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Ann Thorac Surg 2002;74:671-677
© 2002 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Villa Torri Hospital, Bologna, Italy
Accepted for publication April 29, 2002.
* Address reprint requests to Dr Gatti, via Pignolini 5-37019 Peschiera dG, Verona, Italy
e-mail: giusep.gatti{at}tiscali.it
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Abstract |
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 Top Abstract IntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Methods. Between June 1998 and March 2001, 73 consecutive octogenarians (mean age = 83.1 ± 3.0 years) hospitalized and awaiting operation in our Department were analyzed for postoperative complications. We recorded the main risk factors for cardiovascular disease, symptoms of heart failure, previous myocardial infarction, reoperation, left ventricular ejection fraction, use of intraaortic balloon pump, surgical priority, and operative risk. Cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal failure were the preoperative extracardiac comorbidities considered. We adopted a multidisciplinary approach to perioperative management.
Results. Surgical procedures included coronary artery bypass grafting in 36 patients (49.3%), valve procedures in 20 (27.4%), and combined coronary artery bypass grafting and valve procedures in 17 patients (23.3%). In-hospital death occurred in 6 patients (8.2%). Twenty-one patients (28.8%) had major postoperative complications including renal failure (15.1%), respiratory failure (8.2%), and myocardial infarction (8.2%). The main predictors of postoperative complications were New York Heart Association functional class IV, Canadian Cardiovascular Society angina class 4, and prolonged aortic cross-clamping time.
Conclusions. Cardiac operations can achieve satisfactory results even in high-risk octogenarians. Early surgical intervention before severe symptoms appear, and a multidisciplinary approach to perioperative management, may reduce postoperative complications.
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Introduction |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Continued refinements in cardiac anesthesia, surgical technique, and myocardial preservation have led to the increasing application of cardiac surgical procedures in octogenarians. When appropriately applied in selected patients with severe symptoms and low extracardiac comorbidity, cardiac operation achieves satisfactory results [4–13].
The aim of our study is to examine operative results of high-risk octogenarians undergoing cardiac operations at our Department and to identify the predictors of postoperative complications. Our multidisciplinary protocol for perioperative management is also presented.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Arterial hypertension, diabetes mellitus, obesity, and history of cigarette smoking were the most prevalent risk factors for cardiovascular disease. Symptoms of heart failure were classified according to the functional classification of the New York Heart Association (NYHA) and the classification of angina of the Canadian Cardiovascular Society (CCS). We recorded the occurrence of previous myocardial infarction (MI), preoperative left ventricular ejection fraction, previous percutaneous transluminal coronary angioplasty, reoperation, left main coronary artery disease, and use of the prophylactic intraaortic balloon pump (IABP). We considered extracardiac comorbidities such as cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, and renal failure. The priority of each operation was graded according to The Society of Thoracic Surgeons classification. Operative risk was evaluated according to both European and Ontario Province Risk (OPR) systems for cardiac operative risk evaluation (SCORE). European SCORE 6 or higher equals high-risk patients (95% confidence interval [CI] for expected mortality = 10.93% to 11.54%). OPR SCORE 4 to 7 equals mid-risk patients (95% CI for expected mortality = 4.01% to 11.61%) and OPR SCORE 8 or higher equals high-risk patients (95% CI for expected mortality = 13.22% to 20.62%) [14, 15] (Table 1).
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Definitions
High-risk patients were those with a European SCORE of 6 or higher.
Urgent operations were defined as those performed on patients with an evolving MI or with failed percutaneous transluminal coronary angioplasty with ongoing ischemia, or on patients requiring intravenous nitroglycerin and heparin or IABP. Emergent cases were defined as those in which hemodynamic instability persisted preoperatively, despite all available medical measures.
Cerebrovascular disease was defined as symptomatic carotid stenosis more than 50%, nonsymptomatic carotid stenosis more than 70%, vertebral atherosclerotic disease, previous transient ischemic attack, reversible ischemic neurologic deficit, stroke, or previous carotid endarterectomy. Postoperative neurologic dysfunction included delayed awakening, transient ischemic attack, reversible ischemic neurologic deficit, stroke, or manifest psychiatric disorder.
