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Ann Thorac Surg 1999;68:2129-2135
© 1999 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Cardiac surgery in octogenarians: can elderly patients benefit? quality of life after cardiac surgery

^a Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada

Address reprint requests to Dr Ross, Cardiovascular Surgery, IWK Grace Hospital, 4th Floor Link, 5850/5980 University Ave, Halifax, NS, B3J 3G9 Canada
e-mail: dross{at}iwkgrace.ns.ca

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Increasing numbers of the very old are presenting for cardiac surgical procedures. There is little information about quality of life after hospital discharge in this group.

Methods. From March 1995 to February 1997, 127 patients older than 80 years at operation (mean age, 83 ± 2.5 years; range, 80 to 92 years) were entered into the cardiac surgery database and analyzed retrospectively. The RAND SF-36 Health Survey and the Seattle Angina Questionnaire were used to assess quality of life by telephone interview (mean follow-up, 15.7 ± 6.9 months). No patient was lost to follow-up.

Results. Operations included coronary artery bypass grafting (65.4%), coronary artery bypass grafting plus valve replacement (15.8%), and isolated valve replacement (14.2%). Preoperatively, 63.8% were in New York Heart Association class IV. Thirty-day mortality was 7.9%, and actuarial survival was 83% (70% confidence interval, 79% to 87%) at 1 year and 80% (70% confidence interval, 75% to 85%) at 2 years. Preoperative renal failure significantly increased the risk of early death (relative risk, 3.96) as did urgent or emergent operation (relative risk, 6.70). In addition, cerebrovascular disease (relative risk, 3.54) and prolonged ventilation (relative risk, 3.82) were risk factors for late death. Ninety-five patients (92.2%) were in New York Heart Association class I or II at follow-up. Seattle Angina Questionnaire scores for anginal frequency (92.3 ± 18.9), stability (94.4 ± 16.5), and exertional capacity (86.8 ± 25.1) indicated good relief of symptoms. SF-36 scores were equal to or better than those for the general population of age greater than 65 years. Of the survivors, 83.7% were living in their own home, 74.8% rated their health as good or excellent, and 82.5% would undergo operation again in retrospect.

Conclusion. Octogenarians can undergo cardiac surgical procedures at a reasonable risk and show remarkable improvement in their symptoms. Elderly patients benefit from improved functional status and quality of life.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Coronary artery disease is the second leading cause of death in our society, and it increases exponentially as a function of age [1]. Approximately 2.8% of the Canadian population is 80 years of age and older [2]. The average 80-year-old has a life expectancy of 8.1 years [3]. Despite maximum medical therapy, many patients older than 80 years of age are severely symptomatic with cardiovascular disease [4]. The age 85 years and older population is the fastest growing segment of the elderly population [5]. As the proportion of people 80 years of age and older continues to increase, so will the demand for cardiac surgery. It is important, therefore, to know that cardiac operations can be performed on patients in this age group with tolerable operative risk and good long-term results [4, 6, 7]. Although several publications have documented operative results in octogenarians, there is a lack of data about quality of life in this group.

The elderly are a challenging group of patients undergoing surgical procedures. Their functional reserve capacity is diminished compared with younger patients [8], and elderly patients are more likely to have preoperative comorbid conditions [9]. Advances in cardiopulmonary bypass technique, myocardial protection, and improved perioperative care have allowed coronary artery bypass grafting and valve replacement operations to be safely offered to patients older than 80 years of age [8, 10–12]. Quality of life is an important aspect in assessing the outcome of any therapeutic intervention, particularly when invasive procedures such as cardiac operations are performed on a group such as this with limited life expectancy. Measures of functioning, morbidity, and mortality do not provide complete information about physical, functional, emotional, and mental well-being and can be supplemented by the patient’s perceptions of their recovery.

Controversy exists whether the considerable proportion of health-care resources expended on the growing minority of elderly patients represents a cost-effective approach in an attempt to maintain a meaningful quality of life [7,13]. Careful follow-up of these patients is required to continually reevaluate the benefit obtained given the increased cost of delivering health care.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From March 1995 to February 1997, at the Queen Elizabeth II Health Sciences Center in Halifax, Nova Scotia, Canada, 127 open heart operations were performed on 126 patients 80 years of age or older. During the same period, 1,951 operations were performed on patients younger than 80 years of age. All patients were reviewed at a peer review conference before being accepted for cardiac surgical procedures. Selection criteria in octogenarians did not differ from their younger cohort, except that attention was directed toward preoperative neurologic status in elderly patients (ie, clear evidence of absence of Alzheimer’s disease).

Data sources
Preoperative status, perioperative data, and postoperative complications were obtained by retrospective review of each patient’s hospital record and the Society of Thoracic Surgeons National Cardiac Database. Date of death and cause of death were obtained through hospital autopsy records, extended-care facility records, and physician records. Information was obtained through telephone interview with surviving patients, family members, or the patient’s family physician or cardiologist. Follow-up data included present functional status, social status, support systems in place, readmissions to hospital, and comprehensive quality-of-life questionnaires. Postoperative functional capacity was ranked according to the New York Heart Association (NYHA) classification system. No patient was lost to follow-up.

