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Ann Thorac Surg 2000;69:1140-1145
© 2000 The Society of Thoracic Surgeons

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ORIGINAL ARTICLES: CARDIOVASCULAR

Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups

^a Division of Cardiac Surgery, Department of Surgery, Washington Hospital Center; MedStar Research Institute, Washington, DC, USA

Address reprint requests to Dr Corso, Washington Hospital Center, 106 Irving St NW, Suite 316 South Tower, Washington, DC 20010
e-mail: pjc{at}mhg.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Octogenarians have higher morbidity and mortality rates (9% to 16%) after coronary artery bypass grafting with cardiopulmonary bypass, compared with younger patients.

Methods. We compared the perioperative outcome and hospital stay after coronary artery bypass grafting without cardiopulmonary bypass (off-pump) from January 1987 to May 1999, among patients older than 80 years (n = 71), patients between 70 and 79 years (n = 228), and patients whose age ranged from 60 to 69 years (n = 296). In comparison with younger patients, more octogenarians were female (51% versus 39% in patients aged 70 to 79 years and 35% in those aged 60 to 69 years, p = 0.04), they had previous myocardial infarction more frequently (48% versus 47% versus 34%, respectively, p = 0.008), and were operated on urgently (69% versus 56% versus 52%, respectively, p = 0.04).

Results. Postoperative complications that were significantly higher in octogenarians compared with younger groups included pneumonia (6% in octogenarians versus 2% in patients aged 70 to 79 years and 0% in patients aged 60 to 69 years, p = 0.001) and atrial fibrillation (47% versus 32% versus 21%, respectively, p < 0.001). By multivariate logistic regression analysis, age over 80 years was an independent predictor of prolonged hospital stay (odds ratio = 2.7, 95% confidence interval, 1.4 to 5, p < 0.001). The in-hospital mortality rate was higher in octogenarians (6% versus 3% for 70 to 79 year-olds and 0.3% for 60 to 69 year-olds, p = 0.006).

Conclusions. When appropriately applied in patients older than 80 years, off-pump coronary artery bypass grafting can be done with acceptable postoperative morbidity, mortality, and hospital stay.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Longer life expectancy in patients 80 years old or older [1] has led to increased incidence of cardiovascular disease and a concomitant upsurge in the number of cardiac operations in this age group [2–4]. Recent studies have demonstrated improved outcomes in terms of morbidity and mortality rates in elderly patients who have coronary artery bypass operations with cardiopulmonary bypass (on-pump), compared with results of a decade ago [5–7]. Improvements in cardiac anesthesia, surgical techniques, and postoperative treatment have contributed significantly to these favorable results [8–12].

The current trend toward minimally invasive cardiac operations has particular implications for high-risk patients, such as the very elderly. Coronary artery bypass grafting without cardiopulmonary bypass (off-pump CABG) could benefit octogenarians [7]. Lower stroke rates and improved perioperative outcomes have been reported after off-pump CABG compared with on-pump techniques [7]. Moreover, octogenarians are more likely to have atherosclerosis of the ascending aorta, which could result in migration of atheromatous microemboli in the brain during aortic cannulation and thus cause neurologic deterioration shortly after on-pump CABG [11]. In the present study, we compared perioperative morbidity, mortality, and hospital length of stay after off-pump CABG in patients older than 80 years with those in younger age groups.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
The computerized database of the Division of Cardiac Surgery of the Washington Hospital Center was used to identify all patients who had off-pump CABG between January 1987 and May 1999. During the study period, 993 patients had off-pump CABG. Data from patients 80 years old or older (n = 71, 7%) were compared with those from patients 70 to 79 years old (n = 228, 23%) and 60 to 69 years old (n = 296, 30%). Patients younger than 60 years (n = 389, 39%) were not included in the study. Baseline demographics, procedural data, and perioperative outcomes were recorded according to prespecified data entry forms. Data were analyzed according to The Society of Thoracic Surgeons National Cardiac Surgery Database guidelines and definitions (www.ctsnet.org/doc/230). Significant atherosclerosis of the ascending aorta was defined as operator-identified diffuse irregularities, ulcerated plaques, large mobile or protruding atheromata, thrombi, or circumferential involvement of most or all of the ascending aorta were present.

Selection criteria
Indications for off-pump CABG included patients who were considered high risk for on-pump CABG because of medical comorbidities such as renal failure, diffuse cerebrovascular and peripheral vascular disease, aortic atherosclerosis, chronic obstructive pulmonary disease, and religious convictions that precluded blood transfusions. Whenever accuracy or patency of distal anastomosis was in doubt because of fair-sized vessels on the back of the beating heart, on-pump CABG was done.

Surgical techniques
Surgical approaches were median sternotomy or minimally invasive direct coronary artery bypass (MIDCAB) through a left anterior thoracotomy or left posterolateral thoracotomy. Major indications for MIDCAB included isolated disease of the proximal or mid-left anterior descending artery or first diagonal. If more than three vessels were diseased, a median sternotomy approach was favored. Major indications for left posterolateral thoracotomy included stenosis and regrafting of the circumflex arterial system. The three off-pump surgical techniques are briefly described below.

