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Ann Thorac Surg 1999;67:1104-1110
© 1999 The Society of Thoracic Surgeons

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Original Articles

601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups

^a Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA

Accepted for publication November 4, 1998.

Address reprint requests to Dr Puskas, Emory Clinic, 550 Peachtree St, NE, Suite 7700, Atlanta, GA 30365

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Cardiac valve replacement and coronary artery bypass graft surgery (CABG) are being applied with increasing frequency in patients 80 years of age and older.

Methods. Six hundred one consecutive patients older than 80 years, undergoing cardiac surgery between 1976 and 1994 (CABG with saphenous vein graft, 329 [54.7%]; CABG with left internal mammary artery, 101 [16.8%]; CABG + valve, 80 [13.3%]; isolated aortic valve replacement, 71 [11.8%]; isolated mitral valve replacement, 18 [3.0%]), were studied retrospectively to assess short- and long-term survival. They were compared with 11,386 patients aged 60 to 69 years and 5,698 patients aged 70 to 79 years undergoing similar procedures during the same time interval.

Results. In comparison with patients 60 to 69 years old, more octogenarians were women (44.4% versus 25.6%, p < 0.0001), had class IV angina (54.1% versus 38.9%, p < 0.0001), and had congestive heart failure class IV (4.9% versus 3.0%, p = 0.0001). In-hospital death rates (9.1% versus 3.4%, p < 0.0001) and stroke (5.7% versus 2.6%, p < 0.0001) reflected these adverse clinical risk factors. However, Q-wave infarction tended to be less frequent (1.5% versus 2.6%, p = 0.102). Interestingly, hospital mortality (9.1% versus 6.7%, p = 0.028) was only slightly increased, and stroke (5.7% versus 4.7%, p = 0.286) was not more common in octogenarians than in patients 70 to 79 years old. Late-survival curves have similar slopes for the first 5 years in all clinical subgroups. However, after 5 years there is a more rapid decline in octogenarians than in younger age groups. Median 5-year survival was 55% for patients older than 80 years, 69% for patients 70 to 79 years, and 81% for patients 60 to 69 years old.

Conclusions. When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and excellent 5-year survival.

	Introduction

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Continued refinements in cardiac anesthesia, surgical technique, and myocardial preservation, coincident with a broad demographic trend toward a more aged population and the use of percutaneous transluminal coronary angioplasty in younger patients, have led to the application of cardiac surgical procedures with increasing frequency in octogenarians. Octogenarians constitute 3% of the American population; the average 80-year-old patient is expected to survive for at least 8 years [1]. As many as 40% of all octogenarians have symptomatic cardiovascular disease, and a significant number of these may benefit from surgical therapy [2]. Reported series of limited size have suggested that good results can be achieved with cardiac surgery in octogenarians [3]. The purpose of the present report is to analyze the Emory University experience with cardiac surgery in a large group of octogenarians and to compare these with results in younger patient subsets.

	Patients and methods

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Patients
Between 1976 and December 31, 1994, 601 patients 80 years of age or older (80) underwent cardiac surgical procedures at Emory University Hospitals, Atlanta. Demographic and clinical outcome data were entered prospectively into a dedicated, computerized database and were reviewed. Data for the octogenarians were compared retrospectively with those for 11,386 patients aged 60 to 69 years (hexagenarians) and 5,698 patients aged 70 to 79 years (septuagenarians) undergoing similar procedures at our institutions during the same interval. Demographic date included patient age and sex, admitting diagnosis, and the presence of cardiac risk factors including hypertension, diabetes mellitus, and cigarette smoking. Items of the cardiac history recorded included the severity of angina pectoris (Canadian Cardiovascular Society classification) and congestive heart failure (New York Heart Association classification). Patients who had multiple cardiac surgical procedures at Emory during their lifetimes were included in the data analysis of in-hospital events for each surgery, but were included in the survival curve analysis for only their first surgery.

