Asian Cardiovasc Thorac Ann 2003;11:28-32
© 2003 Asia Publishing EXchange Ltd
Does Gender Affect Outcome of Cardiac Surgery in Octogenarians?
Probal Ghosh, FRCS,
Miladin Djordjevic, MD,
Roland Schistek, MD,
Reinhard Baier, MD,
Felix Unger, DSc
Department of Cardiac Surgery, St. John’s Hospital, Salzburg, Austria
For reprint information contact: Probal Ghosh, FRCS Tel: 43 662 4482 3378 Fax: 43 662 4482 3374 email: P.Ghosh{at}lks.at Department of Cardiac Surgery, St. John’s Hospital, Muellner Hauptstrasse 48, Salzburg A-5020, Austria.
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ABSTRACT
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The long-term results of cardiac surgery in 212 consecutive octogenarians (116 men, 96 women) were reviewed retrospectively. Preoperative functional status, Euroscore, and the incidences of hypertension and chronic obstructive pulmonary disease were similar in both sexes. Women had more diabetes mellitus (45% versus 25%; p < 0.05) but less renal dysfunction (16% versus 29%; p < 0.05). Men required emergency procedures more frequently (p < 0.05). Women underwent complete revascularization more often and had more arterial grafts. Hospital mortality was similar (11.5% in women versus 12.9% in men), but women had more complications (76% versus 64%), longer convalescence (24.3 versus 18.5 days), fewer psychiatric disorders (14% versus 23%) and less heart block (9% versus 19%). Men had a slightly better outcome in terms of functional class and Euroqol score during follow-up of up to 114 months. Median survival was longer in women (3.15 versus 2.96 years) but 1-, 3-, and 5-year survival rates and late deaths were similar. Outcomes appear to be equitable for both sexes among octogenarians.
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INTRODUCTION
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Several reports have established the safety and efficacy of cardiac surgery in octogenarians and older patients. Gender-related differences have been noticed in the general population. In Austria, 3.4% of the population is estimated to be over 80-years old. At the age of 80, an Austrian man has a life expectancy of 6.28 years compared to 7.51 years for women.1 This study was designed to assess the influence of gender on short- and long-term outcomes of cardiac surgery in this elderly subset.
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PATIENTS AND METHODS
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Records of 212 consecutive octogenarians (men 116, women 96) who underwent cardiac surgery from September 1989 through October 2000, were reviewed retrospectively. Isolated coronary artery bypass grafting (CABG) was carried out in 127 patients, isolated aortic valve replacement (AVR) in 54, and combined CABG and valve operations in 31. Preoperative status was assessed according to New York Heart Association (NYHA) criteria. Operative risk was evaluated by Euroscore. Table 1
lists the preoperative details of both sexes.
All operations were carried out under moderate hypothermia (31°C to 34°C) and cardiopulmonary bypass (CPB). Bretschneider solution was infused antegradely through the aortic root to the grafts and via the coronary ostia for myocardial protection. The age threshold for implantation of a bioprosthesis increased during this period; almost all patients who needed valve replacements received bioprostheses (78, 92%) including Intact, Mosaic, and Hancock MO II (Medtronic, Inc., Minneapolis, MN, USA), Sorin Pericarbon (Sorin Spa, Saluggia, Italy), and Biocor (Biocor Industria e Pesquisas LTDA, Belo Horizonte, Brazil). Only 10 mechanical valves were used: SJM (St. Jude Medical, Inc., St. Paul, MN, USA) and Carbomedics (Sulzer Carbomedics, Inc., Austin, TX, USA). Selection of the prosthesis was based on the choice of the operating surgeon. The subvalvar apparatus was preserved in concomitant mitral valve replacement. For associated CABG, pedicled in-situ left internal thoracic artery (LITA) was the preferred conduit for the left anterior descending coronary artery. Reversed saphenous vein was the second most frequently used conduit. All distal anastomoses were performed during a single period of aortic crossclamping. The operative data are given in Tables 2 and 3.