Minimally invasive direct coronary artery bypass
A left anterolateral thoracotomy approach was used. After a 6- to 9-cm incision was made, the fourth intercostal space was entered without removing the rib. The costal cartilage was not excised routinely. The left internal mammary artery was harvested under direct vision from the fifth intercostal space to the left subclavian vein, then it was clipped and divided. The pericardium was incised near the internal mammary artery pedicle and parallel to the midline and was suspended by traction sutures. After the diseased artery was located, a silicone elastomer suture bolstered with a pledget encircling the entire artery, epicardial fat, and veins was placed proximally to the anastomotic site to achieve temporary coronary artery occlusion. No ischemic preconditioning was used for myocardial protection. A compression stabilizer (CardioThoracic Systems Inc, Cupertino, CA) was used to stabilize the coronary artery. The anastomosis was done using continuous 7-0 Prolene sutures (Ethicon, Somerville, NJ). A blower device (Aries CO₂ Blower, CardioThoracic Systems Inc, Cupertino, CA) was used to keep the field clear of blood and the incised edges of the coronary artery separated during the anastomosis. After the anastomosis was completed, the internal mammary pedicle was fixed to the epicardium with three 6-0 silk sutures.

Median sternotomy
After a median sternotomy, the left internal mammary artery was harvested using a specialized internal mammary artery access retractor (Rultract; Rultract, Inc, Cleveland, OH). Two or three lap tapes or, alternatively, a glove injected with normal saline via a Foley catheter, was placed beneath the left ventricle to bring the left anterior descending, first diagonal, or ramus marginal artery to the surface and achieve better exposure. Distal anastomoses were done as in the MIDCAB technique using the same compression stabilizer. The inferior and posterolateral arteries were approached using pericardial traction sutures placed anterior to the pulmonary veins and fixed to the drapes on the patient’s left side. Two traction sutures were placed through the acute margin of the right ventricle to approach the right coronary arteries.

Posterolateral thoracotomy
Single-lung ventilation, lateral decubitus positioning of the patient, and a fifth intercostal space approach were used as appropriate. After retraction of the lung, the pericardium was opened posterior to the phrenic nerve. The radial artery or saphenous vein were used as conduits. The proximal anastomosis was usually placed on the descending thoracic aorta with this approach.

Anesthesia and intraoperative monitoring
Routine hemodynamic, electrocardiographic, and arterial blood gas monitoring was done during the procedure. Heparin, in a bolus dose of 10,000 IU intravenously, was administered routinely to all patients. Activated clotting time was kept at a range of 300 to 350 seconds. Before the anastomoses were done, lidocaine and magnesium were administered routinely to all patients. Intercostal blocks with bupivacaine were used to achieve pain control after left posterolateral thoracotomy CABG or MIDCAB.

Statistical analysis
Primary comparisons were performed between age groups. Data are expressed as percentages or as mean ± standard deviation. Categoric variables were compared using the two-tailed Pearson ² test. Continuous variables were compared with two-tailed, one-way analysis of variance for variables with normal distributions and with the two-tailed Kruskal Wallis test for variables with non-normal distributions. A stepwise logistic regression analysis was conducted to define predictors of postoperative stay longer than 7 days (discharge to home). p values of 0.05 or less were considered statistically significant. All statistical analyses were done using the program SPSS 8.0 for Windows 95 (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
An increasing number of off-pump CABG procedures were performed in octogenarians during the more recent years of the study period (Fig 1). The preoperative clinical characteristics of patients in the three age groups are summarized in Table 1. In comparison with the younger age groups, more octogenarians were women (n = 36, 51%) and they were more likely to have a history of previous myocardial infarction (n = 34, 48%) and congestive heart failure (n = 13, 18%). Octogenarians were more likely to have chronic obstructive pulmonary disease (n = 7, 10%) and more than one diseased vessel (n = 44, 62%) than younger patients. Finally, octogenarians had a higher frequency of urgent or emergent operations (n = 49, 69%) than younger patients. Emergent CABG within 24 hours after failed angioplasty was done in 6 patients overall, including 1 octogenarian (1%), 2 septagenarians (1%) and 3 sexagenarians (1%), (p > 0.05). Off-pump CABG and transmyocardial revascularization was done in 3 of 595 concurrent patients (0.5%). Significant atherosclerosis of the ascending aorta was identified in 8 octogenarians (11%), 20 septuagenarians (9%), and 8 sexagenarians (3%) (p = 0.002). Conduit grafts used in patients with significant atherosclerosis were only arterial (n = 14, 39%), both arterial and venous (n = 12, 33%), and only venous (n = 10, 28%).

