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Ann Thorac Surg 2000;69:1471-1475
© 2000 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Stroke in octogenarians undergoing coronary artery surgery with and without cardiopulmonary bypass

^a Division of Cardiothoracic Surgery and the Center for Minimally Invasive Cardiac Surgery, The Buffalo General Hospital, SUNY at Buffalo, Buffalo, New York, USA

Address reprint requests to Dr Karamanoukian, Division of Cardiothoracic Surgery, The Buffalo General Hospital, 100 High St, Buffalo, NY 14203
e-mail: lisbon5{at}yahoo.com

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Myocardial revascularization in elderly patients is associated with a morbidity and a mortality substantially higher than those observed in younger patients. The aim of this study was to analyze the potential benefits of coronary artery bypass grafting without cardiopulmonary bypass (CPB) for octogenarians.

Methods. Of 269 octogenarians who underwent coronary artery bypass grafting at our institution between January 1995 and May 1999, 172 had the operation with CPB (CPB group) and 97, without CPB (off-pump group). Revascularization of the circumflex system or right coronary artery were not considered contraindications to off-pump grafting. Demographic data, preoperative risk factors, comorbid conditions, angiographic findings, postoperative complications, and outcomes were compared.

Results. The groups were comparable for age, sex, Canadian Cardiovascular Society class, operative priority (elective, urgent, or emergent), preoperative risk factors, and left ventricular ejection fraction. A significantly higher proportion of reoperations was observed in the off-pump cohort (16 of 97, 16.5%) compared with the CPB cohort (8 of 172, 4.7%) (p = 0.002). There was a trend toward a higher graft-patient ratio in the CPB group (3.3 versus 1.8; p = not significant). Freedom from postoperative complications was significantly higher in the off-pump group than in the CPB group (83 of 97, 85.6%, versus 129 of 172, 75%; p = 0.04). The incidence of stroke was 0% in the off-pump cohort compared with 9.3% (16 of 172) in the CPB cohort (p < 0.0005). Although there was a trend toward higher 30-day and risk-adjusted mortality rates in the off-pump group than in the CPB group (10.3% versus 5.2% and 2.8% versus 1.8%, respectively), the differences were not significant. The length of hospitalization was slightly lower in the off-pump group (9.1 versus 10.8 days; p = not significant).

Conclusions. This investigation suggests that patients 80 years of age and older undergoing off-pump coronary artery bypass grafting can experience significantly lower rates of perioperative stroke and overall complications compared with those undergoing the same procedure with CPB, although a trend toward higher mortality rates was observed in the off-pump group.

	Introduction

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Considerable advances have been made over the last few decades in the perioperative care of cardiac surgical patients and the techniques of myocardial revascularization. As a result, as the population ages, an increasingly greater number of high-risk elderly patients affected with symptomatic and surgically correctable coronary artery disease have become candidates for coronary artery bypass grafting (CABG). Myocardial revascularization in such patients, however, remains associated with morbidity and mortality substantially higher than those observed in the younger patient population [1, 2]. These considerations along with the growing popularity and favorable results of coronary artery revascularization without cardiopulmonary bypass (CPB) [3–5] have encouraged surgeons to embrace less invasive modalities of coronary artery revascularization from which high-risk patients, such as the elderly, can most benefit.

The aim of the present study was to analyze the potential beneficial role that CABG without CPB may have in reducing morbidity and improving outcomes in patients 80 years of age and older who require coronary artery revascularization. This was accomplished by comparing the outcomes in elderly patients in whom revascularization was achieved using CPB with the outcomes in patients in whom the off-pump technique was employed.

	Material and methods

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The cases of the 269 octogenarians who underwent CABG at our institution between January 1995 and May 1999 were retrospectively reviewed. Of these, 172 patients underwent conventional CABG using CPB (CPB group), and 97 patients had CABG without CPB, ie, on the beating heart (off-pump group). Patients from the two cohorts were operated on by two different groups of surgeons; one group routinely performs the vast majority of CABG procedures using CPB, whereas the other group does operations preponderantly, and in recent years almost exclusively, without CPB. Patients were assigned to one of the two groups on the basis of different referral patterns. The few patients in whom conversion to a procedure with CPB was undertaken were included in the CPB group.

