 14%.
Complications occurred in 27% of patients, and these critically ill octogenarians contributed substantially to resource utilization. The incidence of reoperation for bleeding (2.4%) was low for this age group (2% to 10.5%), but postoperative hospitalization (27 days) was extremely long compared to many reports by Western authors (7 to 17.7 days).3–5,7,9–11,14 However, most of our patients experienced an excellent outcome. There was no difference between elective and urgent operations. Because there is a reluctance to consider surgical therapy for the octogenarian until medical therapy has been exhausted, such patients are often relatively poor surgical candidates and sometimes need emergency operations. Tsevat and colleagues18 reported that most hospitalized patients of 80 years or older were unwilling to trade much time for excellent health, but preferences varied greatly. Because urgent or emergency operation is a significant risk factor for early death in general, scheduled surgical intervention should be offered to octogenarians in particular.3,4,10,11
A limitation of this study is the small sample size and an associated low statistical power. In addition, our data concern in-hospital outcome and do not address late results after discharge. Nevertheless, it could be concluded that cardiac and thoracic aortic operations can be performed with acceptable mortality and morbidity, when appropriately applied in selected octogenarians.
|
REFERENCES
|
|---|
-
Yasuda K, Ayabe H, Ide H, Uchida Y. Thoracic and cardiovascular surgery in Japan during 1998. Annual report by the Japanese Association for Thoracic Surgery Committee of Science. Jpn J Thorac Cardiovasc Surg
2000;48:401–15.[Medline]
-
Health and Welfare Statistics Association. Annual statistical report of national health conditions [Japanese]. Journal of Health and Welfare Statistics 2000;47(Extra edition):390 & 430–1.
-
Craver JM, Puskas JD, Weintraub WW, Shen Y, Guyton RA, Gott JP, et al. 601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg
1999;67:1104–10.[Abstract/Free Full Text]
-
Avery GJ II, Ley SJ, Hill JD, Hershon JJ, Dick SE. Cardiac surgery in the octogenarian: evaluation of risk, cost, and outcome. Ann Thorac Surg
2001;71:591–6.[Abstract/Free Full Text]
-
Alexander KP, Anstrom KJ, Muhlbaier LH, Grosswald RD, Smith PK, Jones RH, et al. Outcomes of cardiac surgery in patients age > or = 80 years: results from the National Cardiovascular Network. J Am Coll Cardiol
2000;35:731–8.[Abstract/Free Full Text]
-
Ohashi M, Fukunaga S, Kawano H, Tayama E, Kashikie H, Akashi H, et al. Cardio-aortic operation in octogenarians. Jpn J Thorac Cardiovasc Surg
2001;49:47–52.[Medline]
-
Akins CW, Daggett WM, Vlahakes GJ, Hilgenberg AD, Torchiana DF, Madsen JC, et al. Cardiac operations in patients 80 years old and older. Ann Thorac Surg
1997; 64:606–14.[Abstract/Free Full Text]
-
Asimakopoulos G, Edwards MB, Taylor KM. Aortic valve replacement in patients 80 years of age and older: survival and cause of death based on 1100 cases: collective results from The UK Heart Valve Registry. Circulation
1997; 96:3403–8.[Abstract/Free Full Text]
-
Medalion B, Lytle BW, McCarthy PM, Stewart RW, Arheart KL, Arnold JH, et al. Aortic valve replacement for octogenarians: are small valves bad? Ann Thorac Surg
1998;66:699–705.[Abstract/Free Full Text]
-
Kirsch M, Guesnier L, LeBesnerais P, Hillion ML, Debauchez M, Seguin J, et al. Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy. Ann Thorac Surg
1998;66:60–7.[Abstract/Free Full Text]
-
Fruitman DS, MacDougall CE, Ross DB. Cardiac surgery in octogenarians: can elderly patients benefit? Quality of life after cardiac surgery. Ann Thorac Surg
1999;68: 2129–35.[Abstract/Free Full Text]
-
Neri E, Toscano T, Massetti M, Capannini G, Carone E, Tucci E, et al. Operation for acute type A aortic dissection in octogenarians: is it justified? J Thorac Cardiovasc Surg
2001;121:259–67.
-
Tsai TP, Chaux A, Matloff JM, Kass RM, Gray RJ, DeRobertis MA, et al. Ten-year experience of cardiac surgery in patients aged 80 years and over. Ann Thorac Surg
1994;58:445–50.[Abstract]
-
Morris RJ, Strong MD, Grunewald KE, Ray Kuretu ML, Samuels LE, Kresh JY, et al. Internal thoracic artery for coronary artery grafting in octogenarians. Ann Thorac Surg
1996;62:16–22.[Abstract/Free Full Text]
-
de Mol BA, Kallewaard M, Lewin F, van Gaalen GL, van den Brink RB. Single-institution effectiveness assessment of open-heart surgery in octogenarians. Eur J Cardio-thorac Surg
1997;12:285–90.[Abstract]
-
Kilo J, Baumer H, Czerny M, Hiesmayr MJ, Ploner M, Wolner E, et al. Target vessel revascularization without cardiopulmonary bypass in elderly high-risk patients. Ann Thorac Surg
2001;71:537–42.[Abstract/Free Full Text]
-
Okita Y, Ando M, Minatoya K, Tagusari O, Kitamura S, Nakajima N, et al. Early and long-term results of surgery for aneurysms of the thoracic aorta in septuagenarians and octogenarians. Eur J Cardio-thorac Surg
1999;16:317–23.[Abstract/Free Full Text]
-
Tsevat J, Dawson NV, Wu AW, Lynn J, Soukup JR, Cook EF, et al. Health values of hospitalized patients 80 years or older. JAMA
1998;279:371–5.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
J. Kpodonu, O. Preventza, V. G. Ramaiah, H. Shennib, G. H. Wheatley III, J. A. Rodriquez-Lopez, J. Williams, and E. B. Diethrich
Endovascular repair of the thoracic aorta in octogenarians
Eur. J. Cardiothorac. Surg.,
September 1, 2008;
34(3):
630 - 634.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. B Abdulgani
Outcome of Cardiac and Thoracic Aortic Operation in Patients Over 80 Years Old
Asian Cardiovasc Thorac Ann,
September 1, 2002;
10(3):
288 - 288.
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
INTRODUCTION
