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Ann Thorac Surg 1995;60:1033-1037
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

CABG in Octogenarians: Early and Late Events and Actuarial Survival in Comparison With a Matched Population

Department of Thoracic and Cardiovascular Surgery, Deborah Heart and Lung Center, Browns Mills, New Jersey, and UMDNJ-Robert Wood Johnson Medical School, New Brunswick, New Jersey

Accepted for publication April 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. With important demographic changes in cardiac surgical practice, more older patients are undergoing complex cardiac operations. Controversy exists as to whether the expenditure of healthcare resources on the growing elderly populations represents an effective approach in maintaining a meaningful quality of life.

Methods. From January 1982 through April 1991, 121 consecutive octogenarians underwent a surgical procedure that included coronary artery bypass grafting. Retrospective review of patient medical records was performed; follow-up information was obtained via telephone contact with the patient, the patient's family, or the patient's physician.

Results. There were 67 men (55%) and 54 women (45%). Mean age was 82.1 years (range, 80 to 89 years). Sixty-nine percent of the patients were having class III or IV symptoms. There were 11 hospital deaths (9.1%); risk factors included longer cardiopulmonary bypass time (p = 0.01), higher preoperative left ventricular end-diastolic pressure (p = 0.02), advanced age (p = 0.05), history of renal disease (p = 0.02), and myocardial infarction (p = 0.04). Late death occurred in 34 patients (30.9%) at a mean of 27 months postoperatively; univariate risk factors included chronic obstructive pulmonary disease (p = 0.009), higher left-ventricular end-diastolic pressure (p = 0.03), and recent myocardial infarction (p = 0.03). Actuarial survival, including hospital death, was 32.8% at 80 months, compared with 37.6% for an age; sex; and race-matched population (p > 0.3). Most late survivors (84%) were in New York Heart Association class I or II.

Conclusions. We conclude that coronary artery bypass grafting can be performed in octogenarians with an acceptable, although increased risk. Hospital survivors have a good late functional status but are at risk for pulmonary and other atherosclerosis-related events, which impair overall survival.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
There have been important demographic changes in cardiac surgical practice, with older patients undergoing more complex cardiac operations [1]. The purpose of this study was to analyze a consecutive group of octogenarians who underwent coronary artery bypass grafting (CABG) to identify hazards and events associated with cardiac operations in the elderly, and to determine risk factors related to these events. In addition, a comparative analysis of the study group was made with an age-, sex-, and race-matched population. To determine the efficacy of CABG in the octogenarian, we reviewed the course of our operative patients 80 years of age or older with regard to morbidity, mortality, and postoperative functional status.

For editorial comment, see page 875.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
From January 18, 1982, through April 30, 1991, 121 consecutive octogenarians at the Deborah Heart and Lung Center, Browns Mills, New Jersey, underwent a cardiac surgical procedure that included CABG. During that period 6,397 patients underwent CABG. Data abstracted from a retrospective review of the patient's medical records included patient age, sex, race, primary diagnosis, cardiac risk factors, procedure performed, and postoperative complications. Chest roentgenographic, electrocardiographic, and cardiac catheterization data were used when available. The New York Heart Association (NYHA) functional classification, based on congestive heart failure, was assigned to each patient. Cardiac catheterization was performed on all patients. Clinical coronary artery stenosis was defined as greater than 50% occlusion of the left main coronary artery or greater than 70% occlusion of the other coronary arteries.

The variables evaluated included age, albumin level less than 3.2 g/dL, aortic diastolic, mean, and systolic blood pressure, left ventricular ejection fraction, sex, height, history of cardiomegaly, history of cerebral vascular disease, history of chronic obstructive pulmonary disease, history of diabetes mellitus, history of hypercholesterolemia, history of hypertriglyceridemia, history of peripheral vascular disease, history of renal disease, history of smoking, left ventricular end-diastolic pressure, preoperative cardiac rhythm, preoperative intraaortic balloon pump, preoperative NYHA class, previous operation, recent myocardial infarction (MI), remote MI, status of the case (elective or urgent), weight, year of operation, aortic cross-clamp time, cardiopulmonary bypass, use of intraaortic balloon pump, use of left internal mammary artery, number of distal and sequential anastomoses, hospital stay, intensive care unit stay, postoperative inotropic support, and postoperative complications including leg wound infection, congestive heart failure, MI, pulmonary embolus, neurologic event, renal insufficiency, sternal wound infection, prolonged ventilation, and reoperation for bleeding.

