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Ann Thorac Surg 1999;67:93-98
© 1999 The Society of Thoracic Surgeons

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Original Articles

Cardiac reoperations in octogenarians: analysis of outcomes

^a Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA

Accepted for publication June 22, 1998.

Address reprint requests to Dr Blanche, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Suite 6215, Los Angeles, CA 90048

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. With the rapid growth of the elderly segment of the population, more octogenarians are referred for complex cardiac interventions, including reoperations. Data regarding the outcomes, quality of life, and long-term results after reoperative open-heart surgical procedures in octogenarians are scarce.

Methods. We retrospectively studied 113 consecutive octogenarians (mean age, 83 ± 2.6 years) who underwent reoperative cardiac procedures within a 13-year period. Coronary artery bypass grafting (CABG) was performed in 49 patients (CABG group), valvular procedures (aortic, mitral, or tricuspid valve, alone or in combination) in 35 (valve group), and combined CABG and valve intervention in 29 (combined CABG and valve group).

Results. The 30-day mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. One- and 5-year actuarial survival rates were, respectively, 85% ± 5% and 58% ± 10% for the CABG group, 78% ± 7% and 53% ± 12% for the valve group, and 69% ± 9% and 63% ± 10% for the combined CABG and valve group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in New York Heart Association class I or II postoperatively at a mean follow-up time of 2.1 ± 2.4 years. Similarly, 91%, 85%, and 80%, respectively, thought that they had an improved quality of life and were satisfied with their functional status.

Conclusions. Cardiac reoperations can be performed successfully in most octogenarians, although with an increased risk, particularly in the combined CABG and valve group. Long-term survival is acceptable with improved quality of life and functional status. However, it is possible that these results could be improved in this high-risk group of patients with earlier referral and surgical intervention, for the effective use of health care resources.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The increased life expectancy of the American population over the past few decades has resulted in a significant increase in the elderly population. There were 6.9 million persons 80 years or older in 1990, and there will be approximately 25 million by the year 2050. Currently, 1 in 35 Americans is older than 80 years, and by the year 2050 this ratio will increase to 1 in 12 [1]. These demographic changes are reflected in an increasing number of elderly people referred for cardiac operations.

Several studies [2–5] from our institution have demonstrated favorable results after open-heart operations in selected septuagenarians, octogenarians, and nonagenarians. We have demonstrated that cardiac operations can be performed with acceptable morbidity and mortality and an improved quality of life in this group of patients. However, the risks and outcomes of reoperative surgical interventions in the elderly have not been clearly defined. In the present study we determined the outcomes in patients 80 years and older who underwent cardiac reoperations and compared them with a similar cohort of patients undergoing their first open-heart procedure during the same time period.

	Patients and methods

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Between September 1983 and October 1996, 113 patients 80 years and older underwent cardiac reoperations at Cedars-Sinai Medical Center. The outcomes of these patients were compared with a group of 789 octogenarians who underwent their first open-heart procedure in the same time interval.

Patients undergoing reoperation were classified according to coronary artery bypass grafting (CABG) (n = 49, CABG group), valve intervention (aortic, mitral, tricuspid valve, alone or in combination) (n = 35, valve group), and combined CABG with valve intervention (n = 29, combined CABG and valve group). The age for the entire group ranged from 80 to 92.3 years (mean, 83 ± 2.6 years). Preoperative patient characteristics and their clinical profiles are shown in Tables 1 and 2.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
In the octogenarians cohort undergoing cardiac reoperations, there were two intraoperative deaths (4%) in the CABG group and four (14%) in the combined CABG and valve group. The in-hospital or 30-day surgical mortality rate was 8% (4 of 49) for the CABG group, 9% (3 of 35) for the valve group, and 17% (5 of 29) for the combined CABG and valve group. Postoperative complications for each group are shown in Table 5. Respiratory failure was defined as ventilatory support that was required for more than 5 days postoperatively. Renal failure was defined as the need for dialysis (temporary or permanent). Data were not sufficient for statistical analysis to accurately assess the incidence of postoperative myocardial infarction in either group. Actuarial survival for each group is shown in Figure 1. In addition 3 patients in the CABG group, 5 in the valve group, and 1 in the combined CABG and valve group are alive beyond 5 years. By comparison, the 30-day surgical mortality rate for octogenarians undergoing their first operation during the same time period was 6% (27 of 464) for the CABG group, 3% (3 of 104) for the valve group, and 10% (21 of 221) for the combined CABG and valve group. Actuarial survival for these groups is also shown in Figure 1.