Peripheral vascular disease was defined as symptomatic or nonsymptomatic iliac or femoral stenosis more than 70%.
Chronic obstructive pulmonary disease was diagnosed when preoperative forced expiratory volume in 1 second was less than 40% of the theoretical value predicted for age. Early extubation was defined as removal of the endotracheal tube within 6 hours from arrival to postoperative intensive care unit. Prolonged mechanical ventilation was defined as mechanical ventilation during more than 48 hours from arrival to postoperative intensive care unit or from reintubation.
Preoperative renal failure was defined as a preoperative serum creatinine concentration of more than 2.0 mg/dL. Postoperative acute renal failure was defined as a postoperative creatinine concentration of more than 2.0 mg/dL in the patients with normal previous creatinine concentration. Postoperative progression of preoperative renal failure was defined as a postoperative increase in creatinine concentration of at least 1.0 mg/dL above baseline. Postoperative renal failure includes postoperative acute renal failure and postoperative progression of preoperative renal failure.
Perioperative MI was defined as appearance of new Q waves or significant loss of R wave forces in two or more contiguous leads on a 12-lead electrocardiogram, or creatine kinase-MB enzyme peak more than 10% of creatine kinase enzyme peak, or new hypokinetic or akinetic areas at echocardiographic examination.
In-hospital mortality was defined as death before hospital discharge or within 30 days from hospital discharge.
Perioperative management
Preoperative evaluation for carotid or vertebral disease by ultrasound-Doppler examination or angiography, and intraoperative evaluation for ascending aorta arteriosclerosis and heart chamber deairing by transesophageal echocardiography were always performed. In the patients with symptomatic carotid stenosis more than 50% or nonsymptomatic carotid stenosis more than 70%, carotid endarterectomy using the Pruitt-Inahara outlying carotid shunt (Horizon Medical Products Inc, St. Petersburg, FL) was always performed, just before cardiac operation.
After premedication with diazepam (0.15 mg/kg; Roche, Milan, Italy), morphine (0.1 mg/kg; Monico, Venice, Italy), and scopolamine (0.2 to 0.5 mg; S.A.L.F.-Laboratorio Farmacologico, Bergamo, Italy), all patients underwent general anesthesia with fentanyl (8 to 10 µg/kg; Pharmacia & Upjohn, Milan, Italy), isoflurane (Abbott, Latina, Italy), and vecuronium (0.1 mg/kg; Organon Teknika, Rome, Italy) for induction, and fentanyl (4 to 5 µg · kg-1 · h-1), isoflurane, and vecuronium (0.1 mg · kg-1 · h-1) for maintenance. In the postoperative intensive care unit, ketorolac (Roche, Milan, Italy), morphine, and fentanyl were used for analgesia.
Normothermic cardiopulmonary bypass (CPB), with crystalloid priming, and antegrade hypothermic crystalloid cardioplegia were used. Preferably, coronary artery bypass grafting (CABG) without CPB (off-pump CABG) was performed in the patients with greater extracardiac comorbidity and urgent surgical priority.
When patients were awake and hemodynamically stable, they were considered for ventilator weaning. Sequence of assisted/controlled ventilation, pressure support ventilation with or without synchronized intermittent mandatory ventilation, and continuous positive airway pressure spontaneous ventilation, was adopted for ventilator weaning. Patients underwent extubation if they met standard criteria: spontaneous respiratory rate of 10 to 25 breaths/min, tidal volume more than 5 mL/kg, vital capacity more than 10 mL/kg, negative inspiratory force more than 25 cm H2O, arterial carbon dioxide tension less than 45 mm Hg, and an arterial oxygen tension-fractional inspiratory oxygen ratio more than 140. If ventilator support was needed for more than 7 days from operation, percutaneous dilatational tracheostomy (Ciaglia technique) was performed.