Follow-up data were obtained from clinic visits, mailed questionnaires, and telephone contact with the referring cardiologists, general practitioners, patients, and families. In addition to clinical assessments, quality of life was evaluated by the Euroqol questionnaire (5 scales, 3 grades). Euroqol scores were assigned by 2 observers as part of the clinical follow-up.2,3 Postoperative NYHA functional class and Euroqol scores were compared with the preoperative Euroscore, disease profiles, comorbidity, and operative details. The sexes were compared in terms of preoperative status, disease profiles, comorbidity, operative details, morbidity, mortality, and outcome. Deaths from all causes were considered. Data are expressed as mean ± standard deviation. The Spearman correlation test assessed sex, ejection fraction, CPB time, aortic crossclamp time, preoperative status, and postoperative Euroqol score.
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RESULTS
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Octogenarians accounted for 3.6% (212/5,971) of all patients undergoing procedures under CPB, 7.6% (85/1,115) of all isolated valve operations, 12.4% (31/250) of all combined procedures, and 2.8% of all isolated CABG cases during this period. Overall, octogenarians had high incidences of preoperative diabetes, hypertension, obstructive lung disease, cardiac decompensation, syncope, dyspnea, angina, renal dysfunction, and cerebrovascular diseases. Lower rates of obesity, hyperuricemia, nicotine abuse, hyperlipidemia, and family history of heart disease were seen in this subset (possibly due to natural attrition) and they were not influenced by sex. A trend towards higher NYHA class was noticed with increasing age, 89% of these patients were in class III or IV, and a high-risk Euroscore was found in 80%. Comorbidity was usually equally distributed between the sexes (Table 1
).
Mean aortic valve area was 0.62 ± 0.17 cm2 (0.3 to 0.9 cm2), with gradients of up to 120 mm Hg. More severe gradients were noted in women (88.6 versus 76.7 mm Hg). Left ventricular (LV) end-diastolic volume was 120 ± 30 mL (61 to 160 mL), LV end-systolic volume was 59 ± 26 mL (21 to 98 mL), ejection fraction was 55.3% ± 13.3% (35% to 84%). In men with coronary artery lesions, 3-vessel disease, left main disease, and previous percutaneous coronary interventions were significantly more common. On multivariate analysis, differences in body surface area, body mass index, NYHA class, incidence of diabetes, and renal dysfunction were significantly different (p < 0.05) between the sexes, but preoperative percutaneous coronary intervention, atrial fibrillation, lung disease, and Euroscore were not. Nearly two-thirds of patients (63%) underwent a non-elective procedure (Table 2), with significantly more emergency procedures in men (p < 0.05). Nine patients (4%) had undergone a previous cardiac operation. Surgical details are listed in Table 3, and perioperative data in Table 4. All explanted valves showed calcified degenerative pathology. A small annulus was found in 13 patients (12 women) who received a 19-mm prosthesis. Aortic root enlargement was performed in 3 patients, one of whom received a 19-mm prosthesis. Stented bioprostheses were most commonly used (92%). Mechanical aortic prostheses were implanted in 7 patients, of whom 2 had a degenerated aortic bioprosthesis. Hospital stay > 2 weeks was necessary in 16% of patients, with no sex bias. Non-elective procedures resulted in longer hospitalization, ventilation, and inotropic support in both sexes. Combined valvular and coronary disease prolonged intensive care unit stay. The cause of death was cardiac-related (perioperative myocardial infarction, sudden cardiac death, heart failure) in most cases. Noncardiac causes included multiorgan failure, gastrointestinal bleeding, and lung infection. There was no significant difference in preoperative Euroscore between survivors and non-survivors.
Follow-up details are given in Table 5. Most patients required convalescence (4 to 88 days) after discharge from the hospital. The duration of follow-up was 2 to 114 months (mean, 40.2 months). Cardiac causes were attributed to 35% of late deaths. Overall survival was similar in men and women, and it was not significantly different from the expected survival of octogenarians in the general population. Varying degrees of dementia were reported in 5 patients. Valve dysfunction was observed in 2 patients, one of whom underwent reoperation after 12 months.
