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Ann Thorac Surg 2003;76:726-731
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Postoperative complications among octogenarians after cardiovascular surgery

^a Inova Heart Institute at Inova Fairfax Hospital, Falls Church, Virginia, USA
^b Cardiovascular and Thoracic Surgery Associates, Annandale, Virginia, USA

Accepted for publication April 3, 2003.

^* Address reprint requests to Dr Barnett, Inova Heart Institute at Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA.
e-mail: scott.barnett{at}inova.com

	Abstract

Top Abstract Introduction Material and Methods Results Comment References

 
BACKGROUND: The octogenarian patient is often perceived as too fragile to undergo cardiothoracic surgery. Our study aimed to compare postoperative complications in patients aged less than 80 versus elderly patients (80 years or more) after surgical cardiac intervention (coronary artery bypass or valve replacement).

METHODS: Subjects were all patients (n = 8,361) who had an open-heart procedure, either coronary artery bypass or valve implantation or replacement, at two medical centers located in northern Virginia using the same surgical group. A computerized medical record database was reviewed to determine preoperative risk factors and postoperative outcomes. Predictors of complications were identified by univariate and multivariate logistic regression.

RESULTS: A total of 3,214 complications were recorded. The most prevalent complications were prolonged ventilation time in the intensive care unit, reoperation for bleeding, and pneumonia. The overall mortality rate was 2.4% (204 of 8,361). Persons aged over 80 years had nearly double the mortality rate compared with younger patients (4.1% [18 of 444] to 2.3% [186 of 7,917]). Age greater than 80 years (odds ratio = 2.65, 95% confidence interval = 2.18 to 3.22) and male gender (odds ratio = 0.62, 95% confidence interval = 0.56 to 0.69) were the best univariate predictors of a single postoperative complication.

CONCLUSIONS: Octogenarian patients manifested twice the risk of death from a cardiac intervention with an average 2-day longer hospital stay compared with their younger counterparts. Furthermore, octogenarians were at markedly higher risk of nonfatal postoperative complications.

	Introduction

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Compared to 31.5 million in an expected 68.5 million Americans will be over the age of 65 years by the year 2050 [1]. The proportion of persons aged over 65 years is expected to increase from 12.5% in to 22.9% in 2050 [1]. Persons over age 85 can be expected to account for 3.4% of the general population, compared with 1.2% in 1990 [1]. As the average age in the United States increases, so too will the proportion of elderly patients presenting for cardiac surgical intervention. Successful cardiothoracic operations in the elderly have been well documented [2–5]. Outcomes research among octogenarians (aged 80 years or more) who have had cardiac operations is less well documented. Compared with their younger counterparts, cardiac surgery patients aged over 80 may have higher risk of mortality, increased length of stay, and acceptable 5-year survival rates [6–10].

The purpose of this study was to compare the incidence of postoperative morbidity and mortality among patients aged 80 years or more versus less than 80 years who had a cardiac surgical intervention and to determine which preoperative risk factors are predictive of an increased incidence of postoperative complications.

	Material and Methods

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Subjects were all patients who had a cardiac surgical repair or replacement operation, either coronary artery bypass (CAB) or valve repair between January 1994 and December 2000. These procedures encompass approximately 70% of all procedures performed by our cardiovascular surgical team in the elderly population over the defined period. The remaining 30% were excluded carotid endarterectomies (25%) and other assorted procedures (5%). We excluded these patients so as to include only open-heart procedures. Furthermore, small stratified sample sizes within the octogenarian group make meaningful comparisons difficult. Data were abstracted from a computerized medical record system that is consistent with the Society of Thoracic Surgeons National Database. Preoperative risk factors and postoperative complications were defined by the Society of Thoracic Surgeons National Adult Cardiac Surgery Database. Survivorship data beyond 30 postoperative days or hospital discharge was not available for analysis from this database.

Preoperative risk factors
The preoperative risk factors that we identified were defined by the Society of Thoracic Surgeons Cardiac Surgery Database and included age, race, gender, smoking (defined as past or current use of tobacco), diabetes, hypertension (defined as either a documented history of hypertension controlled by medication, diet, or exercise or blood pressure greater than 140 systolic or > 90 diastolic on a least two occasions), hypercholesterolemia (defined as a documented history of increased cholesterol), previous CAB, renal failure (defined by serum creatinine level > 2.0), and a family history of coronary artery disease (defined as any blood relatives with angina, myocardial infarction, sudden cardiac death without obvious cause at age younger than 55 years). Our surgical database does not capture preoperative nutritional status. However, we have used morbid obesity (yes/no) as a proxy for nutrition. Previous myocardial infarction was defined as previous hospitalization for myocardial infarction documented in the medical record. Previous cerebrovascular accident was defined as a central neurologic deficit lasting for more than 24 hours.

