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Ann Thorac Surg 2000;69:1048-1051
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: CARDIOVASCULAR

Hypothermic circulatory arrest in octogenarians: risk of stroke and mortality

^a Division of Cardiac Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA

Address reprint requests to Dr Redmond, Division of Cardiac Surgery, Johns Hopkins Hospital, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

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Background. The proportion of patients in their ninth decade of life undergoing complex cardiovascular procedures has increased over the past decade. The purpose of this study is to quantify the potential for stroke and mortality associated with deep hypothermic circulatory arrest (DHCA) in this age group.

Methods. At our institution, 251 adult patients had cardiovascular procedures that required DHCA since 1989. This included 20 patients 80 years of age or older (group I) and 231 patients less than 80 years (group II). Additionally, we analyzed 632 patients 80 years of age or older who underwent a variety of cardiovascular procedures since 1989 that required cardiopulmonary bypass but not DHCA (group III). Neurologic outcomes have been maintained in our database prospectively since 1991.

Results. The 30-day mortality in group I was 5%, in group II 15.2%, and in group III 8.2%. The stroke rate was 20% in group I, 8.8% in group II, and 6.5% in group III.

Conclusions. DHCA can be performed with acceptable early mortality in patients in their ninth decade of life, but they are at an increased risk of stroke. Follow-up shows satisfactory late survival.

	Introduction

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It is anticipated that 6.2% of the population of the United States will be over 80 years of age by the year 2000 [1]. Those aged 80 years have a life expectancy of 8.1 years [1]. This aging of the population and improvements in outcomes after cardiovascular procedures have resulted in an increase in referrals of elderly patients to be considered for complex surgical intervention [2]. In our practice at Johns Hopkins Hospital, we have been referred an increasing number of patients over 80 years of age for cardiovascular procedures requiring deep hypothermic circulatory arrest (DHCA).

Over the past 10 years, there have been many reports describing the operative morbidity and mortality in octogenarians undergoing coronary artery bypass grafting [3–5]. However, to date, there has been a paucity of data regarding the outcomes after DHCA, specifically in this patient population. Therefore, we reviewed our experience with these patients.

	Material and methods

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Data for this study were obtained from our computerized databases at Johns Hopkins Hospital, which include all patients undergoing cardiovascular procedures at our institution. The study population consisted of a consecutive series of patients 80 years of age or older (octogenarians) undergoing procedures requiring cardiopulmonary bypass (CPB) and DHCA from January 1989 to January 1999. There were 20 such patients identified (group I). The diagnosis, operative procedure, operative status, and outcomes for group I patients are presented in Table 1. Over the same time period, two other groups were identified for comparison: 231 patients below the age of 80 years who underwent cardiovascular procedures that involved DHCA (group II), and 632 octogenarians who underwent cardiovascular procedures that required CPB without the need for DHCA (group III).

Surgical technique
All patients were operated on using standard CPB techniques. Deep hypothermic circulatory arrest was instituted using a standardized protocol of core-cooling on cardiopulmonary bypass for 30 to 40 minutes, with final arterial inflow temperature of 13°C. Steroids were administered and ice packs were placed on the patient’s head during cooling. Antegrade or retrograde cerebral perfusion has been used more recently at the discretion of the individual surgeon. Eleven patients in group II (4.7%) and 1 patient in group I (5%) underwent retrograde cerebral perfusion. Two patients in group II and none in group I underwent selective antegrade cerebral perfusion.

Data analysis
Data are presented as frequency distributions and percentages. Continuous variables are expressed as mean ± standard deviation of the mean. To compare groups, univariate analysis of selected variables was performed using a two-tailed Student’s t test. Multivariate analysis for stroke risk in group I was performed using the regression equation:

where Y = stroke, X₁ = age, X₂ = DHCA time, X₃ = CPB time, X₄ = lowest temperature, X₅ = aortic cross-clamp time, X₆ = concomitant CABG procedure, and X₇ = status of the procedure (elective vs nonelective). CABG was coded 1 if present and 0 if not; the status of the procedure was coded 1 if elective and 0 if other. Statistical significance was assumed at a p value less than 0.05. Group I actuarial survival was calculated by the Kaplan-Meier method.

	Results

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Mortality
Mortality data are summarized in Table 2. The demographic and operative data assembled to evaluate the risk of death are presented in Table 3. Patients in groups I and III were of similar age and significantly older than patients in group II. Circulatory arrest and CPB times were similar in groups I and II. The CPB times were significantly longer in groups I and II than in group III (p = 0.02). There was a similar proportion of elective versus nonelective cases in all groups.

