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Ann Thorac Surg 1995;60:1038-1043
© 1995 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Determinants of Operative Mortality in Octogenarians Undergoing Coronary Bypass

Department of Thoracic and Cardiovascular Surgery, Mount Sinai Medical Center of Greater Miami, Miami Beach, Florida

Accepted for publication April 14, 1995.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. The elderly segment of the population is increasing rapidly, and surgeons are being asked to consider patients more than 80 years old as candidates for coronary bypass. The objective of this study was to identify risk factors that may adversely affect mortality as well as analyze functional outcomes and survival in octogenarians undergoing coronary bypass.

Methods. From July 1989 through February 1994, 300 consecutive patients 80 years of age and older underwent coronary artery bypass grafting. There were 176 men (58.7%) and 124 women (41.3%) with a mean age of 80.9 years (range, 80 to 99 years). Preoperatively, 274 patients (91.3%) had disabling angina, 76 (25.3%) had left main coronary stenosis greater than 50%, and 293 patients (98.3%) were in New York Heart Association class III or IV.

Results. The overall hospital mortality was 11.0% (33/300) with an elective mortality of 9.6% (23/240), urgent mortality of 11% (5/45), and emergent mortality of 33.3% (5/15). Significant independent predictors of operative mortality were preoperative renal dysfunction, postoperative pulmonary insufficiency, postoperative renal dysfunction, use of intraaortic balloon pumping, and sternal wound infection. The actuarial survival for patients discharged from the hospital was 74.6% ± 5.6% (standard error of the mean) at 54 months.

Conclusions. A favorable outcome may be expected when coronary artery bypass grafting is performed in patients 80 years of age or older with severe angina.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The elderly segment of the population in the United States is rapidly increasing. According to recent statistics from the US Bureau of Census, 6.2% of the United States population will be more than 80 years of age by the year 2000 [1]. Statistical data from population studies demonstrate that individuals aged 80 years currently have a life expectancy of 8.1 years [2]. In 1990, there were 7.4 million Americans more than 80 years of age and approximately 40% of these patients suffered from symptomatic cardiovascular disease [3]. The number of patients aged 80 years and older undergoing coronary artery bypass grafting (CABG) is increasing as well [4]. Prior to 1988 approximately 1.2% of patients undergoing CABG were octogenarians, whereas at least 2.6% of patients thereafter are more than 80 years old [5]. Consequently, the number of patients aged 80 years and older with cardiovascular disease referred for CABG will increase in the future.

For editorial comment, see page 875.

Age has been shown to be a strong predictor of CABG operative mortality; with each 10 years of age mortality increases by approximately 40% [6, 7]. Early reports of octogenarians undergoing CABG in the 1970s and 1980s documented mortalities as high as 24% [8], whereas more recent studies report mortalities in the range of 8% to 12% [4, 9–11]. Despite an apparent significant reduction in octogenarian mortality, this subset of elderly patients continues to have a much higher mortality than younger patients [12, 13]. Risk factors that have a significant impact on CABG mortality in younger patients may affect mortality in elderly patients in a different way. Studies relating to CABG in octogenarian patients thus far have not clearly defined those risk factors that adversely affect mortality [4, 9, 10, 11, 14]. The objective of this study was to identify risk factors that may adversely affect mortality as well as analyze functional outcomes and survivability in an octogenarian population operated on recently.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Patient Population
Three hundred consecutive patients 80 years of age and older who underwent isolated CABG between July 1989 and February 1994 are the focus of this study. There were 176 men (58.7%) and 124 women (41.3%), ranging in age from 80 to 99 years with a mean of 82.9 ± 2.7 years. Figure 1 shows the age distribution of patients at operation.

View larger version (18K): [in this window] [in a new window]   Fig 1. . Patient age distribution at time of operation.

Disabling angina was present in 274 patients (91.3%) and chronic stable angina in 16 patients (5.3%). The patient's preoperative functional status was ranked according to the New York Heart Association (NYHA) classification system. Five patients (1.7%) were in class II, 117 (39.0%) in class III, and 178 (59.3%) in class IV.