View larger version (62K): [in this window] [in a new window]   Fig 1. Actuarial survival of octogenarians undergoing first operations or reoperations: (A) coronary artery bypass grafting (CABG) group survival; (B) valve group survival (Valve); (C) combined CABG and valve group survival (CABG + Valve).

Survivors of cardiac reoperations were interviewed personally or through formal and validated quality-of-life questionnaires. Ninety-one percent of patients in the CABG group, 85% in the valve group, and 80% in the combined CABG and valve group thought their condition had improved and were satisfied overall with their functional status, whereas 5%, 15%, and 5%, respectively, noted no real changes. Although limited by the number of survivors with long-term follow-up, 61% of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in NYHA functional class I or II postoperatively, whereas, 31%, 40%, and 31% respectively, were in NYHA functional class IV (Fig 2).

View larger version (25K): [in this window] [in a new window]   Fig 2. Postoperative New York Heart Association (NYHA) functional status in operative survivors stratified by type of surgical intervention. Other abbreviations as in Figure 1.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Consideration for surgical intervention in octogenarians was made on the basis of their life expectancy in terms of other disease factors. Selective criteria, which evolved over the years as experience with this group of patients accumulated, were used. These criteria excluded patients with recent cerebrovascular accidents and those with multiple organ failure as a result of cardiogenic shock. Patients with chronic or acute renal dysfunction, or both, were carefully screened, and the risk to benefit ratio was assessed individually. Every attempt was made to improve and optimize renal function preoperatively. In addition, advanced senile dementia, major psychosocial factors, or debilitating musculoskeletal disorders were considered contraindications if the potential benefits from surgical intervention were thought to be minimal.

Previous studies have identified several risk factors associated with mortality in octogenarians undergoing first-time open-heart operations and include NYHA functional class III or IV [3, 7, 9], previous myocardial infarction [9, 10, 13], triple-vessel coronary artery disease [9], depressed left ventricular ejection fraction [9, 13], chronic obstructive pulmonary disease [6, 10], higher left ventricular end-diastolic pressure [3, 10], postoperative stroke [6], preoperative intraaortic balloon pump [6, 9], congestive heart failure [6, 13], mitral valve operation [3, 13], urgency of operation [3], chronic renal disease [9, 13], peripheral and cerebrovascular disease [13], sternal wound infection [9], and female gender [13].

Although the safety and efficacy of first-time open-heart procedures in octogenarians have been well established, little is known regarding the risk factors, predictors of successful outcomes, and long-term survival for reoperations in this cohort. This issue becomes relevant, and the potential for increased morbidity and mortality may outweigh the benefits of surgical intervention. The Society of Thoracic Surgeons national data base indicates that the incidence of reoperations for CABG has increased progressively from 1.9% in 1980 to 7.0% in 1990 [15]. In contrast, it has been well documented that reoperative coronary revascularization carries a higher mortality rate than primary intervention, with a range from 3.4% to 12.5% [15, 16].

In a multicenter study, He and colleagues [16] showed that advanced age was, among others, a risk factor for reoperative CABG as well as an independent variable that correlated with operative mortality in a multivariate logistic regression analysis. The Cleveland Clinic experience with reoperative coronary revascularization identifies several independent risk factors other than advanced age. They include left main coronary artery disease, NYHA functional class III or IV, year of operation, and incomplete revascularization [17]. Other risk factors, such as long perfusion time, emergency operation, depressed left ventricular ejection fraction, previous arrhythmia, and female gender, have also been associated with increased mortality after reoperation [16].

The paucity of data regarding the appropriateness of cardiac reoperations in the elderly prompted the present study. The univariate survival analysis in this study identified several risk factors as predictors of survival in the reoperative CABG group. They include history of congestive heart failure and NYHA functional class IV. A similar analysis for the valve and the combined CABG and valve group could not be performed because of the small sample size, which precluded statistical validation.

It is clear from the present study that the 30-day surgical mortality for octogenarians undergoing reoperative interventions is substantial and is higher than that for octogenarians undergoing their first cardiac operation. This difference in survival becomes more pronounced as the interval from operation increases, perhaps reflecting the fact that the decreased survival rate is multifactorial in origin rather than purely age related. Several studies have reported a high incidence of postoperative complications in the elderly [3, 6, 8, 10], and our experience confirms these findings. The absence of postoperative renal failure in our study is surprising and cannot be adequately explained. Perhaps it represents a variable absent in those patients for whom data were available for analysis. Because postoperative renal failure (defined as the need for temporary or permanent dyalisis) has a direct impact on morbidity and mortality, it may also be a reflection of a selective preoperative criteria or careful postoperative management, or both.