Questionnaires included the RAND SF-36 Item Health Survey 1.0 and the Seattle Angina Questionnaire. The RAND SF-36 has been previously well validated and is widely used [14, 15]. It examines eight general health concepts: physical functioning, bodily pain, role limitations because of physical health problems, role limitations because of personal or emotional problems, emotional well-being, social functioning, energy or fatigue, and general health perceptions. It also includes an indication of perceived change in health. The Seattle Angina Questionnaire is more sensitive to important clinical changes because it is more disease specific. It monitors five aspects of coronary artery disease: exertional capacity, anginal stability, anginal frequency, treatment satisfaction, and emotional burden. It is well standardized and has been shown to be a valid measure of quality of life in patients with coronary artery disease [16, 17]. Patients were also asked whether, in retrospect, they would have the surgical procedure again.

Statistical analysis
Data are presented as frequency distributions and simple percentages. Values of continuous variables are expressed as the mean ± the standard deviation. The life table representing freedom from death was calculated using the Blossom statistical program (Blossom, BR Cole, National Institutes of Health, Bethesda, MD). Confidence intervals (CI) at 70% were approximated from the standard error for actuarial survival estimates. The expected survival curve was calculated by the actuarial method using life tables for Canada from Statistics Canada [3]. Statistical analyses of relative risk (RR) were performed using ² analysis on Epi Info version 6.0 (Centers for Disease Control, Atlanta, GA) and StatView version 4.5 (Abacus Concepts, Berkeley, CA).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Preoperative data
The preoperative variables are listed in Table 1. The mean age at operation was 83.0 ± 2.5 years (range, 80 to 92 years). Figures 1 and 2 compare the preoperative NYHA functional class and operative urgency, respectively.

View larger version (10K): [in this window] [in a new window]   Fig 1. Comparison of preoperative New York Heart Association functional class between patients older than 80 years and younger than 80 years of age.

View larger version (13K): [in this window] [in a new window]   Fig 2. Surgical priority of patients 80 years of age and older compared with patients younger than 80 years of age. (Emerg/Salv. = emergency/salvage.)

View larger version (14K): [in this window] [in a new window]   Fig 3. Actuarial survival of the study group and of an age- and sex-matched population.

The length of stay from procedure to discharge was significantly longer in the elderly group (median, 10 days; interquartile range, 8 to 13 days) compared with the younger group (median, 7 days; interquartile range, 6 to 9 days; p < 0.001).

Risk analysis
All recorded preoperative, operative, and postoperative characteristics were analyzed for relative risk for both early death (30 days) and late death (6 months). Obesity, preoperative intraaortic balloon pump, reoperation, postoperative renal failure, and postoperative cerebrovascular accident each occurred six or fewer times in the data set and were excluded from the analyses because of low statistical power. Use of an internal mammary artery was also excluded from the analyses because of a small number of deaths resulting in low statistical power.

Renal failure and urgent or emergent procedure were significant risk factors for early death. The relative risk for renal failure was 3.96 (95% CI, 1.18 to 13.35) and for urgent or emergent procedures was 6.70 (95% CI, 1.49 to 30.18). Renal failure, cerebral vascular disease, urgent or emergent procedure, and prolonged postoperative ventilation were significant risk factors for late death. Relative risk for renal failure was 3.08 (95% CI, 1.18 to 8.07), cerebral vascular disease was 3.54 (95% CI, 1.44 to 8.69), urgent or emergent procedure was 3.68 (95% CI, 1.37 to 9.93), and prolonged ventilation was 3.82 (95% CI, 1.55 to 9.38). Preoperative cerebrovascular accident, NYHA class IV, ejection fraction less than 50%, and postoperative atrial fibrillation were not found to be significant risk factors for early or late death.

Quality of life
Mean length of follow-up was 15.7 ± 6.9 months (range, 4.7 to 27.7 months). Of the 103 patients surviving, 95 (92.2%) were in NYHA functional class I or II (Fig 4). All but one patient improved by at least one functional class after the operation.

View larger version (12K): [in this window] [in a new window]   Fig 4. New York Heart Association functional class of patients 80 years of age and older preoperatively (Pre-op) and at follow-up.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

The major limitation of this study is the relatively small number of patients compared with much larger studies in younger patients. The number of patients represented here, however, was similar to other recent studies assessing cardiac surgery in the elderly [4, 7, 10, 11, 13, 19–21]. Other potential limitations include the relatively short follow-up period and the fact that this study is from a single institution, which may introduce institutional bias in relation to patient selection, operative procedure, and postoperative management.

In the selection of our elderly patients, more attention was paid to preoperative dementia; otherwise, they were judged by the same criteria as our younger patient population. The preoperative patient characteristics in our population of octogenarians were similar to those listed in other publications [4, 9, 12]. The early mortality in this group of patients was 7.9% (70% CI, 5.4% to 11.1%), which is within the range of early mortality rates previously reported of 7% to 12.5% [4, 7, 8, 10, 20]. Elective cases had a significantly lower mortality than both urgent and emergent cases (Table 4). Patients who underwent procedures that included a mitral valve replacement had a higher mortality than those without. This difference was not found to be significant, although the number of patients undergoing mitral valve operations was very small (Table 4).