There were 37 patients (12.3%) who had previously undergone percutaneous transluminal coronary angioplasty, and 24 patients (8.0%) had previous CABG.

Preoperative Angiographic Findings
All patients had selective coronary arteriography before operation. Significant coronary artery disease was defined as an estimated reduction in luminal diameter of 50% or more. Preoperative angiography demonstrated triple-vessel disease in 268 patients (89.3%), double-vessel disease in 24 patients (8.0%), and single-vessel disease in 8 patients (2.7%). Left main coronary artery disease was present in 76 patients (25.3%). Ejection fraction determination from left ventriculography was available in 297 patients (99.0%). The ejection fraction was greater than 0.50 in 123 patients (41.4%), between 0.30 and 0.50 in 148 patients (49.8%), and less than 0.30 in 26 patients (8.8%). Table 1 summarizes the patient profile data.

Operative Data
A total of 1,110 coronary artery grafts were performed (mean, 3.7 per patient; range, 1 to 6). The type of conduit used and its recipient artery are shown in Table 2. The mean cardiopulmonary bypass time was 58.0 ± 17.9 minutes (range, 10 to 162 minutes). The mean aortic cross-clamping time was 27.3 ± 11.5 minutes (range, 4 to 78 minutes).

A patient registration form and a patient follow-up form were completed for each participant in the study. These data collection instruments provided standardized reporting of each patient's clinical status before and after the operation. Data were entered into the Patient Analysis and Tracking System (Dendrite Systems, Inc, Portland, OR). A 100% follow-up was achieved.

Statistical Analysis
Data are presented as frequency distributions and simple percentages. Values of continuous variables are expressed as the mean ± the standard deviation. Univariate analysis of selected preoperative and postoperative discrete variables was accomplished by ² analysis, the continuity-adjusted ² analysis, or a two-tailed Fisher exact test with the appropriate degrees of freedom. Multivariate logistic regression analysis of preoperative and postoperative variables achieving statistical significance (p < 0.05) was performed to identify predictors of hospital mortality.

Patient survival is expressed by actuarial analysis according to the method of Berkstrom and Gage [15] using time zero as the date of operation and death as the end-point and by linearized occurrence rates. Data collected were subjected to both quantitative and qualitative analysis with the aid of the Statistical Package for the Social Sciences (SPSS/PC+ 5.0). Statistical significance was assumed when the p value was less than 0.050.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Hospital Morbidity
Hospital complications included reoperation for bleeding, 9 patients (3.0%); sternal infection, 5 patients (1.7%); perioperative myocardial infarction, 4 patients (1.3%); pulmonary insufficiency, 60 patients (20.0%); renal dysfunction, 39 patients (13.0%); and cerebrovascular accident, 7 patients (2.3%).

Patients with sternal infection had positive wound cultures requiring additional surgical treatment including incision and drainage, debridement, or flap closure. Pulmonary insufficiency was defined as intubation for more than 48 hours after operation or reintubation after initial extubation. Myocardial infarction was defined as new onset of Q waves with or without elevation of myocardial enzyme levels. Renal dysfunction was defined as a creatinine level greater than 2.0 mg/dL and cerebrovascular accident as a fixed neurologic deficit.

Placement of the intraaortic balloon pump was required in 16 patients (5.3%). Nine patients (3.0%) had an intraaortic balloon pump placed preoperatively, 4 (1.3%) intraoperatively, and 3 (1.0%) postoperatively. There were no major complications attributed to placement or use of the intraaortic balloon pump. The average postoperative length of stay was 14.0 ± 11.5 days.

Hospital Mortality
Hospital mortality was defined as death occurring during the hospitalization in which the operation was performed or after hospital discharge but within 30 days of the surgical procedure. Patients operated on within 24 hours of catheterization were considered urgent. Patients operated on the same day as the heart catheterization were considered emergent. All other patients were considered to be elective.

The overall hospital mortality for the series was 11.0% (33/300). The elective mortality was 9.6% (23/240), the urgent mortality 11.1% (5/45), and the emergent mortality 33.3% (5/15). The increase in mortality between elective and urgent cases was not statistically significant. However, the mortality for emergent cases was significantly greater than the mortality for elective cases (p < 0.015).

