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Ann Thorac Surg 2001;71:591-596
© 2001 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Clinical Resource Management, California Pacific Medical Center, San Francisco, California, USA
b Department of The Research Institute, California Pacific Medical Center, San Francisco, California, USA
Accepted for publication May 11, 2000.
Address reprint requests to Dr Avery, 2100 Webster St, Suite 320, San Francisco, CA 94115
e-mail: leyj{at}sutterhealth.org
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Abstract |
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Methods. One hundred four octogenarians undergoing a variety of heart–lung procedures were prospectively studied between 1995 and 1998 for comparison with similar patients aged 65 to 75 years (n = 351).
Results. Octogenarians were more likely to be of female gender, and be nondiabetic than the younger group. The 30-day mortality rate for patients aged 65 to 75 years was 3.4% (12 of 351 patients), versus 13.5% (14 of 104) for patients aged 80+ (p = 0.0004), which ranged from 2% (1 of 50) in nonemergent coronary artery bypass grafting to 75% (3 of 4) in double valve procedures. Complications occurring more frequently in octogenarians were severe low output state, reintubation, and atrial fibrillation. Elders experienced a longer intensive care (69.2 versus 43.3 hours, p = 0.002) and postoperative stay (10.09 versus 7.45 days, p = 0.001), and were discharged to a skilled nursing facility more often than younger patients (47% versus 21.1%, p = 0.0001). Total direct costs were $4,818 higher in the octogenarian group (p = 0.0007).
Conclusions. Although emergency operations and complex procedures carried high risks for the octogenarian, the majority of these patients can be offered operation with short-term morbidity, mortality, and resource use that only modestly exceeds that of younger patients.
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Introduction |
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Recent advances in myocardial preservation and perioperative management have enabled cardiac operations to be performed in the octogenarian with acceptable morbidity and mortality, despite notably higher risks than in younger cohorts [3–7]. In response to these encouraging results, a 67% increase in cardiac surgical procedures for this age group was noted nationwide between 1987 and 1990 [8]. The purpose of this descriptive study was to identify the inpatient results of cardiac operations at our center in patients 80+ years during the recent past, including clinical, financial, and disposition outcomes. Comparisons were made with a younger cohort aged 65 to 75 years that represented the majority of our non-octogenarian patients who underwent similar procedures during the same time interval.
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Material and methods |
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Demographic data included patient age, gender, and prior medical history, including the presence of cardiac risk factors (eg, diabetes, hypertension, hyperlipidemia, smoking) or other disease entities as noted in the medical record at the time of admission. The cardiac history included number and timing of prior myocardial infarctions, severity of angina (Canadian Cardiovascular Society classification), and congestive heart failure (New York Heart Association classification), as well as prior cardiovascular procedures. Cardiac catheterization data including location of significant (
70%) stenoses, presence and degree of valvular dysfunction, and left ventricular ejection fraction were recorded, if available. Emergent procedures were classified using defined criteria [9]: myocardial salvage (severe rest angina with maximal intravenous nitrates or intraaortic balloon pump (IABP) therapy), hemodynamic instability (shock with or without circulatory support), or salvage (cardiac arrest with cardiopulmonary resuscitation just before operation). All other patients were grouped into a nonemergent status for comparison.
Operative mortality was defined as death occurring within 30 days of operation or before hospital discharge. Postoperative complications were noted using the criteria of The Society of Thoracic Surgeons. Perioperative myocardial infarction was defined as elevation of cardiac enzymes ( 50 IU) in association with new Q waves or ST-T wave changes on the postoperative electrocardiogram. Stroke was defined as a new, focal neurologic deficit that persisted at discharge. Pneumonia was defined by clinical criteria including chest roentgenogram findings and sputum culture results that required antibiotic therapy.
Severe renal failure was defined as the new requirement for dialysis, severe low output state was identified by the need for multiple inotropes or an IABP in the postoperative period for at least 24 hours. Atrial fibrillation was noted when it was sustained for at least 30 minutes or required treatment.
Significant benchmarks of resource utilization were also noted, including duration of intubation, intensive care stay, and postoperative length of stay. Inpatient acute care costs and disposition data were obtained for all patients operated on after January 1, 1996, from the hospital-based cost accounting system (TrendStar, San Francisco, CA). These costs were divided into the following categories: operating room/anesthesia, critical care, medical–surgical care, laboratory/blood, pharmacy, radiology, supply, and other. At the conclusion of the acute care stay, patient disposition was classified for surviving patients as either home (with or without home health nursing services) or transfer to a skilled nursing facility.
