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Ann Thorac Surg 1997;63:634-639
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Rapid Recovery After Coronary Artery Bypass Grafting: Is the Elderly Patient Eligible?

Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Orange, California

Accepted for publication August 23, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Rapid recovery protocols after coronary artery bypass grafting have been applied successfully to young patients with normal ventricular function. However, the success of such protocols when applied to the elderly population has not been thoroughly validated, and at some centers there is still reluctance in allowing elderly patients to be discharged early from the hospital.

Methods. One hundred fifty-two consecutive younger patients (<70 years) were compared retrospectively with 167 consecutive elderly patients (70 years) who underwent isolated coronary artery bypass grafting using cardiopulmonary bypass. A rapid recovery protocol emphasizing an anesthetic protocol for early extubation, reduced cardiopulmonary bypass time, and perioperative administration of corticosteroids and thyroid hormone was applied to all patients. The protocol also emphasized early identification and management of postoperative atrial fibrillation, a proactive negative fluid balance, rapid return of bowel function, mobilization of the patient, and aggressive use of the intraaortic balloon pump preoperatively.

Results. The 30-day mortality rate for the younger group of patients was 3.3% (Parsonnet risk 7.2 ± 6.2), compared with 4.2% (Parsonnet risk, 17.7 ± 6.8) for the elderly group of patients. There were no statistically significant differences in the 30-day mortality rates or postoperative complications between the elderly and younger patient groups. Rapid recovery with discharge before the fifth postoperative day was achieved in 19% of the elderly, in comparison with 48% of the younger patients (p < 0.001). The younger patients were discharged earlier after operation than the older patients (5.7 ± 5.2 versus 8.0 ± 8.5 days; p < 0.01).

Conclusions. Application of the rapid recovery protocol helped expedite recovery for all patients regardless of age, acuity of illness, or associated conditions. Although younger patients had a significantly shorter postoperative length of hospital stay, older patients performed well and are suitable candidates for rapid recovery protocols.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
For editorial comment, see page 606.

The advent of managed care has significantly influenced the delivery of cardiovascular services. Even though a recent report [1] has noted reduced interventional procedures and improved operative outcomes in a strict managed care environment, many regions are experiencing a confusing adjustment as capitation is replacing the traditional fee-for-service practice. As a consequence, the transition to managed care frequently results in restricted access to the cardiovascular specialist, with a high percentage of patients obtaining consultations only after presenting with an acute coronary syndrome or acute myocardial infarction [2]. This can effectively shift the patient population requiring coronary artery bypass grafting to an urgent or emergent status, thereby increasing the operative risk. These factors, coupled with an aging population that is increasingly turning to health maintenance organizations, have added further risk to the profile of the patient requiring coronary artery revascularization.

Today's cardiac surgeon is expected to produce excellent results at minimal cost, regardless of the age of the patient, acuity of presentation, or associated comorbid conditions. To meet this challenge, rapid recovery and early discharge protocols have been highly successful [3–5]. These protocols, however, are typically applied to young patients (<70 years) with normal ventricular function. In contrast, elderly patients (70 years) are frequently managed more conservatively, with a preference for a longer hospitalization [6, 7]. We believe that elderly patients requiring coronary artery bypass grafting, while representing increased operative risk, will respond to an accelerated recovery program. To test this hypothesis, we applied a rapid recovery protocol to a consecutive series of patients undergoing isolated coronary artery bypass grafting, with the goal of achieving rapid convalescence and earlier discharge. Results in unselected elderly patients (70 years) were compared with those of a younger (<70 years) patient cohort.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
From January 1993 to May 1995, 319 patients underwent isolated coronary artery bypass grafting using cardiopulmonary bypass (CPB) and were reviewed retrospectively. The series consisted of 152 consecutive patients less than 70 years of age and another 167 consecutive patients 70 years of age or older.

All operations were performed within 24 hours of cardiac catheterization unless additional time was needed to optimize the clinical condition. Patients who required an urgent or emergent operation because of failed percutaneous transluminal coronary angioplasty (PTCA), an emergency reoperation, a critical left main stenosis (70%), pronounced left ventricular dysfunction (ejection fraction 0.40), or unstable angina refractory to medical therapy received preoperative intraaortic balloon pump (IABP) support.