View larger version (15K): [in this window] [in a new window]   Fig 1. Octogenarians who had off-pump versus on-pump coronary artery bypass grafting during the study period (1987 to 1999). There has been an increase in the percentage of octogenarians operated off-pump, over time: from 10% during 1987 to 1989 to 76% during 1996 to 1999. White and black bars represent the percentage of octogenarians operated on-pump and off-pump, respectively.

To investigate whether age over 80 years was an independent predictor of prolonged hospital stay in patients who had off-pump CABG, a multivariate logistic regression analysis was conducted using the factors that were significant in the univariate analysis as independent variables and postoperative stay more than 7 days as the dependent variable (Table 3). In the multivariate analysis, the preoperative factors of age 80 years or more (p = 0.002), congestive heart failure (p = 0.04), previous stroke (p = 0.02), and ejection fraction less than 0.34 (p = 0.04), and the postoperative factors of atrial fibrillation (p < 0.001) and need for inotropic support (p < 0.001) emerged as independent predictors of prolonged postoperative length of stay.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Perioperative morbidity and mortality rates increase with increasing age for patients who have CABG with or without cardiopulmonary bypass [12–14]. A rising trend has been documented in the number of octogenarians who have cardiac operations [4, 15]. Less invasive approaches have been favored in this subset of patients because of advanced age and associated medical conditions [16–18]. Off-pump CABG might be a reasonable alternative for octogenarians; however, the risks and outcomes of off-pump CABG in patients older than 80 years have not been clearly defined.

During the past 10 years, the number of off-pump CABG operations performed at our institution has increased significantly. A parallel increase in the age of patients who had off-pump procedures has also been documented. We prefer MIDCAB in patients over 80 years of age to reduce operative time and to minimize interventions in geriatric patients. In comparison with the younger patients, octogenarians were more likely to present with congestive heart failure, Canadian Cardiological Society angina class III or IV, ejection fraction lower than 0.34, and more than one vessel coronary artery disease, and they were slightly more likely to present with chronic obstructive pulmonary disease (Table 1). These comorbid conditions increased operative morbidity and mortality, echoing previously reported findings [5, 19, 20]. In addition, a higher percentage of octogenarians were women. Female sex has been recognized as a predictor of operative death [5], partially because of the late referral pattern of women [19] and possibly because of their smaller coronary arteries, which makes myocardial revascularization technically more demanding [5]. However, more recent data suggest that the mortality rate in women is no different than that in men [21]. Moreover, more than two thirds of the octogenarians were operated on an urgent basis, a factor that has a profound effect on perioperative morbidity and mortality rates [9].

Previous studies have reported a high incidence of postoperative complications in octogenarians [13, 22]. Similarly, in our study, octogenarians had a slightly higher rate of pulmonary complications compared with the younger age groups. Additionally, octogenarians more often required postoperative inotropic agents and had a relatively higher in-hospital stroke rate than younger patients, in accordance with a previous report [4].

The postoperative atrial fibrillation rate was significantly higher in the octogenarians, further complicating their in-hospital outcome, and was an independent predictor of prolonged postoperative stay. Advanced age consistently has been associated with an increase in the risk of atrial fibrillation and is considered a major factor for increased morbidity, mortality, and prolonged hospital stay after CABG [23]. Almassi and associates [23] have reported an 1.6-fold increase in the incidence of postoperative atrial fibrillation for each additional decade of life.

Predictors of prolonged postoperative stay
Age 80 years and over emerged as an independent predictor of prolonged postoperative stay in patients who had off-pump CABG. Preoperative congestive heart failure, history of stroke, and ejection fraction less than 0.34 and postoperative inotropic support and new onset atrial fibrillation were also found to prolong postoperative stay.

A trend during the study period was the abbreviation of postoperative stay in octogenarians in more recent years. Specifically, for the first 35 octogenarians in our study the median postoperative stay was 8 days (mean, 11 ± 8 days), whereas for the last 36 patients the median postoperative stay was 6 days (mean, 7 ± 4 days). In the current era of reduced health care funds, a shortened hospital stay could favorably affect the relative risk-benefit ratio for cardiac operations, reduce the use of hospital resources, and therefore the cost of care.

An interesting trend documented in our study was the increasing percentage of patients receiving one or more internal mammary artery grafts. Use of internal mammary artery grafts has been associated with better short- and long-term outcome [16, 17]. Of the first 35 octogenarians, fewer patients (n = 14, 40%) received internal mammary artery grafts compared with the last 36 patients (n = 32, 89%), reflecting a shift in cardiac surgical practice during the past decade.

In-hospital mortality
Despite the associated comorbid conditions, in-hospital mortality in octogenarians after off-pump CABG was low and comparable to rates reported for octogenarians who had on-pump CABG [4, 5, 16, 17, 22, 24–26] (Table 4). Further research and comparison between risk-stratified and adjusted populations are needed to compare the two techniques and to identify the indications for off-pump versus conventional on-pump CABG in octogenarians.

	Footnotes

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

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