Dopamine (Astra Farmaceutici, Milan, Italy), at doses of 2 to 3 µg · kg-1 · min-1, was used in all patients. Dobutamine (Eli Lilly Italia, Florence, Italy), at doses of 2 to 3 µg · kg-1 · min-1, was used in patients with preoperative left ventricular ejection fraction less than 0.40 and, at doses of 3 to 8 µg · kg-1 · min-1, in case of difficulty weaning from CPB or postoperative low cardiac output (LCO) syndrome (cardiac index lower than 2.0 L · min-1 · m-2). The IABP was inserted preoperatively in patients with cardiogenic shock after percutaneous transluminal coronary angioplasty or unstable angina refractory to medical therapy. After operation, IABP was installed in patients with postoperative cardiac ischemia with LCO unresponsive to inotropic therapy.
Prevention of postoperative paroxysmal atrial fibrillation (AF) with continuous intravenous amiodarone (Sigma-Tau Industrie Farmaceutiche Riunite, Rome, Italy) infusion (0.45 to 0.80 mg · kg-1 · h-1) starting in the operative room, low-dose ß-blocker (50 mg of metoprolol; Astra Farmaceutici, Milan, Italy), and magnesium sulfate (2 g; Bioindustria-Laboratorio Italiano Medicinali, Alessandria, Italy) starting on the first postoperative day was given to all patients with preoperative left ventricular ejection fraction less than 0.40 or with paroxysmal AF. Postoperative AF was treated with synchronized electrical cardioversion, if significant hemodynamic compromise was evident, otherwise with intravenous (5 to 10 mg/kg for >20 minutes, then 0.45 to 0.80 mg · kg-1 · h-1 until sinus rhythm recovered) and oral (600 to 1,200 mg for 2 to 5 days, then 200 to 600 mg) amiodarone.
Preoperative electrolytic levels were normalized, and dopamine (2 to 3 µg · kg-1 · min-1) was administered in all patients with renal failure undergoing elective cardiac operation. Postoperative renal failure without oliguria (urine output more than 0.50 mL · kg-1 · h-1) was treated aggressively, with higher blood pressure, avoidance of negative fluid balance and anemia, withdrawal of any medications with adverse effects on renal function, and use of boluses of furosemide (30 to 500 mg; Hoechst Marion Roussel, Milan, Italy). In case of postoperative renal failure with oliguria or anuria (urine output less than 0.50 mL · kg-1 · h-1), continuous intravenous furosemide infusion (0.25 to 0.75 mg · kg-1 · h-1) or continuous venous-venous hemofiltration were used. In case of postoperative renal failure with polyuria, a negative fluid balance was never allowed.
Prophylactic antibiotic therapy with single bolus doses (1 to 2 g) of ceftriaxone (Roche) was given at induction of anesthesia, immediately after CPB, and daily until 24 hours after removal of the last intravascular or endotracheal device. In all patients, an antibiotic solution with rifamicine (Gruppo Lepetit, Milan, Italy) was used for mediastinal washing [16].
A steel reinforced closure of median sternotomy (Robicsek technique) was systematically adopted.
Diabetic patients were treated with a continuous intravenous insulin (Novo Nordisk Farmaceutici, Rome, Italy) infusion in an attempt to maintain a blood glucose level lower than 200 mg/dL [17].
Statistical analysis
As noted earlier, the variables examined included age, gender, NYHA functional class, CCS angina class, previous MI, left ventricular ejection fraction, reoperation, surgical priority, cerebrovascular disease, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, operative procedures, off-pump CABG, aortic cross-clamping and CPB times, and European and OPR SCOREs. Values of variables are expressed as mean ± standard deviation or as percentage.
Methods of univariate analysis included the Student’s t test for continuous variables and the 
2 test for categorical variables. Significant variables from the univariate analysis were subjected to multivariate analysis using the Cox binary logistic regression model. Statistical significance was assumed for a p value less than 0.05. To assess the ability of the significant variables from the multivariate analysis to predict postoperative complications, the odds ratio was calculated.