Cardiac catheterization results, including degree and distribution of coronary artery stenoses and left ventricular ejection fractions, were recorded. The priority of each operation (elective versus urgent versus emergent) was graded according to the Society of Thoracic Surgeons classification. Urgent operations were defined as those performed on patients with an evolving infarction, or with failed transluminal coronary angioplasty with on-going ischemia, or patients requiring intravenous nitroglycerin or heparin, or intraaortic balloon pump (IABP) counterpulsation. Emergent cases were defined as those in which hemodynamic instability persisted preoperatively, despite all available medical measures; these included patients for whom cardiopulmonary resuscitation or defibrillation was performed in or en route to the operating room.

The selection of octogenarian candidates for cardiac operations at Emory has been at the discretion of individual referring physicians, cardiologists, and surgeons. Routine assessment of cardiac function by history, catheterization, and echocardiography must be supplemented by appropriate objective measures of comorbid disease, including pulmonary function tests for dyspneic patients and carotid duplex studies for patients with bruits or symptoms of transient ischemic attacks or cerebrovascular accidents. Patients with forced expiratory volume in 1 second less than 1000 mL after optimal medical therapy for chronic obstructive pulmonary disease are usually refused cardiac surgery. Asymptomatic carotid lesions tighter than 80% and symptomatic lesions tighter than 70% are usually managed by staged carotid endarterectomy under local anesthesia followed 48 hours later by the cardiac surgery. Very important in selecting octogenarians for cardiac surgery is the surgeon’s subjective impression after interviewing and examining the patient. Family history of longevity, general level of fitness and activity, intellectual function, and "fighting spirit" are important predictors of outcome that cannot be easily quantified or reported.

Care of octogenarian cardiac patients
Meticulous preoperative and postoperative care, including aggressive early mobilization, is mandatory to minimize complications and shorten postoperative stay. Perioperative arrhythmias are treated prophylactically in all octogenarians with digoxin and low-dose ß-blockade begun immediately postoperatively unless there is some contraindication. Nephrotoxic drugs are avoided when selecting prophylactic antibiotics. Central venous catheters are removed as soon as possible to avoid sepsis. Enteral feeding is begun early postoperatively and is used liberally. With the selection criteria and management techniques described in Methods above, 76.9% of the 601 octogenarians in our series had an uncomplicated postoperative course.

The operative technique varied during this interval and between surgeons with respect to cardioplegia composition, route, and temperature, and techniques of perfusion, ischemic arrest, and left ventricular venting. All distal coronary artery anastomoses were sewn with running 6-0, 7-0, or 8-0 Prolene (Ethicon, Somerville, NJ). Valve choice was based on surgeon’s preference. Perioperative myocardial infarction was defined as a new Q wave on the postoperative electrocardiogram. Operative mortality was defined as occurring within 30 days of surgery or in-hospital. Respiratory complications included development of pneumonia or adult respiratory distress syndrome and prolonged ventilatory support greater than 1 week. Other complications included the occurrence of stroke, transient neurologic event, excessive bleeding requiring reoperation, sternal wound infection or dehiscence, and the incidence of atrial and ventricular arrhythmias requiring treatment.