A protocol that emphasizes reduced CPB time coupled with a recipe for rapid recovery was advocated in all patients [2]. General anesthesia was conducted with the goal of early extubation for patients who were not intubated preoperatively [8]. Our approach included midazolam (0.05 mg/kg), fentanyl (10 to 15 µg/kg), pancuronium (0.1 mg/kg), and propofol (1.5 to 2.0 mg/kg) as a continuous drip. The propofol was then weaned postoperatively within 4 hours provided that the patient was hemodynamically stable and bleeding was absent. Myocardial preservation in all cases was performed with a combination of warm induction, cold maintenance, and warm reperfusion of blood cardioplegic solutions [9]. General cardioplegia was delivered through a combination of antegrade and retrograde techniques [10].

The major operative goal for all patients was to limit the CPB time to 75 minutes or less. To achieve this, the ischemic time was not to exceed 45 minutes. At the beginning of CPB, a single dose of triiodothyronine, 10 µg, was delivered to counteract the euthyroid sick state [11–13]. During CPB, the flows were maintained at 2.3 Lmin^-1m^-2 with a pressure of 60 to 90 mm Hg. The temperature was allowed to drift to 32°C routinely; active cooling to a lower temperature was reserved for complex reconstructions.

Cardiopulmonary bypass was not initiated until all preparations were complete, so that the aortic cross-clamp could be placed immediately. A departure from this occurred when hemodynamic instability required early initiation of CPB, or in the case of redo operations when decompression of the heart further aided dissection.

After cardioplegic arrest, each distal anastomosis was performed. Conduits for myocardial revascularization included the left internal mammary artery and saphenous vein exclusively. At the completion of each distal anastomosis, additional cold blood cardioplegia was delivered through a retrograde coronary sinus catheter as the surgeon tied the suture. By the time the heart was repositioned and the next site was isolated, the infusion was completed. After completion of all distal anastomoses, the warm blood reperfusate solution was delivered and the aortic cross-clamp was released. The vein bypass grafts were then perfused individually as the proximal anastomoses were completed under partial aortic occlusion.

At this point, an additional dose of 10 µg triiodothyronine was administered, followed by titration of inotropic agents to achieve a cardiac index greater than 2.7 Lmin^-1m^-2. When in place, the IABP was activated before weaning from CPB; however, if hemodynamic indices after CPB were such that the IABP was not necessary, it was removed early postoperatively (<12 hours).

The patient was transported directly to the intensive care unit, where, in the absence of postoperative bleeding, extubation was done within 4 to 8 hours of the operation. Corticosteroids and thyroid hormone were administered postoperatively to promote recovery. Dexamethasone 4 mg was administered intravenously every 6 hours during the first 24 hours postoperatively. This low dose of steroids provided the patient with an early sense of well-being, as well as continued therapy for the generalized inflammatory response that follows CPB [14]. Thyroxine 200 µg was administered intravenously once a day during the first 2 days postoperatively.

Active diuresis was begun within 24 hours with the use of loop diuretics, provided that renal indices were normal. A blood urea nitrogen level of 20 to 25 mg/dL was targeted. The goal was to establish an early negative fluid balance so that congestive heart failure, pleural effusions, and seeping wounds would not develop. Patients with an initial postoperative serum creatinine level greater than 1.5 mg/dL received dopamine at renal dose. In addition, a low to intermediate dose of dobutamine (2.5 to 5.0 µgkg^-1min^-1) was used for 36 hours in patients with impaired left ventricular function (ejection fraction 0.40) until all extracellular fluid was satisfactorily managed.

All patients without evidence of conduction abnormalities were given digitalis postoperatively. Frequent premature atrial contractions (>6 per minute) or new-onset atrial fibrillation was treated with an intravenous loading dose of procainamide 500 to 1,000 mg over 1 hour, followed by a continuous infusion of 2 to 4 mg/min. Serum levels were followed and doses were adjusted accordingly. No patients in the series required electric cardioversion. After chemical conversion, oral procainamide (Procan SR; Parke-Davis, Morris Plains, NJ), 500 to 1,000 mg, was given every 6 hours and continued for 4 weeks. Use of the antiarrhythmic agents in this manner allowed quick treatment of new-onset atrial fibrillation, thereby avoiding delays in transfer from the intensive care unit.