There were two additional deaths within 1 year of surgery in group I: one from complications of endocarditis and another from pneumonia. There were five late deaths at an average of 3.2 years (range 1 to 7 years). One patient died of lung cancer, 2 died of congestive heart failure, and 2 died of unknown causes. There are 9 patients currently alive at a mean of 2.9 years (range 0.5 to 10 years). The mean actuarial survival rate of group I is 4.41 years (95% CI 2.30 to 6.53). Two patients were lost to long-term follow-up.

Stroke
The incidence of stroke in all three groups is presented in Table 2. In group I, 4 patients had a stroke (20%). The stroke rate in group II was 8.8% (18 of 203) and in group III was 6.5% (32 of 495). The demographic and operative data available to assess the risks related to stroke are presented in Table 4. The findings were similar to those determined in the mortality data sets (Table 3).

Within group I, none of the independent variables analyzed using univariate analysis significantly affected the risk of stroke (Table 5). Because 3 of the 4 patients who had stroke in group I underwent concomitant CABG, we further examined the relationship of CABG and stroke within our three groups (Table 6). In group I, 7 patients underwent CABG as part of their operative procedure (35%), and in this subset, there were three strokes (43%). In group II, 51 patients underwent CABG (25%) with a stroke risk of 5.9%. In group III, 81% underwent CABG, with a stroke risk of 7%.

	Comment

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Our results indicate that octogenarians undergoing procedures involving DHCA have a low early mortality of 5%, which compares favorably with a mortality of 8.2% for octogenarians undergoing cardiac procedures involving CPB only and 15.2% for younger patients undergoing DHCA.

The incidence of stroke after procedures involving DHCA is significantly higher in the octogenarian group compared with both other groups. The higher incidence of stroke in group I compared with group II may be explained on the basis of age, as we have previously demonstrated that age over 70 years is a risk factor for stroke in cardiac operations [6]. The higher stroke rate in group I compared with group III (similar age) may be explained by the longer cross-clamp and cardiopulmonary times in the former group, both of which are predictive of stroke after cardiac surgery [7]. The association of coronary artery bypass grafting with stroke in group I suggests that the atherosclerotic coronary artery disease may be a marker of both intracranial and extracranial carotid artery disease, resulting in a higher incidence of stroke. However, there is no apparent correlation between coronary artery disease and stroke in groups II and III.

Follow-up of hospital survivors in this study demonstrates that these patients are still at risk for pulmonary and neurologic events impairing their long-term survival. The actuarial survival of 40% at 6 years compares favorably with the 32.8% 6-year actuarial survival reported by Cane and associates for octogenarians undergoing isolated CABG [3] and with the 53% actuarial survival for octogenarians undergoing open heart surgery without DHCA reported by our group previously [8]. Our present study confirmed a satisfactory independent and ambulatory existence for patients alive at the time of follow-up, which is again in accordance with our previous quality of life study in octogenarians [8].

While the favorable mortality in octogenarians in this study supports the use of DHCA in these patients, we believe the higher stroke rate mandates selective use of the technique. In our practice, we have not defined any absolute contraindications to the use of DHCA specific to this age group. However, the anticipated benefit of reducing the risk of stroke by replacing a heavily diseased ascending aorta or aortic arch in octogenarians may be offset by the increased risk of postoperative stroke after the use of DHCA in this age group.

	References

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1. National Center for Health Statistics. Vital Statistics of the United States, 1989. Washington, DC: U.S. Government Printing Office, 1992:11.
2. Peterson E.D., Cowper P.A., Jollis J.G., et al. Outcomes of coronary artery bypass graft surgery in 24,461 patients aged 80 years or older. Circulation 1995;92:85-91.[Abstract/Free Full Text]
3. Cane M.E., Chen C., Bailey M.B., et al. CABG in octogenarians. Ann Thorac Surg 1995;60:1033-1037.[Abstract/Free Full Text]
4. Tsung-Po T., Nessim S., Kass R.M., et al. Morbidity and mortality after coronary artery bypass in octogenarians. Ann Thorac Surg 1991;51:983-986.[Abstract]
5. Talwalkar N.G., Damus P.S., Durban L.H., et al. Outcome of isolated coronary artery bypass surgery in octogenarians. J Card Surg 1996;11:172-179.[Medline]
6. McKhann G.M., Goldsborough M.A., Borowicz L.M., Jr, et al. Predictors of stroke risk in coronary artery bypass patients. Ann Thorac Surg 1997;63:516-521.[Abstract/Free Full Text]
7. Cernaianu A.C., Teimouraz V.V., Flum M.M., et al. Predictors of stroke after cardiac surgery. J Card Surg 1995;10:334-339.[Medline]
8. Kumar P.B.M., Zehr K.J., Chang A., et al. Quality of life after open heart surgery. Chest 1995;108:919-926.[Abstract/Free Full Text]

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