All data were prospectively collected and entered into a computerized database. Data are displayed as a percent or mean ± standard deviation as appropriate. Categorical variables were compared by ² and continuous variables were analyzed by analysis of variance. When data are displayed by decade, p values refer to the total trend in the population by decade. Long-term survival was determined for the whole population (in-hospital deaths and survivors) by the Kaplan-Meier method [4]. Statistical testing was performed with BMDP (BMDP Statistical Software, Inc., Los Angeles, CA) and SAS (SAS Institute, Inc., Cary, NC) statistical software. Follow-up information was obtained by telephone, mail, or interview and was 84.6% complete for all groups and 89.2% complete for the octogenarian group.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Preoperative clinical profile of the three age groups
The preoperative clinical profile of the three groups is depicted in Table 1. In comparison with the patients aged 60 to 69 years, more octogenarians were women (44.4% versus 25.6%, p < 0.0001), had class IV angina (54.1% versus 38.9%, p < 0.0001), and had congestive heart failure class IV (4.9% versus 3.0%, p < 0.0001). However, preoperative requirement for intraaortic balloon pump (IABP) counterpulsation was not different (3.9% versus 3.7%). Importantly, octogenarians had a lower left ventricular ejection fraction (53.3% ± 13.3% versus 56.2% ± 14.7%, p = 0.0001) and were more likely to require emergency cardiac surgery (10.9% versus 7.2%, p < 0.0001). By contrast, fewer octogenarians had been smokers (38.4% versus 59.2%, p < 0.001), had diabetes (15.1% versus 21.0%, p < 0.004), had suffered previous myocardial infarction (40.6% versus 46.9%, p = 0.009), or had undergone prior cardiac surgery (6.5% versus 9.6%, p = 0.031).

Operative procedures
Consistent with demographic and practice trends throughout the United States, the proportion of cardiac surgical patients at Emory who were octogenarians increased steadily during the study period, from 0% in 1976 to approximately 8% of the annual total in 1994 (Fig 1). The operative procedures are summarized for each age group in Tables 2 and 3. Within the group of octogenarians, 430 (71.5%) had only coronary artery revascularization (CABG), of which 329 (54.7%) were revascularized exclusively with saphenous vein grafts (CABG-SVG), 101 (16.8%) had a left internal mammary artery graft (CABG-LIMA, almost always in conjunction with saphenous vein grafts), and 79 (13.2%) had CABG with valve replacement (Table 2). Isolated aortic valve replacement (AVR) was performed on 71 octogenarians (11.8%), and 18 (3.0%) had isolated mitral valve replacement (MVR) (Table 3). Valves implanted are shown for each age group in Table 4. Previous cardiac surgery had been performed in 6.5% of octogenarians, 9.8% of septuagenarians, and 9.6% of hexagenarians.

View larger version (13K): [in this window] [in a new window]   Fig 1. Percentage of total cardiac patients 80 years of age or older. Octogenarians accounted for 8% of all cardiac surgical patients in 1994.

Survival curves
The 546 octogenarian operative survivors were followed up for a mean of 2.8 ± 2.4 years. For all procedures, actuarial survivals of 75% at 2 years, 55% at 5 years, and 12% at 10 years were achieved by octogenarians, with a median survival of 5.5 years in this group (Fig 2). Patients aged 70 to 79 years had 2-, 5-, and 10-year survivals of 83%, 69%, and 35%, respectively, with a median survival of 7.9 years. Those aged 60 to 69 years had 2-, 5-, and 10-year survivals of 90%, 81%, and 58%, respectively, with a median survival of 11.2 years. Survival curves for all three age groups are presented in Figures 3 through 8 for each specific procedure performed. In each set of survival curves, the slopes are similar among groups for the first 5 years after discharge from hospital. Thereafter, the octogenarian curves decline more rapidly than those for the younger age groups.

View larger version (19K): [in this window] [in a new window]   Fig 2. Survival for all patients. Median survival was 5.5 years for octogenarians. The slopes of survival curves were similar for all three groups for the first 5 years after discharge. Thereafter, the octogenarian curve declined more rapidly than those for younger age groups.

View larger version (20K): [in this window] [in a new window]   Fig 3. Survival curves for those patients undergoing coronary revascularization with saphenous vein grafts (CABG-SVG).

View larger version (19K): [in this window] [in a new window]   Fig 4. Survival curves for those patients undergoing coronary revascularization with a left internal mammary artery graft (CABG-LIMA).

View larger version (19K): [in this window] [in a new window]   Fig 5. Survival curves for those patients undergoing an aortic valve replacement (AVR).