Nonparametric estimates of survival at 6 months, 1 year, and 3 years were obtained by the method of Kaplan and Meier.
Statistical analysis was performed using MINITAB release 13 statistical software (MINITAB Inc, State College, PA).
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Results |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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Surgical procedures included CABG in 36 patients (49.3%), valve repair or replacement in 20 (27.4%), and combined CABG and valve procedures in 17 patients (23.3%) (Table 2). In the patients who had off-pump CABG, both mean European and mean OPR SCOREs were greater than in those who had conventional CABG, but differences were not significant. The CABG of the left anterior descending coronary artery was performed with the left internal mammary artery or radial artery in 84.8% of patients (39 of 46). Aortic cross-clamping time was less than 60 minutes in 66.7% (42 of 63 patients), and CPB time was less than 90 minutes in 49.2% (31 of 63).
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There were six in-hospital deaths (8.2%). Causes of death included perioperative MI with LCO syndrome unresponsive both to moderate doses of dobutamine and IABP in 4 patients, ventricular fibrillation during perioperative MI in 1 patient, and multisystem organ failure from postoperative progression of preoperative renal failure in 1 patient (Table 3).
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Mean postoperative hospital stay was 10.3 ± 5.5 days, with a median of 8 days (5 to 38 days). In patients with and without postoperative complications, mean postoperative hospital stay was 15.8 ± 8.1 days and 9.2 ± 3.7 days, respectively (p = 0.036). Among patients without major postoperative complications, mean postoperative hospital stay of the patients with and without paroxysmal AF was 9.7 ± 4.8 days and 9.0 ± 3.4 days, respectively (p = not significant). Mean postoperative intensive care unit stay was 2.7 ± 1.1 days, with a median of 2 days (2 to 6 days).
Significant predictors of postoperative complications from univariate analysis were NYHA functional class IV, CCS angina class 4, previous MI, urgent or emergent surgical priority, chronic obstructive pulmonary disease, preoperative renal failure, off-pump CABG, combined CABG and valve procedure, mitral valve procedure, aortic cross-clamping and CPB times, and European and OPR SCOREs (Table 4). Significant predictors from multivariate analysis were NYHA functional class IV, CCS angina class 4, previous MI, urgent or emergent surgical priority, combined CABG and valve procedure, mitral valve procedure, aortic cross-clamping time of more than 60 minutes, CPB time of more than 90 minutes, European SCORE 10 or greater, and OPR SCORE 8 or more. The most significant predictors of postoperative complications were NYHA functional class IV, aortic cross-clamping time of more than 60 minutes, and CCS angina class 4 (Table 5).
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Actuarial survival at 6 months, 1 year, and 3 years was 98.51% (95% CI = 95.60% to 100%), 95.51% (95% CI = 90.55% to 100%), and 87.15% (95% CI = 77.96% to 96.35%), respectively. Seven patients (10.4%) died during follow-up: 3 patients from cardiac causes and 4 patients from noncardiac causes. Of the 60 surviving patients, 53 (88.3%) were in NYHA functional class I or II.