A variety of surgical approaches were used in the off-pump group (median sternotomy, left anterior small thoracotomy, left posterior thoracotomy, and subxiphoid access), although a median sternotomy was usually favored and was most commonly performed to obtain complete myocardial revascularization. The left anterior small thoracotomy, as popularized by Calafiore and associates [6, 7] and others [8], was used in a minority of patients with isolated left anterior descending coronary artery disease and occasionally in redo operations. The left posterior thoracotomy and the subxiphoid approach were employed exclusively during reoperations. Revascularization of the marginal branches of the circumflex and distal right coronary arteries was not considered contraindications to off-pump coronary artery grafting.

The technical aspects of coronary artery revascularization on the beating heart have all been previously described in the literature [7, 9]. Briefly, these involve elevation of the heart using a "single-suture" technique in the oblique sinus of the posterior pericardium to obtain exposure [10], mechanical stabilization with an epicardial footplate to reduce motion, preservation of distal flow within the target vessel by a "shunt occluder," use of a carbon dioxide blower-aerosolizer to maintain a bloodless operative field [11], and intraoperative measurement of flows within the bypass grafts using a Doppler flowmeter. In recent years, refinements of such techniques have greatly enhanced the ability to adequately expose all target vessels, including those located on the lateral and inferior walls of the heart.

All relevant information, which included demographic data, preoperative risk factors and comorbid conditions, angiographic data with severity and distribution of coronary artery disease, and morbidity and mortality, were recorded. The severity of angina was categorized according to the Canadian Cardiovascular Society classification. The left ventricular ejection fraction was determined in all patients by coronary angiography during left ventriculography. Operative priority was defined as emergent when the severity and the distribution of the coronary disease process in combination with hemodynamic instability mandated immediate intervention. The management of some of these patients included inotropic agents, intraaortic balloon counterpulsation, and cardiopulmonary resuscitation. An urgent operation was defined as prompt surgical intervention because of ongoing ischemia, failed angioplasty, or unfavorable anatomy (ie, left main disease).

In regard to outcomes, the absence of complications, including death, was referred to as freedom from complications. Stroke was defined as a new neurologic deficit lasting more than 24 hours postoperatively. In all patients, the diagnosis was confirmed by a neurologist, and all patients underwent computed tomography of the head. Transient ischemic attacks were excluded. Deep sternal wound infection was defined as infection of the wound requiring return to the operating room for debridment, followed by secondary closure or closure by myocutaneous flap. Perioperative myocardial infarction was defined as new Q waves on the electrocardiogram or abnormal elevation of cardiac enzymes (MB fraction of creatine kinase) in combination with electrocardiographic abnormalities (ie, ST segment elevation). Renal failure was defined as need of dialysis during the postoperative period. Respiratory failure was defined as need of mechanical ventilation for more than 48 hours after operation.

Thirty-day mortality was defined as any in-hospital death occurring within 30 days after the operation. The expected mortality rate was calculated according to New York State database criteria, which are based on the preoperative risk factors of the patient population. The risk-adjusted mortality rate was calculated by dividing the crude mortality by the expected mortality and multiplying this figure by the state mortality rate (2.52% for 1995) (crude mortality/expected mortality x 2.52 = risk-adjusted mortality rate).

The data collected from both study groups were statistically analyzed and compared. Statistical analysis was conducted using Epi Info, version 6 [12]. Continuous, normally distributed variables were contrasted using the Student t test. The Fisher exact test was used when the expected value of a cell was less than 5. Differences between variables were considered significant when the p value was less than 0.05.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
As shown in Table 1, there was no significant difference between the two study groups in terms of age, sex, left ventricular ejection fraction, type of operative priority, and severity of angina (Canadian Cardiovascular Society class). Most of the preoperative variables in the two cohorts were similar (Table 2). However, the percentage of reoperations in the off-pump cohort was nearly four times greater than that in the CPB group (16.5% versus 4.7%; p = 0.002). In addition, the incidence of peripheral vascular disease (femoral or popliteal) was significantly higher in the CPB patients (17.4% versus 7.2%; p = 0.026). Table 3 shows the severity and the distribution of coronary artery occlusive disease as outlined by coronary angiography. We observed a trend toward more extensive multivessel involvement in the CPB cohort, which reached significance in the case of 70% to 100% stenosis of the middle or distal left anterior descending coronary artery (p = 0.030) and 70% to 100% right coronary artery stenosis (p = 0.002). Such discrepancy in severity and distribution of coronary artery involvement by atherosclerotic disease may have been partly responsible for the difference in graft-patient ratio observed in the CPB cohort (3.3) compared with the off-pump cohort (1.8), which was not a significant difference.