Other factors have also been proposed to predispose the elderly to higher morbidity and mortality [9]. Elderly patients are usually referred for surgical intervention later in the course of their disease and have less functional reserve and an increased frequency of associated medical problems. Our group has argued that a mortality rate nearly equivalent to that of younger patients can be obtained in the older population if surgical intervention is undertaken within 24 hours of admission [14]. This aggressive approach also implies that octogenarians referred for reoperations may have better outcomes if referred for surgical intervention early rather than late in their disease course.

Given this high morbidity and mortality rate, it is necessary to justify an aggressive surgical approach for those octogenarians who require a second intervention. An improvement in functional status and acceptable long-term survival are mandatory in light of the intense scrutiny of the delivery of expensive technology under the provisions of health care reform. This issue is particularly relevant because the trend is rapidly moving toward achieving cost-effective outcomes. This increased emphasis on cost containment in health care targets the elderly segment of the population in particular, because even though they only represent 15% of the population, they use 70% of the available resources [18].

Our experience indicates that after reoperation most octogenarians have an improved quality of life, and the greatest improvement was seen in the CABG group. Sixty-one percent of patients in the CABG group, 40% in the valve group, and 38% in the combined CABG and valve group were in NYHA functional class I or II postoperatively at a mean follow-up time of 2.1 years after reoperation. Surprisingly, 31%, 40%, and 31%, respectively, were in NYHA functional class IV postoperatively, indicating poor functional recovery, perhaps because of late referral to reoperation and advanced comorbidity factors. Because reoperations in octogenarians are not a common occurrence in the overall surgical population, one should not underestimate the poor functional reserve and the propensity for complications in these patients [19]. In addition, late functional status is most likely adversely affected by concurrent medical diseases that have a direct impact on their quality of life as they approach their last decade of life.

The argument against reoperations in octogenarians can be made because the operative mortality is high, particularly in those patients requiring combined CABG and valve procedures; the actuarial survival is low; and functional recovery may not be optimal for all patients. However, in the present study, most patients survived the operation and improved after intervention, and more than half of these octogenarians are alive at 5 years. These long-term results seem acceptable when we consider that the annual mortality rate for a patient 83 years of age (the mean age of all patients in the present study) is 9.9% ± 0.7%/year, with a median expected survival of 5.9 ± 0.5 years [20]. If quality of life and functional independence are key indicators in assessing the effectiveness of any surgical intervention in the elderly, then our experience suggests that reoperation in this geriatric population can accomplish that goal. Our experience most likely represents the ongoing trend in clinical practice in the United States.

The limitations of the present study include the deficiencies of a retrospective study, the relatively small number of patients in each group, and the incomplete data for some variables analyzed, which precluded a multivariate analysis. As a retrospective study, it lacks a control group for the evaluation of an alternate type of treatment (ie, medical therapy). In addition, all valve interventions were grouped together as a single group or in combination with CABG (Table 4). This was purely arbitrary and perhaps not a representative model because patients with aortic valve disease manifest different pathophysiologic characteristics than those with mitral valve disease. For example, the impact on survival of mitral valve repair is different from that of mitral valve replacement. However, the heterogenicity of surgical procedures and the even smaller numbers of patients involved in each subgroup made an individual analysis for each procedure meaningless because of the lack of statistical power. As arbitrary as this classification may be, it perhaps provides an overview of the types of reoperations performed on octogenarians, their operative risks, and actuarial survival. The issue of cost in relation to the type of operation by age groups in our institution has previously been described [5].

We conclude that severely symptomatic octogenarians should not be denied the benefit of cardiac reoperation if they are reasonably good surgical candidates. Early reoperations applying selective criteria before clinical deterioration ensues may improve these results. These selective criteria involve careful consideration of individual clinical characteristics, risks, and potential benefits in a selective fashion independent of age. Age by itself should not be the deciding factor or form the basis for these complex decisions. It is clear that with the ongoing demographic changes, cardiologists and cardiac surgeons will be faced with an ever-increasing number of elderly patients in need of reoperative interventions. The ethical and socioeconomic implications are complex, and the decisions involving resource use and expenditures could be made more easily with increased knowledge concerning the effectiveness of this approach in the geriatric population.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We thank Susan J. Miller for secretarial assistance and Marilyn Sanders from Ortho Biotech, Inc, in the preparation of the manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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