Elderly patients had a higher incidence of postoperative complications as compared with their younger cohort. Age has been shown to be a significant predictor of neurologic outcomes after coronary artery bypass grafting operations [22]. The increased incidence of strokes is expected in this age group because the elderly tend to have more advanced cerebral vascular disease, a greater incidence of cerebrovascular accidents, and more advanced aortic arteriosclerosis [7]. The frequency of neurologic complications has been previously reported to be in the range of 2% to 14% [4, 8, 10]. Atrial fibrillation was the most common postoperative complication in both patient groups, and it was significantly more common in the elderly population. Atrial fibrillation can be an important cause of prolonged hospitalization as well as readmission [22].

It has been previously reported that octogenarians tend to have a longer postoperative length of stay than younger patients. We found that in addition to elderly patients having a longer postoperative length of stay, 54 of the 127 elderly patients (42.5%) were in their home hospital before their surgical admission to our hospital (Table 6). Twenty-two (40.7%) of these patients were in the intensive care unit. If these previous admissions are taken into account, the population of patients 80 years of age and older spent a median of 22 days (interquartile range, 12 to 31 days) in hospital. Shortening this preoperative in-hospital phase would be a logical way to reduce costs.

Previous reports have shown that in spite of a relatively higher morbidity and mortality when compared with younger patients, elderly patients have an acceptable operative risk, and the long-term functional results are gratifying [10, 18]. There is a limitation of not having a control group of elderly patients who did not undergo surgical procedures, which makes the issue of mortality comparison a difficult one to adequately interpret. However, 42.5% of the elderly patients were in-hospital before their operation, suggesting that medical therapy had failed. The 2-year actuarial survival was 80% (70% CI, 75% to 85%) compared with that of the expected survival of 86.6% in an age- and sex-matched Canadian population not having an operation, suggesting that elderly patients having cardiac operations have an increased but acceptable mortality.

In addition to survival, patient perceptions of recovery can help to provide more complete information of medical outcomes. A general quality-of-life questionnaire, such as the RAND SF-36, when combined with a disease-specific quality-of-life questionnaire, such as the Seattle Angina Questionnaire, takes into account all measures of physical, emotional, and health-related quality of life. Those patients who had coronary artery bypass grafting operations were, generally, very satisfied with their treatment and had stable and infrequent anginal symptoms if symptoms were present. This suggests that their limited functional capabilities and low vitality seen in their RAND SF-36 scores could likely be related to other health problems or to the aging process itself. Overall, most patients stated that their coronary artery disease did not affect their enjoyment of life.

At follow-up, 87 patients (83.7%) were living in their own home (Table 6), and although patients had more support systems in place postoperatively, 37 patients (35.6%) were completely independent. Eighty-five patients (82.5%) said they would undergo cardiac surgical procedures again, in retrospect, and 77 patients (74.8%) rated their present health as excellent, very good, or good. These results are similar to previous reports of self-rated health in elderly patients [8, 23]. Global health concepts have been validated as good predictors of mortality [24].

Elderly patients tend to have a lack of functional reserves and an increased presence of chronic medical diseases. These patients also tend to have a higher NYHA class and a higher surgical priority than patients younger than 80 years of age (Figs 1 and 2). These findings suggest that patients 80 years of age or older referred for cardiac operation seem to have more advanced ischemic disease when compared with younger patients [6].

Cardiac operations can be performed in octogenarians with acceptable morbidity and mortality. This group benefits from improved functional status and quality of life after surgical procedures. The increase in postoperative complications and length of stay reflects the increased fragility of the organ systems in the elderly and emphasizes the need for anticipation of these events so they can be identified and managed early [18]. Earlier referral for operation, particularly in those already hospitalized, should be encouraged both for the patient’s benefit and to reduce costs. There is an important need to determine the risk factors in octogenarians undergoing cardiac operations. It is possible that the same risk factors associated with increased mortality in younger patients, which included age, do not extrapolate to the elderly population. Once important risk variables are defined, objective criteria can be established to select elderly patients for operations and to redefine the preoperative and postoperative care of these patients.

	Acknowledgments

 
Funding was supplied by the Burroughs Wellcome Summer Research Studentship. The RAND SF-36 Health Survey 1.0 was supplied by Ron D. Hays, C.D. Sherbourne, and R.M. Mezel, Santa Monica, CA (RAND, 1992. Used by permission). The Seattle Angina Questionnaire (copyright ©1993, John Spertus; all rights reserved), was reproduced with permission of the Medical Outcomes Trust. We thank Paul MacDonald, MD, of Cape Breton Regional Hospital, and Jill Cossett, of the Queen Elizabeth II Health Sciences Centre, for their assistance. Thanks to Christopher T. Naugler, BScH, MD, MSc, and Karen Buth, MSc, for their help as consultant statisticians and with editing.

	References

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