	Comment

Top Abstract Introduction Material and methods Results Comment References

In light of these adverse outcomes after conventional myocardial revascularization in elderly individuals, we decided to review our experience with off-pump CABG operations in patients 80 years of age and older and to compare the outcomes of these patients with those of patients who underwent conventional CABG during the same period. In this regard, Pfister and co-workers [17] reported their experience with 440 patients who underwent CABG with and without CPB. Their series also included 43 elderly patients (75 years of age and older), 24 of whom had operation without CPB and 19, with CPB. Their investigation revealed that elderly patients in the off-pump cohort were at lower risk for the development of postoperative low-output syndrome compared with their on-pump counterparts (16% versus 31%). Moreover, their length of hospital stay was shorter (13.3 days versus 18.4 days), and they were less likely to experience mental confusion postoperatively (4.2% versus 15.8%). However, because of the small sample size, such differences were not significant. On the basis of these results, the authors hypothesized that elderly patients as well as patients with poor left ventricular function and those requiring redo operations may benefit most from off-pump coronary artery revascularization.

In analyzing the results of our study, it is worthy of note that in 62.2% (107 of 172) of the patients in the CPB cohort and in 54.6% (53 of 97) of those in the off-pump cohort, surgical intervention was undertaken urgently or emergently. Although there was no significant difference between the two groups, the considerable proportion of urgent and emergent operations may have been partly responsible for the substantial mortality rates noted in the two cohorts; our rates, however, do compare favorably with those reported in the literature by others [14, 16]. Although there was a trend toward higher crude and risk-adjusted mortality rates in the off-pump group, such differences were not supported by statistical analysis and also were observed in the face of a significantly higher proportion of redo operations in the off-pump cohort (16.5% versus 4.7%; p = 0.002).

As previously reported by others [14–16], our investigation shows that the incidence of postoperative complications after CABG in the elderly population remains significant. Nonetheless, our analysis also revealed that patients in the off-pump group displayed a significantly higher rate of freedom from complications (p = 0.04) and enjoyed a significantly lower incidence of postoperative stroke (0% versus 9.3%; p < 0.0005) (see Table 4).

Despite the popularization of off-pump coronary artery revascularization in recent years [4, 7] combined with the documented feasibility and durability of coronary artery grafting on the beating heart [3], concerns have been raised regarding completeness of revascularization associated with off-pump CABG. Not surprisingly, the arguments supporting these objections have been the difficulty of grafting vessels on the lateral or inferior wall of the heart and the observation of a lower graft-patient ratio in patients who receive off-pump as opposed to traditional on-pump myocardial revascularization. In our experience, however, as well as in that of others [18], complete myocardial revascularization on the beating heart can be accomplished safely and effectively using the previously described methods of cardiac elevation and stabilization. As a result, even the distal right coronary system as well as the branches of the circumflex artery can be efficiently grafted in the vast majority of patients. Accordingly, perhaps the trend toward a higher graft-patient ratio in the CPB group in our series, which was not significant, can be explained by the fact that off-pump revascularization procedures, particularly at the beginning of our experience, were performed preponderantly in patients who were seen with coronary artery disease limited to the left anterior descending coronary artery. In fact, this was reflected by the higher degree of multivessel involvement in patients in the CPB group (see Table 3).

In conclusion, the data from our investigation show that myocardial revascularization in patients 80 years of age and older is associated with considerable perioperative morbidity and mortality. The results of our study should be interpreted with caution in light of the fact that our investigation has several limitations. These include, and are not limited to, the small sample size, the retrospective nonrandomized nature of the study, and the selection bias related to the fact that patients received one of the two treatments solely on the basis of different referral patterns. In addition, it is important that the patients in the two groups were operated on by different surgeons, and this should be taken into account. These confounding variables may have resulted in substantial differences between the two study groups, which, in turn, may have adversely affected the meaningfulness of our data analysis.

Despite these important limitations, we believe that some conclusions can be drawn. The analysis of our data suggests that elderly patients can benefit from off-pump revascularization. In fact, these patients had a more favorable postoperative course as reflected by the significantly higher rate of freedom from complications and enjoyed a significantly lower rate of postoperative stroke than those who underwent conventional CABG using CPB. Nevertheless, patients in the off-pump group experienced a higher mortality, which, although not significant, cannot be ignored and deserves further investigation.

	Footnotes

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

	References

Top Abstract Introduction Material and methods Results Comment References

 

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