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DISCUSSION
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Life expectancy is longer in women than men. Women constituted 41% to 81% of octogenarian cardiac surgical patients in previous studies; the incidence appears to be higher in European reports. This possibly reflects late referral, which may contribute to poorer outcomes in elderly women after cardiac surgery. In the Cleveland Clinic experience, 26% of the octogenarians (81% female) received a 19-mm prosthesis, but neither early or late mortality nor cardiac event rate were adversely affected.4 In this study, the 13 patients who received a 19-mm prosthesis were predominantly female with small body surface areas; mortality was similar to that in patients with larger prostheses and body surface areas. Outcome after AVR does not depend on prosthesis size alone, and clinically evident patient-prosthesis mismatch can be avoided even with a small prosthesis.5,6 However, some centers avoid implanting 19-mm valves even in octogenarians, and advocate aortic root enlargement. The Mayo Clinic group used aortic root enlargement in 11.8% of octogenarians undergoing AVR.7
The poorer preoperative status in octogenarians, prevalence of congestive heart failure, higher LV end-diastolic pressures (often due to age-related changes in LV architecture and function), sternal osteoporosis and related healing problems, inconsistent myocardial protection, atheroemboli from the aorta, cerebrovascular disease, comorbidity leading to diminished reserve of subsystems, and tissue fragility contribute to an increased risk of complications and mortality. The age-related increase in LV mass is more marked in women, possibly because men with increased LV mass die earlier.8 This difference in the biology of ageing may be a factor in gender-specific differences after cardiac surgery. In agreement with our findings, an event-free postoperative course is rare (20% to 27%).9–12 Prior stroke, diabetes mellitus, NYHA class IV, and prolonged crossclamp time were reported to be independent predictors of morbidity.12 Common postoperative complications in the elderly, such as wound problems and renal failure, were infrequent in our patients, but perioperative neurobehavioral disturbances in 19% was higher than in recent reports of 2% to 9%.7,13 Interestingly, psychological problems were more frequent in men. New atrial fibrillation was the most common complication in both sexes. However, the higher rate of nonfatal postoperative complications in this age group did not affect the quality of life during long-term survival. Most octogenarians require convalescence in a nursing home or rehabilitation center. This "invisible" segment of care adds to the cost of treatment, but few studies have focussed on this factor.11 Such care was necessary in most of our 186 hospital survivors, and it was longer for women than men.
Recent studies reported 1.8% to 27.3% mortality for isolated AVR and 6.6% to 24% for AVR combined with CABG (overall mortality, 4.2% to 28%) in octogenarians. The need for CABG in addition to AVR trends to increase hospital mortality.4,9,13 Most early deaths are from cardiac causes, and the risk increases 4.3 times when CPB time exceeds 95 minutes.14,15 However, such increased mortality may reflect prolonged aortic crossclamp time and suboptimal myocardial protection, because isolated AVR has similar results to combined surgery.13 Preoperative NYHA class, prior CABG, history of heart failure, renal dysfunction, crossclamp time, and emergency procedures have been considered independent risk factors for mortality and morbidity.10 Female sex was noted to be a risk factor for mortality after AVR, attributed to smaller aortic roots and coronary arteries.16,17 In this study, mortality was similar in both sexes, as found by Kirsch and colleagues,13 whereas, Glower and colleagues18 observed a lower hospital mortality in elderly women. Late outcome reflects the extent of myocardial damage as a consequence of primary disease rather than myocardial insult during operation. As seen in this study, combined surgery appears to be a significant predictor of late mortality.13 Causes of late death are often difficult to ascertain as many occur suddenly.
In this series, the quality of life postoperatively was excellent. Postoperative Euroqol score correlated with preoperative Euroscore, but CABG patients had better outcomes than those undergoing AVR or combined procedures. Euroqol score and NYHA functional class were slightly poorer in women, as noted by others.16 The majority of survivors led an independent life at home or in retirement hostels. Nursing care may be needed in 6% to 11% patients.15,18 The patients in this study were somewhat selected as they had lower incidences of carotid, pulmonary, and renal disease than the general octogenarian population. None had coexisting malignancy, nutritional impairment, severe motor or cognitive deficit, orthopedic disability, hematological disorder, pacemaker dependence, or tissue atrophy. Only 25% of men had diabetes. It was concluded that the overall outcome of cardiac surgery was equitable in elderly men and women. While selection bias may have played a role in referral, the outcomes appear to be related to the natural history of cardiovascular disease, and there is no overwhelming evidence of an impact of gender on outcome.