After early extubation (4 to 8 hours postoperatively) and in the absence of the IABP, the patient was dangled at 12 hours postoperatively, and was given a clear liquid meal in a chair at 24 hours postoperatively. All lines and drains were then removed, and the patient was transferred to a stepdown telemetry unit. Ambulation began at 36 hours postoperatively with the supervision of a physical therapist. Patients who succeeded at unassisted ambulation without a 15% increase in heart rate or complaints of shortness of breath or dizziness were graduated to further activity [3]. Rapid convalescence was then emphasized, and progress was assessed regularly by the surgeon and clinical specialists. A disposition day was then targeted and orchestrated by the clinical social worker. Within 72 hours of discharge, all patients were seen by the surgeon for follow-up.

A database and risk assessment profile were completed retrospectively for each patient. Results are expressed as mean ± standard deviation. Comparison of continuous variables was accomplished using the t test, whereas categoric variables were compared with the ² test.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
One hundred fifty-two consecutive younger patients (<70 years) were compared with 167 consecutive elderly patients (70 years). Table 1 compares the preoperative comorbidity and operative mortality rates. The elderly group represented higher-risk patients, with a greater proportion of women (p < 0.001), as well as patients with congestive heart failure (p < 0.001) and ambulatory difficulties (p < 0.05). The elderly group also showed a trend toward a greater proportion of patients who underwent a previous coronary artery bypass operation (12% versus 9%), as well as patients with critical left main disease (13% versus 7%), decreased left ventricular function (26% versus 17%), acute myocardial infarction (26% versus 18%), and symptomatic vascular disease (20% versus 13%). On the other hand, the young patients showed a trend toward a greater proportion with a previous PTCA (29% versus 19%) as well as failed PTCA (15% versus 9%). The preoperative risk assessment using the Parsonnet scale [15] was 7.2 ± 6.2 for the younger patients and 17.7 ± 6.8 for the elderly (p < 0.001). The 30-day mortality rate for the entire series was 3.8% (12 patients). There was no statistically significant difference in the 30-day mortality rate between the groups.

Table 2 compares the intraoperative variables. On average, the elderly patients required slightly fewer bypass grafts and consequently had a shorter operation than the younger patients. A CPB time of less than 75 minutes was achieved in 80% of the patients. The aortic cross-clamp time was less than 45 minutes in 85% of the patients.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
In the managed care environment, clinical outcomes are compulsively monitored and compared with cost effectiveness. As a result, rapid recovery protocols, or so-called "fast-track" protocols, which lead to earlier discharge from the hospital, have been critical for maintaining the competitiveness of the cardiovascular group in the managed care era [2–5]. These protocols have been applied successfully to young patients with normal ventricular function. However, the success of such protocols when applied to the elderly population has not been thoroughly validated, and at some centers, there still exists reluctance in allowing elderly patients to be discharged early from the hospital.

Elements common to all rapid recovery protocols include an anesthetic protocol that permits early extubation, utilization of corticosteroids to blunt the inflammatory process that follows CPB, promotion of early return of bowel function, and rapid mobilization of the patient [3–5]. We have further expanded the protocol to include markedly reduced CPB time, perioperative administration of thyroid hormone, early identification and management of postoperative atrial fibrillation, establishment of early negative fluid balance, and aggressive use of the IABP preoperatively. Although many of these elements remain controversial and may not contribute to early discharge in young, low-risk patients, they may be of more relevance in elderly patients with an acute coronary syndrome and multiple comorbid conditions [2].

In this study, a rapid recovery protocol was applied to 167 consecutive elderly patients (70 years) and compared with 152 consecutive younger patients (<70 years). Rapid recovery with discharge before the fifth postoperative day was achieved in 19% of the elderly, in comparison with 48% of the younger patients (p < 0.001). Application of the rapid recovery protocol to the elderly patients helped expedite recovery, but not to the extent that elderly patients had an LOS as short as that achieved for the younger patients. Although the younger patients were discharged earlier after operation than the older patients (5.7 ± 5.2 versus 8.0 ± 8.5 days; p < 0.01), the elderly patients (70 years) in this series had a very short LOS [6, 7, 18].

Unusual in our series is the considerable use of the IABP, which reflects the patient population profile and the specified insertion criteria. Traditionally, the IABP has been reserved for patients who fulfill criteria for cardiogenic shock and require immediate operative intervention, or for patients who cannot be weaned from CPB [16, 17]. In this series, we placed the IABP in a broader group of patients who were at an increased risk for perioperative cardiac decompensation. The intent was to provide additional hemodynamic stability perioperatively for patients with decreased left ventricular function, and to increase the ratio of myocardial oxygen delivery to consumption for patients with an acute myocardial infarction or an accelerating coronary insufficiency syndrome. The goal was to reduce episodes of low output syndrome and subsequent end-organ dysfunction, especially in the more susceptible elderly patients.