There were 67 men (55%) and 54 women (45%). Mean age at operation was 82.1 years (range, 80 to 89 years). Eight of the patients were in NYHA class I preoperatively (7%), 29 were in class II (24%), 28 were in class III (23%), and 56 were in class IV (46%). The operations were performed during the 10-year period from 1982 to 1991, with increasing frequency during the last half of the decade (Fig 1). There was a significant history in our patients of MI (52 patients; 43%). Other co-morbid conditions include hypercholesterolemia (41 patients; 34%), diabetes mellitus (20 patients; 17%), serum albumin level less than 3.2 g/dL (18 patients; 15%), smoking (13 patients; 11%), peripheral vascular disease (10 patients; 8%), cerebral vascular disease (9 patients; 7%), chronic obstructive pulmonary disease (7 patients; 6%), and renal disease (3 patients; 3%). Previous cardiac operation occurred in 3 patients (3%): 1 had undergone CABG, 1 had an aortic valve replacement, and 1 an aortic valve repair, previously performed at a mean interval of 38 months (range, 6 to 56 months).

View larger version (21K): [in this window] [in a new window]   Fig 1. . Year of operation.

The extent of coronary artery disease in our patients as determined angiographically was as follows: single-vessel disease, 15 patients (12%); double-vessel disease, 29 patients (24%); triple-vessel disease, 75 patients (62%); and left main coronary artery stenosis, 16 patients (13%).

The operative technique mostly consisted of a standard median sternotomy, routine aortic and right atrial cannulation, and nonpulsatile moderate systemic hypothermic (30°C) cardiopulmonary bypass. The routine use of blood cardioplegia started in our institution in 1987. Disposable membrane oxygenators were primed with a crystalloid solution and albumin. Intermittent cold cardioplegia (4°C) and topical myocardial cooling was used for myocardial protection.

The mean number of distal anastomoses was 2.5 (range, 1 to 4). Forty-one (34%) of our patients had a left internal mammary artery conduit used. The mean aortic cross-clamp time was 45 minutes (range, 9 to 116 minutes). The mean cardiopulmonary bypass time was 86 minutes (range, 24 to 191 minutes).

Isolated CABG was performed in 84 patients (69%). Concomitant procedures, performed in 37 patients (31%), are summarized in Table 1. Twenty-four valves were implanted in 23 patients (19%). Sixteen of those were mechanical (12 aortic and 4 mitral, all St. Jude Medical valves [St. Jude Medical Inc, St. Paul, MN]), whereas 8 were bioprosthetic (6 aortic: 4 Carpentier-Edwards [Baxter Healthcare Corp, Irvine, CA] and 2 Ionescu-Shiley [Shiley Inc, Irvine, CA], and 2 mitral: Ionescu-Shiley).

Three methods were used to evaluate the possibility that differences in events were due to chance. These included calculation of p values by ² or Fisher's exact methods for categoric variables and Wilcoxon's rank sum test for continuous variables. A p value of less than 0.05 was considered significant. Incremental risk factors for both hospital and late death were first determined by Wilcoxon test. Multivariate analysis for late death using the Cox proportional hazard model was performed, and variables with a univariate p value greater than 0.1 were eliminated in this procedure. Actuarial survival rate was calculated by the Kaplan-Meier method. Comparison with an age-, sex-, and race-matched population using a model developed by Blackstone and associates [2] was made.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
This group of octogenarians consisted of 67 men and 54 women whose mean age at operation was 82.1 years (range, 80 to 89 years). Sixty-nine percent of the patients were having NYHA functional class III or IV symptoms, and emergent or urgent operation was performed in 17 patients (14%). There were 11 hospital deaths (9.1%; 70% confidence limits, 6% to 12%), which occurred at a mean of 19 days (range, 0 to 104 days; median, 10 days) and 2 of which were intraoperative. Five patients had acute cardiac failure (46%), 4 patients died with septicemia (36%), 1 patient died of an arrhythmia (9%), and 1 patient died of subacute cardiac failure (9%).