Univariate analyses of 24 perioperative variables potentially associated with hospital mortality were conducted. Table 3 lists preoperative and postoperative variables associated with increased hospital mortality that achieved statistical significance (p < 0.05). These statistically significant variables were then entered into a multivariate logistic regression model to identify independent predictors of mortality. Of the preoperative variables entered into the multivariate model only renal dysfunction (p < 0.022) was found to be predictive of increased mortality. Of the postoperative variables entered into the multivariate model, pulmonary insufficiency (p < 0.001), renal dysfunction (p < 0.003), use of the intraaortic balloon pump (p < 0.005), and sternal wound infection (p < 0.016) were found to be independent variables associated with increased hospital mortality (Table 4).

View larger version (20K): [in this window] [in a new window]   Fig 2. . Actuarial survival of coronary bypass patients 80 years of age and older discharged from the hospital. (SEM = standard error of the mean.)

View larger version (19K): [in this window] [in a new window]   Fig 3. . Preoperative and postoperative New York Heart Association (NYHA) functional classification of survivors.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
The operative morbidity and mortality associated with CABG in octogenarians is increased over that in younger patients [12, 16, 17]. Over the last 10 years, the CABG mortality in octogenarians has decreased significantly, probably because of improved surgical techniques and postoperative management. The patient profiles, morbidity, and mortality in this report are similar to those of other studies recently published [4, 9, 10, 11] and confirm that the mortality in octogenarians is higher than in younger patients.

During the period covered by the present study, 1989 to 1994, our surgical team accepted essentially all octogenarian patients referred for CABG except those who were either seriously physically handicapped or mentally infirm. Despite the fact that our octogenarian morbidity and mortality data are similar to those of other reports, we were unwilling to dismiss these results as acceptable. Hence, it was thought necessary to analyze our octogenarian patient group to determine which risk variables might forecast unfavorable outcomes. Once important risk variables were defined, objective criteria could be established to more thoughtfully select octogenarian patients for operation and perhaps to refine preoperative preparation and postoperative care of these elderly patients. Furthermore, to justify our continued aggressive surgical treatment of octogenarians it was necessary to document and report functional status and long-term survival of the operative survivors in light of the intense emphasis on surgical outcomes in coronary bypass patients.

The increased mortality associated with coronary bypass in elderly patients compared with younger patients has a multifactorial basis and is probably not solely a reflection of the aging process. In our series, almost all patients were in NYHA class III or IV preoperatively, 60% had a prior myocardial infarction, 90% had disabling symptoms, 90% had three-vessel disease, and more than half had compromised left ventricular function. Other studies have also noted that elderly patients coming to CABG tend to have more advanced disease angiographically and more unstable symptoms, more frequently have a history of prior myocardial infarction, and in general are sicker medically than younger patients [4, 7, 13, 18]. Hence, elderly patients referred for coronary bypass seem to have more advanced ischemic disease compared with younger patients, suggesting that elderly patients are being referred for operation later in the course of their disease. The lack of functional reserves in elderly patients and the increased presence of chronic medical diseases combined with late referral patterns may predispose elderly patients to higher morbidity and mortality rates than younger patients who are referred earlier. Encouraging earlier referrals in elderly patients who will benefit from CABG potentially will improve the morbidity and mortality rates for these patients as a group, because the operative risks are seemingly better in patients who are referred early.