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Comment |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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In our experience, cardiac operation can be performed with acceptable mortality and morbidity, even in octogenarians whose surgical risk is increased by advanced heart disease and high extracardiac comorbidity. Our postoperative neurologic deficit prevention strategy is composite: preoperative diagnosis of carotid or vertebral arteries disease, possible carotid endarterectomy (with Pruitt-Inahara outlying carotid shunt) just before cardiac operation, systematic intraoperative transesophageal echocardiography to select the best aortic cannulation site and to guide heart deairing, extensive use of internal mammary artery to avoid or at least reduce the ascending aorta side-clamping time, use of off-pump CABG when indicated, maintenance of high mean arterial pressure during CPB and early after operation, and timely prevention and treatment of paroxysmal AF. The aim of our policy of always performing (when indicated) carotid endarterectomy just before cardiac operation is to optimize the cerebral flow before the cerebral ischemia risk due to operation [18–20]. Advanced age is frequently considered a risk factor for paroxysmal AF and often prolongs the hospital stay [21]. In our series, paroxysmal AF was the most common postoperative complication, but it did not lengthen hospital stay for those patients who did not have any other complication. Frequent postoperative renal failure may be explained by the high prevalence of preoperative renal failure. Perioperative MI, often complicated by LCO syndrome, was more frequent in our series than in other reports. This may be partially explained by the characteristics of our population: a high prevalence of CCS class 4, previous MI, left main coronary artery disease, three-vessel coronary artery disease, previous percutaneous transluminal coronary angioplasty, and frequent urgent or emergent operations. Preoperative use of an IABP was never associated with postoperative MI or vascular complications. Moreover, when an IABP was installed postoperatively to treat MI with LCO syndrome, it did not prevent death. Therefore, we agree with those who advise more liberal use of preoperative IABP in elderly patients with high operative risk [22]. We believe that the incidence of systemic and wound infection and sternal separation can be reduced by intraoperative mediastinal irrigation, steel reinforced closure of median sternotomy, early ventilator weaning, prolonged antibiotic prophylaxis, and continuous intravenous insulin infusion in diabetic patients. In comparison to other reports, our patients had greater extracardiac comorbidity, equivalent heart disease and risk factors for cardiovascular diseases, more severe preoperative symptoms, and a greater frequency of urgent or emergent operations. After cardiac operation, infections and sternal diastasis were eliminated, and neurologic dysfunction minimized. Postoperative renal failure and perioperative MI rates were slightly greater than those reported by other investigators, whereas respiratory failure rates and postoperative hospital stays were equivalent.
Postoperative complications are common even when operations are planned in a painstaking way, but they are usually curable when promptly and aggressively treated. They require a multidisciplinary approach, supported by special protocols for prevention and treatment (including hemofiltration, prolonged mechanical ventilation, percutaneous dilatational tracheostomy, use of IABP). Nevertheless, postoperative complications lengthen intensive care unit and hospital stay. All these considerations make cardiac operations in octogenarians more expensive [4]. Identification of those octogenarians with a high risk of postoperative complications allows advance planning and preventive treatment, which translates into improved results and lower costs. We, therefore, tried to identify the predictors of postoperative complications (rather than mortality). In our series, as noted earlier, it was possible to identify many cardiac predictors, but even major extracardiac comorbidities were not associated with higher postoperative complication rates. Very high European and OPR SCOREs were excellent predictors of postoperative morbidity. The finding that off-pump CABG patients had twice as many complications as on-pump CABG cases is largely explained by selection of patients undergoing off-pump CABG. In fact, off-pump CABG was a significant variable from univariate analysis, but not from multivariate analysis.
Postoperative complications in octogenarians undergoing cardiac operation can be reduced and successfully treated by a multidisciplinary strategy of prompt and aggressive diagnosis, prevention, and treatment. In fact, only a multidisciplinary management strategy allows a global view of these complex and demanding patients. Because symptoms of severe heart failure and urgent or emergent operations are among the predictors of postoperative complications, earlier surgical intervention could improve outcomes and reduce costs in octogenarians.
Although at present cardiac operation in octogenarians is reserved for carefully selected patients, it could be extended with reasonable safety even to octogenarians with high extracardiac comorbidity, advanced symptoms of heart disease, and urgent or emergent indications for operation. Nevertheless, some physicians still do not recognize the usefulness of operation as a therapeutic option in octogenarians, especially those with high operative risk, and these surgeons consider operation in very aged people to be the last resort before death. This becomes a self-fulfilling prophecy. When we enlisted our patients, we followed the same surgical indications that were internationally approved for younger patients. This involves looking at, studying, and evaluating the various physiologic and systemic data that makes people candidates for operation, no matter their age. Patients should be judged according to their physiologic age, and how they might expect to benefit from whatever surgical procedure is needed.
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Acknowledgments |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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TopAbstractIntroductionPatients and methodsResultsCommentAcknowledgmentsReferences |
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