Incremental risk factors for hospital death determined by univariate analysis included longer cardiopulmonary bypass (p = 0.01), higher preoperative left ventricular end-diastolic pressure (p = 0.02), advanced age (83.3 ± 2.5 versus 81.9 ± 1.9 years; p = 0.05), lower preoperative body weight (p = 0.007), history of remote MI (>30 days) (p = 0.04), preoperative intraaortic balloon pump (p = 0.04), and history of renal disease (p = 0.02).

A variety of perioperative events occurred in 58 (49%) of the 119 patients who survived the operation. Inotropic support greater than 24 hours was required in 25 patients (21%), and prolonged ventilatory support (greater than 24 hours) was required in 15 patients (12%). Cerebral events occurred in 17 patients (14%) as follows: confusion in 9 patients, all resolved by discharge; 1 episode each of hemiparesis, slurred speech, disorientation, and depression, all resolved by discharge; right cerebrovascular accident and coma in 1 patient; and continued unresponsiveness after operation in 3. The latter four events all resulted in death. Atrial fibrillation or atrial flutter developed in 24 patients (20%), complete heart block developed in 1 patient, and bundle-branch block developed in an additional 6 patients (5%). Other complications included congestive heart failure in 13 patients (11%) and renal insufficiency in 12 patients (10%). Postbypass intraaortic balloon pump insertion was necessary in 12 patients (10%), and leg wound infection developed in 11 patients (1 major, 10 minor) (9%). Eight patients (7%) required reoperation for postoperative bleeding. Four patients (3%) had an MI, and a superficial sternal wound infection developed in 4 patients (3%). Pulmonary embolus occurred in 1 patient (1%).

The mean postoperative intensive care unit stay was 2.9 days (range, 1 to 31 days). Mean overall hospital stay was 17.8 days (range, 1 to 104 days), with hospital stay for hospital survivors ranging from 8 to 60 days (mean, 17 days; median, 15 days). The mean overall hospital stay for 2,198 of our patients undergoing CABG concurrently during the period from January 1991 to April 1993 was 13.2 days (range, 1 to 174 days; p = 0.0001). Clinical follow-up data were available for all 110 hospital survivors (100%) (mean, 36 months; range, 2 to 125 months). Late death occurred in 34 patients (31%). Modes of late death included cardiac failure in 19 patients (53%) (11 chronic, 6 acute, 2 arrhythmia), septicemia in 5 (15%), pulmonary complications in 3 (9%; 2 pulmonary embolism, 1 chronic obstructive pulmonary disease), and neurologic events in 2 (6%). Miscellaneous causes of death in 5 patients (15%) were carcinoma (2), intestinal obstruction (1), trauma (1), and undetermined (1). Late deaths occurred at a mean of 27 months postoperatively (range, 1.5 to 84 months). Incremental risk factors for late death by univariate analysis included history of chronic obstructive pulmonary disease (p = 0.009), higher preoperative left ventricular end-diastolic pressure (p = 0.03), and recent MI (p = 0.03). The only significant risk factor for late death by multivariate analysis was higher preoperative left ventricular end-diastolic pressure (p = 0.004). The actuarial survival rate of the entire study group parallels that of their age-, sex-, and race-matched population, indicating a 32.8% survival at 80 months compared with a 37.6% survival (Fig 2).