Surgical methods
Standard techniques of cardiopulmonary bypass were used for all patients in both age groups. Myocardial preservation was achieved by cold blood cardioplegia given antegrade, retrograde, or both depending on surgeon preference. The use of cell savers and administration of tranexamic acid or amicar were routinely used as blood conservation measures, with immediate preoperative plasmapheresis added for a majority of patients. Anesthetic techniques permitting early extubation were increasingly used for both groups during the study period, and were routine for virtually every patient beginning in 1997 in the absence of severe ventricular compromise or emergent operation. Additional components of our "fast track" program included prompt central line removal and early ambulation, but pharmacologic adjuncts such as ß-blockers or steroids were not routine.
Statistical analysis
Results are expressed as the mean ± standard deviation of the mean for continuous variables and percentages for dichotomous variables. Student’s t tests were used to compare differences of means, between the groups, and Fisher’s exact 
2 tests were used to assess proportional differences. A predetermined level of significance of 0.05 was used throughout.
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Results |
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Mortality
The overall 30-day mortality rate for patients 80 years and above was 13.5% (14 of 104 patients), including 2 intraoperative and 12 postoperative deaths (Table 3). Of note, half of all deaths occurred in patients undergoing emergency procedures, with a mortality rate of 87.5% (7 of 8) in this group. In contrast, for nonemergent procedures, mortality was 7.3% (7 of 96 patients). The mortality rate varied considerably by type of procedure, from 9.3% (5 of 54) in patients undergoing isolated CABG to 75% (3 of 4) in patients undergoing complex double or triple valve procedures. The nonemergency CABG group experienced a mortality rate of 2% (1 of 50 patients).
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Complications
The incidence of postoperative complications in the elderly group ranged from 2.0% for sternal wound infection and reoperation for bleeding (n = 2), to 55.3% for atrial fibrillation (n = 57), as listed in Table 4. The occurrence of stroke was 7.8% in octogenarians, which was not significantly different from the younger cohort (4.3%, p = 0.1971). In addition, the incidence of perioperative myocardial infarction, reoperation for bleeding, and sternal infection were similar between groups. Complications that occurred more often in the octogenarian group included severe low output state (10.7% versus 3.1%, p = 0.0037), reintubation (7.9% versus 1.1%, p = 0.0011), and atrial fibrillation (55.3% versus 39.7%, p = 0.0065).
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Comment |
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Numerous factors have been identified that increase mortality rates, including surgical complexity, ventricular function, and the number of preexisting comorbid conditions [6, 10, 11]. Glower and colleagues [12] noted in-hospital mortality rates of 23% in patients with one or more comorbidity versus 7% in patients without comorbid conditions. In contrast, we found that only 8.6% of octogenarians were free from comorbid conditions, with at least one preoperative comorbidity in a majority of survivors.
Several high-risk groups were identified from our analysis. In particular, we have identified that octogenarians with severe preoperative hemodynamic compromise are ill-equipped to rebound from the insult posed by severe ischemia followed by cardiac operation and cardiopulmonary bypass. In this small (n = 8) set of patients, predominantly arriving from the cardiac catheterization laboratory or emergency room, all with hemodynamic instability requiring inotropes (and all but one with IABP or cardiopulmonary support), there was only one survivor. This was a patient with tamponade that responded to pericardiocentesis before operation, but nonetheless sustained a permanent neurologic injury. This is in contrast to the report by Craver and colleagues [7], who noted a 24.1% mortality rate for emergency CABG in their group of 601 octogenarians. Although it seems intuitive that older patients possess diminished physiologic reserve, our data imply that cardiac surgical intervention for the octogenarian in extremis is ill-advised.
An additional set of patients with a high mortality rate (3 of 4, 75%) were patients requiring double or triple valve procedures, considerably higher than the 30% early mortality for octogenarians with double valve replacement reported by Tsai and associates [11]. All 4 patients in our small multiple-valve group were in class IV heart failure, had pulmonary hypertension, and a history of dysrhythmias. The sole survivor in this group had preserved ventricular function, no comorbidities, and underwent an elective mitral valve repair with tricuspid valve repair.
Complications associated with cardiac operations in our series ranged from 2% for mediastinitis and reoperation for bleeding, to 55.3% for atrial fibrillation or flutter. Our incidence of reoperation for bleeding is notably lower than other reports in this age group, which range from 5.6% to 13% [3, 4, 6, 7]. The need for a second, typically emergent procedure for bleeding, coupled with large volume blood transfusion, carries additional risks of infection, pulmonary failure, and is reportedly the cause of death in up to 17% of the patients [3].
Although our postoperative transfusion indicators are established at a hematocrit of 22% for the majority of patients, this value was increased to 30% for the octogenarian. Although 79.8% of these older patients received at least one red cell transfusion during their hospitalization, only 32% of these patients required more than 2 U of blood.