In this series, the IABP was placed preoperatively in 50% of the patients. After coronary catheterization when the arterial sheath was still in place, a decision was made whether preoperative placement of an IABP was necessary. Of the patients who received an IABP, approximately one third required an urgent operation because of a failed PTCA, an emergency redo, or a critical left main stenosis (70%); one third had an ejection fraction of 0.40 or less; and one third had unstable angina that was refractory to intravenous anticoagulant and nitrite therapy. In our series, no patients required an emergency femoral artery cutdown for IABP placement, and the overall complication rate among 160 patients was 1.9% (3 patients).

Use of the IABP in this series is high in comparison with other published reports [16, 17]. Although many patients may have done well without a preoperative IABP, the benefit achieved for those who really needed the IABP outweighs the additional cost incurred per patient, as demonstrated by Dietl and colleagues [19]. Clearly, centers with ever-available operating suites may require substantially less reliance on the IABP for these instances of medically refractory angina. However, we believe that it is better to err on placing the IABP preoperatively than to be faced with the challenge of placing the IABP when the patient cannot be weaned from CPB. Liberal criteria for placement of the IABP preoperatively should be advocated, as controlled placement clearly reduces associated morbidity [16, 17].

Perioperative administration of thyroid hormone continues to be a controversial issue [11–13]. Triiodothyronine increases cardiac output while reducing systemic vascular resistance, with no significant change in myocardial oxygen consumption [12]. In our series, all patients received thyroid hormone. It is unclear from our data whether thyroid hormone administration significantly alters outcome or shortens hospitalization.

Atrial fibrillation can be an important cause of prolonged hospitalization and therefore must be identified and managed early. A proactive approach was used whereby all patients without evidence of conduction abnormalities were given digitalis postoperatively, and patients with frequent premature atrial contractions (>6 per minute) or new-onset atrial fibrillation were treated immediately with intravenous procainamide. We observed that by minimizing delays in establishing adequate rate control and using chemical agents for cardioversion, no patients in our series required electric cardioversion.

The overall incidence of new-onset atrial fibrillation in our series was 9.4%, which is quite low in comparison with other published reports [11]. Perioperative utilization of thyroid hormone may partly explain this low incidence of postoperative atrial fibrillation, according to a prospective study conducted by Klemperer and associates [11]. In their series, the incidence of postoperative atrial fibrillation was reduced from 46% to 24% by administering thyroid hormone perioperatively. We believe that additional factors, such as establishing an early negative fluid balance, may also contribute to our reduced incidence of postoperative atrial fibrillation.

Expeditious procedures reduce the operative time and have the dual purpose of positioning the patient for early extubation and promoting rapid transfer to a less intensive monitoring unit. A reduction in operative time has value in minimizing postoperative complications. Prolonged CPB, particularly in the elderly, is frequently associated with dysfunction of various end organs [14]. Postoperative renal insufficiency and prolonged mechanical ventilation secondary to pulmonary dysfunction are consequences of a prolonged operative procedure. Therefore, every effort should be made to simplify the operation by reducing the number of steps necessary to achieve each part, so that the total CPB time may be maximally reduced.

In our series, we targeted an ischemic time of less than 45 minutes and a CPB time of less than 75 minutes. These were achieved in at least 80% of the patients. Although these target times can be achieved more easily when fewer bypass grafts are used, no attempt was made to underrevascularize any patient. The average number of bypass grafts for the younger group of patients was 3.2, in comparison with 2.9 for the elderly. These average numbers of bypass grafts are consistent with other series [1, 3, 6, 7, 11, 18]. We believe that unnecessary overrevascularization should be discouraged because it leads to a prolonged operation with an increased risk of perioperative complications. We believe that the future of cardiac surgery will be geared toward a quicker operation with a reduced CPB time.