Risk factors associated with increased operative mortality in younger patient groups, which include age itself, have been well defined by the Coronary Artery Surgery Study [19]. It is possible that these same risk factors, however, do not extrapolate to the elderly population. Our multivariate analysis suggests that five risk factors including preoperative renal dysfunction, postoperative renal dysfunction, pulmonary insufficiency, intraaortic balloon pump support, and sternal wound infection are independent predictors of increased hospital mortality in octogenarians. Other reports of CABG in octogenarians have documented urgency of operation, compromised left ventricular function, and intraaortic balloon pumping [9, 10, 14, 20] as predictors of increased mortality. Emergent operation and left ventricular dysfunction were found to be risk factors in younger patients reported in the Coronary Artery Surgery Study [19]. In our univariate analysis of risk factors, both left ventricular dysfunction and emergent operation were found to correlate with increased hospital mortality. Emergent operation had a 33.3% (5/15) mortality, and the mortality was significantly greater than the elective mortality (9.6%; 23/240; p < 0.015). These two variables, however, were not found to be independent predictors of mortality in the multivariate analysis. Our definition of emergent operation differs from that of Ko and associates [9], who found emergent operation to be predictive of increased operative mortality. Although more than half of our octogenarians had an ejection fraction of less than 0.50, left ventricular dysfunction was not an independent predictor of increased mortality. Higgins and colleagues [21] found that increased serum creatinine levels and pulmonary dysfunction were important factors in operative morbidity and mortality in younger patients, which is similar to our analysis in octogenarians.

Based on our analysis of variables predictive of increased operative mortality, we now use preoperative dopamine hydrochloride infusion routinely on elderly patients with renal dysfunction and carry the infusion for at least 48 hours after operation. If possible, emergent operation is avoided and maximal efforts are directed at stabilizing patients' renal function preoperatively. Although intraaortic balloon pump use correlates with increased mortality in our study, we continue to use it when necessary to stabilize patients and avoid emergent operation. Sisto and colleagues [22] have shown that intraaortic balloon pump use in octogenarians is both safe and effective circulatory support, and our own experience supports this contention. Patients with underlying pulmonary disease are carefully screened preoperatively, and early extubation, vigorous pulmonary toilet, and reduction of pulmonary congestion by keeping patients relatively ``dry'' is stressed. Exquisite care is taken to avoid intraoperative injury of the phrenic nerves. Although the sternal wound infection rate was relatively low in this series, it was a strong independent predictor of increased mortality. In an effort to keep our infection rate as low as possible, we do not use bilateral internal mammary arteries in the elderly and use the left internal mammary artery only in selected cases where the quality of sternal tissue is good. The impact of internal mammary artery use on morbidity, mortality, and long-term survival in octogenarians remains unclear at this time.

Although outcome analysis stresses morbidity and mortality, the functional improvement and the long-term survival of patients is of equal importance. The follow-up data analysis in this study shows a gratifying improvement in the functional status of survivors similar to that reported in other studies in the elderly [9, 11, 18, 20, 23]. The majority of patients were in NYHA class I or II after operation. The survival of our patients at 54 months was 76%, which is better than the 48-month survival of 51% reported by Ko and associates [9] and is at least comparable with the 60-month survival of 62% reported by Tsai and co-workers [14] and Weintraub and colleagues [10]. Figure 4 shows the survival curve for our postoperative patients in comparison with the survival curve for the general population aged 80 years or older. It is interesting to note that our octogenarian operative survivors have almost the same life expectancy for the first 4 to 5 years after operation as does the general population older than 80 years. This suggests that CABG has indeed a salutary effect on survivability in this patient group.

View larger version (16K): [in this window] [in a new window]   Fig 4. . Comparison of actuarial survival for coronary artery bypass grafting (CABG) patients 80 years of age and over and the general population.

In the future, physicians will be seeing increasing numbers of octogenarian patients with ischemic heart disease. In light of the emphasis on outcomes and cost-effectiveness, physicians will be pressured to select therapeutic algorithms that have been shown to be cost-effective while optimizing the outcome in terms of function and survival. Ko and associates [24] found that octogenarian patients treated surgically had improved function and survival compared with a medically treated group, despite the fact that the surgical group had more advanced disease. Our data confirm excellent function and survival in octogenarians who have had myocardial revascularization. The surgical community, however, must address the increased morbidity and mortality associated with CABG in the elderly so that operation for selected octogenarian patients becomes a more attractive alternative than continued medical therapy. A multicenter study with standardized data reporting is needed to confirm our data on risk factors predictive of early mortality. Only then will surgeons faced with operating on elderly patients be able objectively to assess operative risk and modify preoperative preparation and postoperative care to reflect the risk factors unique to elderly patients.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Address reprint requests to Dr Williams, 4300 Alton Rd, Miami Beach, FL 33140.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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