Hospital costs have previously been reported to be 20% higher in the older patient, attributable in part to a length of stay that averaged 3.9 days longer than in younger patients [8]. Our data reflect the impact of a heavily managed care market, which currently includes 35% managed care contracts, and an additional 30% senior HMO payer base. We noted a 26.8% ($4,818) increase in total direct costs for the octogenarian group, which can be attributed at least partially to a higher severity index in this age group. Using the All Patient Refined Diagnosis-Related Group classification, almost 20% (15 of 77) of octogenarians fell into the most severe (class IV) risk category, versus 11% (25 of 225) of younger patients (p = 0.07). This group of critically ill octogenarians contributed to a substantial increase in resource utilization for the group as a whole, whereas median cost and length of stay values were increased by 22% ($3,330) and 1 day, respectively. Despite this effect, our average 10-day acute care stay for octogenarians was much shorter than the 14 to 16 days reported in the literature [6, 8, 12]. Our program of fast tracking cardiac surgical patients has been successful in reducing intubation times and length of stay for all age groups. Programs such as this appear to offer quality care delivery at reduced cost; the octogenarians in this report experienced shorter length of stays than previously reported, with comparable or reduced morbidity and mortality.
Important limitations of this study include its descriptive nature, using a relatively small cohort of patients at a single institution. Our purpose was to describe a wide host of clinical and financial outcomes that are realistic using contemporary cardiac surgery practices, not to develop a risk-adjustment model. In addition, our data represent short-term, inpatient outcomes and do not address late results after discharge.
We conclude that although mortality rates are higher in octogenarians than younger patients, cardiac operations can be safely performed, with acceptable risk, for the majority of these older patients. Indeed, mortality rates for nonemergent CABG compare favorably with similar procedures in younger patients. It is noteworthy that more than 70% (10 of 14) of octogenarian deaths occurred in the two high-risk groups we identified, either emergency operation or double valve procedures. We concur with Craver and colleagues [7] and other investigators who advocate an aggressive, proactive approach in managing cardiac disease in this age group, thus avoiding emergency intervention in poor surgical candidates. Given the generally positive results noted here and elsewhere, planned surgical intervention can be offered to appropriate candidates early in their disease process to optimize surgical outcomes. In addition, targeted strategies, such as minimally invasive procedures in high-risk patients, may result in additional lives saved. When compared to younger patients, most octogenarians experienced excellent outcomes, with only modest increases in length of stay and resource utilization, following a variety of cardiac surgical procedures. As improvements in surgical care continue, ongoing analysis of outcomes for octogenarians with surgically treated heart disease will be needed to help us guide patients to appropriate therapy.
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References |
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80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 2000;35:731-738.This article has been cited by other articles:
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|
|
|
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|
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|
|
|
|
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|
|
|
|
 |
|
 D. Rosborough Cardiac Surgery in Elderly Patients: Strategies to Optimize Outcomes Crit. Care Nurse, October 1, 2006; 26(5): 24 - 31. [Full Text] [PDF]
|
|
|
|
 |
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|
|
|
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|
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|
|
|
|
|
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|
|
|
|
 |
|
 J. Claude, C. Schindler, G. M. Kuster, M. Schwenkglenks, T. Szucs, P. Buser, S. Osswald, C. Kaiser, C. Gradel, W. Estlinbaum, et al. Cost-effectiveness of invasive versus medical management of elderly patients with chronic symptomatic coronary artery disease: Findings of the randomized trial of invasive versus medical therapy in elderly patients with chronic angina (TIME) Eur. Heart J., December 2, 2004; 25(24): 2195 - 2203. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Mortasawi, B. Arnrich, J. Walter, I. Frerichs, U. Rosendahl, and J. Ennker Impact of Age on The Results of Coronary Artery Bypass Grafting Asian Cardiovasc Thorac Ann, December 1, 2004; 12(4): 324 - 329. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
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|
|
|
|
|
|
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|
|
|
|
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|
M. D. Bacchetta, W. Ko, L. N. Girardi, C. A. Mack, K. H. Krieger, O. W. Isom, and L. Y. Lee Outcomes of cardiac surgery in nonagenarians: a 10-year experience Ann. Thorac. Surg., April 1, 2003; 75(4): 1215 - 1220. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
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|
|
|
|
|
|
R. G. Demaria, M. Carrier, S. Fortier, R. Martineau, A. Fortier, R. Cartier, M. Pellerin, Y. Hebert, D. Bouchard, P. Page, et al. Reduced Mortality and Strokes With Off-Pump Coronary Artery Bypass Grafting Surgery in Octogenarians Circulation, September 24, 2002; 106(12_suppl_1): I-5 - I-10. [Abstract] [Full Text] [PDF]
|
|
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|
|
|
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|
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|
|
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