View larger version (19K): [in this window] [in a new window]   Fig 2. . Actuarial survival: comparison of study group versus matched population.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
In the past 25 years, cardiac surgery has played an increasing role in reducing morbidity and mortality resulting from ischemic heart disease in the adult population [3]. Controversy exists as to whether the considerable proportion of healthcare resources expended on the growing minority of elderly patients represents a cost-effective approach in an attempt to maintain a meaningful quality of life [4]. It is therefore important to examine late postoperative survival and functional outcome in addition to operative morbidity and mortality after cardiac operations in this group of patients. In our study, we examined the early and late results and actuarial survival in octogenarians undergoing coronary artery bypass grafting. Comparison of late survival rate between our study population and an age-, sex-, and race-matched population was made to further define potential risk versus benefits of such intervention.

Demographic changes suggest that there will be an increase in elderly patients undergoing CABG as the number of people 80 years of age or older in the American population is increased [5, 6]. There has been an understandable conservatism at offering octogenarians CABG because of advanced age and frequent associated medical problems [7, 8]. In recent years, this pessimistic philosophy has been modified as a result of improvements in myocardial protection, surgical technique, extracorporeal perfusion, anesthetic management, and perioperative care. Several reports have confirmed the safety and efficacy of open heart operations in octogenarians [9–11]. In those for whom the decision was made for surgical intervention, efforts were made to keep the operation simple and expeditious. Late clinical improvement, as judged by return to an independent lifestyle, justifies this approach for selected patients.

Several series have reported a high incidence of postoperative complications in elderly patients [12–15]. Our experience confirms this as evidenced by the fact that only 61 (51%) of our patient population had an entirely uncomplicated course. Nonfatal events were common in the postoperative hospital period but did not affect long-term survival. Particularly frequent problems were requirements for prolonged inotropic and ventilatory support. Fourteen percent of our patients suffered some neurologic impairment (delirium, confusion, or stroke) after operation. In this fragile patient subset, a stroke resulting in permanent and serious paresis is a catastrophic event, which is always incapacitating and often fatal. In our series, 4 patients sustaining cerebrovascular accidents died of resulting complications, which accounts for 9% of the overall deaths in our series.

The operative risk is related to the procedure performed, as well as the degree of cerebral, vascular, renal, and respiratory impairment present preoperatively. With proper preoperative selection, our data confirm that good results can be achieved in patients beyond 80 years of age. Although an operation can be undertaken, both the physician and patient must fully understand the magnitude of the operative risk. Our 9.1% operative mortality, with subsequent improvement in functional capacity and prolongation of late survival, justifies CABG for revascularization in the select octogenarian patient. This can be seen in the graphic representation of instantaneous risk of death per year (Fig 3).

View larger version (19K): [in this window] [in a new window]   Fig 3. . Hazard function indicating annualized risk of death.

There is an important surgical risk for cardiac operations in octogenarians. Hospital survivors have a good late functional status but are at a higher risk for pulmonary and atherosclerosis-related events, which impair their overall survival. Of the 76 late survivors, 70 (92%) on follow-up were home and active. Only 5 patients (6.6%) required transfer to a nursing care situation. This indicates a good chance for an independent, ambulatory existence. Our data comparing this group of patients with an age-, sex-, and race-matched population indicate that CABG can be performed in octogenarians with an acceptable, although increased risk.

Physicians and surgeons are now encountering increasing numbers of highly symptomatic elderly patients with serious coronary artery disease that warrant consideration for a cardiac operation. Due to advanced patient age, pursuit of necessary operative intervention is often neglected. Octogenarians should be offered the opportunity for CABG, with the expectation of reasonable results and late survival that parallels their demographic group. As our institution is a referral center, without an emergency room, it is possible that our study group may not reflect the patient population at large.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Mrs Nancy Couitt-LaFountaine for her assistance with the preparation of the manuscript.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr McGrath, Department of Surgery, Deborah Heart and Lung Center, 200 Trenton Rd, Browns Mills, NJ 08015.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael E. Cane Javier Fernandez Glenn W. Laub William A. Anderson Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cane, M. E. Articles by McGrath, L. B. Search for Related Content PubMed PubMed Citation Articles by Cane, M. E. Articles by McGrath, L. B. Related Collections Related Article