As demonstrated by this study, elderly patients undergoing isolated coronary artery bypass grafting perform remarkably well in an accelerated recovery program. Criteria to exclude patients on the basis of age, acuity of presentation, or comorbid conditions should be discouraged.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
We thank Pamela Dumas for her assistance.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Ott, Division of Cardiothoracic Surgery, University of California Irvine Medical Center, Building 53, Rt 81, 101 City Dr S, Orange, CA 92668.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

1. Starr A, Furnary AP, Grunkemeier GL, He GW, Ahmad A. Is referral source a risk factor for coronary surgery? Health maintenance organization versus fee-for-service system. J Thorac Cardiovasc Surg 1996;111:708–17.[Abstract/Free Full Text]
2. Ott RA, Moscoso R, Eugene J, et al. Managed care cardiac surgery in the elderly: results of the impact-recovery protocol. In: Ott RA, ed. Managed care and the cardiac patient. Philadelphia: Hanley & Belfus, 1995:203–19.
3. Krohn BG, Kay JH, Mendez MA, et al. Rapid sustained recovery after cardiac operations. J Thorac Cardiovasc Surg 1990;1001:194–7.
4. Engelman RM, Rousou JA, Flack JE III, et al. Fast-track recovery of the coronary bypass patient. Ann Thorac Surg 1994;58:1742–6.
5. Engelman RM. Mechanisms to reduce hospital stays. Ann Thorac Surg 1996;61:S26–9.
6. Katz NM, Hannan RL, Hopkins RA, Wallace RB. Cardiac operations in patients aged 70 years and over: mortality, length of stay, and hospital charge. Ann Thorac Surg 1995;60:96–101.[Abstract/Free Full Text]
7. Gehlot AS, Santamaria JD, White AL, Ford GC, Ervine KL, Wilson AC. Current status of coronary artery bypass grafting in patients 70 years of age and older. Aust N Z J Surg 1995;65:177–81.[Medline]
8. Arom KV, Emery RW, Petersen RJ, Schwartz M. Cost-effectiveness and predictors of early extubation. Ann Thorac Surg 1995;60:127–32.
9. Brown MM, Jay JL, Parker GJ, et al. Warm blood cardioplegia: superior protection after myocardial ischemia. Ann Thorac Surg 1993;55:32–42.
10. Ihnken K, Morita K, Buckberg GD, et al. Simultaneous arterial and coronary sinus cardioplegic perfusion: an experimental and clinical study. Thorac Cardiovasc Surg 1994;42:141–7.[Medline]
11. Klemperer JD, Klein IL, Ojamaa K, et al. Triiodothyronine therapy lowers the incidence of atrial fibrillation after cardiac surgery. Ann Thorac Surg 1996;61:1323–9.[Abstract/Free Full Text]
12. Klemperer JD, Ojamaa K, Klein I. Thyroid hormone therapy in cardiovascular disease. Prog Cardiovasc Dis 1996;38:329–36.[Medline]
13. Bennett-Guerrero E, Jimenez JL, White WD, D'Amico EB, Baldwin BI, Schwinn DA. Cardiovascular effects of intravenous triiodothyronine in patients undergoing coronary artery bypass graft surgery. JAMA 1996;275:687–92.[Abstract/Free Full Text]
14. Butler J, Rocker GM, Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1993;55:552–9.[Abstract]
15. Parsonnet V, Dean D, Berstein A. A method of uniform stratification of risk for evaluating the results of surgery in acquired heart disease. Circulation 1989;79(Suppl 1):3–12.
16. Creswell LL, Rosenbloom M, Cox JL, et al. Intraaortic balloon counterpulsation: patterns of usage and outcome in cardiac surgery patients. Ann Thorac Surg 1992;54:11–20.[Abstract]
17. Makhoul RG, Cole CW, McCann RL. Vascular complications of the intra-aortic balloon pump: an analysis of 436 patients. Am Surg 1993;59:564–8.[Medline]
18. Magovern JA, Sakert T, Benckart DH, et al. A prospective analysis of risk, cost, and outcome of coronary bypass in the elderly. Presented at the 32nd Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29–31, 1996.
19. Dietl CA, Berkheimer MD, Woods EL, Gilbert CL, Pharr WF, Benoit CH. Efficacy and cost-effectiveness of preoperative IABP in patients with ejection fraction of 0.25 or less. Ann Thorac Surg 1996;62:401–9.[Abstract/Free Full Text]

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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): Richard A. Ott Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ott, R. A. Articles by Tanner, T. M. Search for Related Content PubMed PubMed Citation Articles by Ott, R. A. Articles by Tanner, T. M. Related Collections Related Article