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Footnotes
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Presented at the 15th Biennial Congress of the Association of Thoracic and Cardiovascular Surgeons of Asia, December 6–9, 2001, Mumbai, India.
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REFERENCES
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- Statistiches Jahrbuch 2001. Wien. 2001. 03 Gesundheit. P 48. http://www.statistik.at. Accessed on 4 December 2001.
- Kind P. Measuring valuations for health states: a survey of patients for general practice. Discussion paper 76. Centre for Health Economics. University of York, 1990.
- Sollano JA, Rose EA, Williams DL, Thornton B, Quint E, Apfelbaum M, et al. Cost-effectiveness of coronary artery bypass surgery in octogenarians. Ann Surg
1998;228: 297–306.[Medline]
- Medallion B, Lytle BW, McCarthy PM, Stewart RW, Arheart KL, Arnold JH, et al. Aortic valve replacement in octogenarians: are small valves bad? Ann Thorac Surg
1998;66:699–706.[Abstract/Free Full Text]
- Ghosh P, Kumar S, Pandey S, Kumar AS, Sinha N. Small aortic annulus: a functional definition. Ann Thorac Cardiovasc Surg
1998;4:251–61.[Medline]
- Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol
2000;36:1131–41.[Abstract/Free Full Text]
- Gehlot A, Mullany CJ, Ilstrup D, Schaff HV, Orszulak TA, Morris JJ, et al. Aortic valve replacement in patients aged eighty years and older: early and long-term results. J Thorac Cardiovasc Surg
1996;111:1026–36.[Abstract/Free Full Text]
- Hayward CS, Webb CM, Collins P. Effect of sex hormones on cardiac mass. Lancet
2001;357:1354–6.[Medline]
- Elayda MA, Hall RJ, Reul RM, Alonzo DM, Gillette N, Reul GJ Jr, et al. Aortic valve replacement in patients 80 years and older. Operative risks and long-term results. Circulation
1993;88(Suppl II):11–6.[Abstract/Free Full Text]
- Freeman WK, Schaff HV, O’Brien PC, Orszulak TA, Naessens JM, Tajik AJ. Cardiac surgery in the octogenarian: perioperative outcome and clinical follow-up. J Am Coll Cardiol
1991;18:29–35.[Abstract]
- Levin IL, Olivecrona GK, Thulin LI, Olsson SB. Aortic valve replacement in patients older than 85 years: outcomes and the effect on their quality of life. Coron Artery Dis
1998;9:365–72.[Medline]
- Deiwick M, Tandler R, Mollhoff T, Kerber S, Rotker J, Roeder N, et al. Heart surgery in patients aged 80 years and above: determinants of mortality and morbidity. Thorac Cardiovasc Surgeon
1997;45:119–26.[Medline]
- 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]
- Tsai T, Chaux A, Matloff JM, Kass RM, Gray RJ, DeRobertis MA, et al. Ten-year experience of cardiac surgery in patients aged 80 years and older. Ann Thorac Surg
1994;58:445–51.[Abstract]
- Cane ME, Chen C, Bailey BM, Fernandez J, Laub GW, Anderson WA, et al. CABG in octogenarians: early and late events and actuarial survival in comparison with a matched population. Ann Thorac Surg
1995;60:1033–7.[Abstract/Free Full Text]
- Azariades M, Fessler CL, Ahmed A, Starr A. Aortic valve replacement in patients over 80 years of age: a comparative standard for balloon valvuloplasty. Eur J Cardio-thorac Surg
1991;5:373–7.[Abstract]
- Aranki SF, Rizzo RJ, Couper GS, Adams DH, Collins JJ, Gildea JS, et al. Aortic valve replacement: effect of gender and coronary artery disease on operative mortality. Circulation
1993;88:17–23.
- Glower DD, Christopher TD, Milano CA, White WD, Smith IR, Jones RH, et al. Performance status and outcome after coronary artery bypass grafting in persons aged 80 to 93 years. Am J Cardiol
1992;70:567–71.[Medline]
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ABSTRACT
INTRODUCTION