View larger version (20K): [in this window] [in a new window]   Fig 6. Survival curves for those patients undergoing a mitral valve replacement (MVR).

View larger version (22K): [in this window] [in a new window]   Fig 7. Survival curves for those patients having a combined aortic valve replacement and coronary revascularization (CABG-AVR).

View larger version (21K): [in this window] [in a new window]   Fig 8. Survival curves for those patients having a combined mitral valve replacement and coronary revascularization (CABG-MVR).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Our overall perioperative mortality of 9.1% in 601 patients older than 80 years undergoing cardiac surgical procedures compares favorably with those reported from other authors [10–15]. Mortality from isolated elective CABG and AVR were 6.6% and 5.7%, respectively. This suggests that advanced age alone is not associated with an excessive operative risk and that these operative procedures can be safely performed in selected octogenarians with correctable lesions.

Octogenarians who had CABG with LIMA (virtually always in combination with one or more saphenous vein grafts) had a significantly lower operative mortality (2.3%) than octogenarians having elective CABG with saphenous vein grafts alone (8.2%). This significant difference was borne out over time: octogenarians had 79% 2-year and 61% 5-year survivals after elective CABG-LIMA (Fig 4) compared with 74% and 53% 2- and 5-year actuarial survivals after elective CABG-SVG (Fig 3). The origins of this difference are unclear. A strong selection bias may be responsible in part for the observed difference. Emergent operations with a much higher perioperative mortality risk comprised a higher percentage of CABG-SVG (16.6%) than CABG-LIMA (7.1%) in octogenarians. The clinical profile of octogenarians who had CABG-SVG versus CABG-LIMA is shown in Table 9. Patients chosen to have CABG-LIMA tended to be better surgical candidates by a variety of criteria, but only the incidence of preoperative IABP and emergency operation reached statistical significance.

Interestingly, although MVR and CABG-MVR carried the highest risk of any operation (octogenarians had an operative mortality of 16.7% for MVR and 33.3% for CABG-MVR), these were not significantly higher than for septuagenarians or hexagenarians. These results in particular compare favorably with other reported series [10, 11]. Indeed, other authors have suggested that MVR has a limited role in the octogenarian population [11]. Our data also suggest that mitral valve surgery in this age group should be considered a higher risk procedure.

When compared with elective procedures, patients in each age group having emergency operations had a three-fold increased mortality. Unfortunately, there is a widespread reluctance to consider surgical therapy in the octogenarian until medical therapy has been exhausted, at which point the patient is often a relatively poor surgical candidate. It is possible that a more aggressive approach, like that taken in younger patients, to correct the disease process earlier during a period of stability might result in a higher overall rate of success in the octogenarian population [11].

Six hundred one consecutive octogenarians undergoing cardiac surgery are reported. The overall surgical mortality was 9.1%. Mortality rates for specific procedures were as follows: elective CABG-SVG, 8.3%; elective CABG-LIMA, 2.3%; isolated AVR, 5.7%; AVR + CABG, 9.7%; and isolated MVR, 16.7%. In comparison with the patients aged 60 to 69 years, more octogenarians were women, had class IV angina, and had congestive heart failure class IV. In-hospital death and stroke rates reflected these adverse clinical risk factors. Q-wave infarction tended to be less frequent, however. Interestingly, hospital mortality was not more common in octogenarians than in septuagenarians. The long-term results in octogenarians after cardiac surgical procedures have been encouraging. The slope of survival curves are similar for the first 5 years in all three age groups. However, after 5 years there is a more rapid decline in octogenarians than in younger age groups. When appropriately applied in selected octogenarians, cardiac operations can be performed with acceptable mortality and excellent 5-year survival.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
The authors gratefully acknowledge the indispensable support and assistance of Carolyn Wright, MS, Sandra M. Ruffing, MEd, and Lisa Satterwhite, Med Asst.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

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