Patients were also categorized by their immediate need for an operation as elective, urgent, or emergent. Urgent cases were those not elective patients with worsening, sudden chest pain, congestive heart failure, or unstable angina. Emergent cases were those with ischemic dysfunction, acute evolving myocardial infarction within 24 hours of operation, or mechanical dysfunction.

Postoperative complications
Postoperative complications recorded were hemorrhage requiring reoperation, sternal wound infection (defined as an infection requiring excision of tissue, positive culture, or treatment with antibiotics), prolonged ventilation time (defined as pulmonary insufficiency requiring ventilator support more than 24 hours), leg wound infection (defined as an infection involving a leg vein harvest site requiring excision of tissue, positive culture, or treatment with antibiotics), stroke (a central neurologic deficit lasting for more than 72 hours), and pneumonia (defined by positive cultures of sputum, blood, etc, or consistent with the diagnoses and radiographic findings of pneumonia). Mortality was defined as all deaths occurring during hospitalization and deaths occurring after discharge but within 30 days postoperatively, given that the death is clearly unrelated to the operation.

Statistical analysis
Frequency distributions and descriptive statistics were calculated for categorical and continuous variables. P values were generated by ² tests for categorical values, and the Wilcoxon rank-sum test was used for continuous values. Preoperative risk factors were examined as predictors of either a postoperative complication or mortality by both univariate and multivariate unconditional logistic regression (SAS Institute, Cary, NC). Odds ratios and 95% confidence intervals were reported. Statistical significance was set at the 0.05 level and all tests are two-tailed.

	Results

Top Abstract Introduction Material and Methods Results Comment References

 
Three thousand two hundred fourteen patients had at least one complication among 8,361 patients who underwent a cardiac operation. Male patients comprised 74.1% (6,196 of 8,361) of the patient population. Overall mean age was 63.0 ± 11.4 years. Octogenarians comprised 5.3% (444 of 8,361) and were 57.0% (253 of 444) male. Of the 1,505 valve procedures, 166 were valve repair alone (4.2% aortic, 93.4% mitral, 0.0% pulmonary, and 5.4% tricuspid), 1,264 were valve replacement alone (71.1% aortic, 35.4% mitral, 3.8% pulmonary, and 1.5% tricuspid), and 75 were replacement and repair combinations (77% were either an aortic or mitral valve replacement with a tricuspid repair).

Table 1 contains preoperative risk factors stratified by cardiac procedure (CAB and valve) and age group (octogenarian versus nonoctogenarian). Compared with nonoctogenarians, octogenarians who had CAB were significantly less likely to be male, smoke, have high cholesterol, be morbidly obese, diabetic, and have a family history of coronary artery disease. However, octogenarians who had CAB were more likely to be hypertensive, have had renal failure, chronic obstructive pulmonary disease, and congestive heart failure. Octogenarian CAB patients were as likely to have had a previous CAB, renal failure, an ejection fraction less than 40% and have their current cardiac procedure regarded as more immediately necessary, ie, urgent or emergent.

Postoperative outcomes stratified by cardiac procedure and age group are presented in Table 2. Octogenarian patients who had CAB compared with nonoctogenarians were statistically significantly more likely to have an increased hospital length of stay, at least one complication, reoperative bleeding, prolonged ventilation time, leg infection, and pneumonia. Octogenarian CAB patients were at no increased risk of a sternal wound infection, stroke, or death.

When all cardiac procedures are combined, the single best univariate predictor of at least one complication was age greater than 80 years (odds ratio [OR], 2.65; 95% confidence interval [CI], 2.18 to 3.22) (Table 3). The risk factor most protective of at least one complication was being male (OR, 0.62; 95% CI, 0.56 to 0.69). After adjustment for all other risk factors, age greater than 80 years was the most significant predictor of at least one complication (OR, 2.19; 95% CI, 1.74 to 2.80) and male gender remained the most protective (OR, 0.69; 95% CI, 0.61 to 0.78) (Table 3).

	Comment

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In the most recent studies reporting mortality rates among octogenarian cardiac surgery patients, Colon and colleagues [11] documented a mortality rate of 14.7%, and Liu and Leung [12] reported a mortality rate of 5%. Wong and associates [13] reported a mortality rate of 11% among 37 patients who had cardiac operations (54% CAB). Fruitman and colleagues [14] reported a low mortality rate of 7.9% among 127 patients who had cardiac operations (65.4% CAB). In the largest sample of octogenarians who had cardiac operations to date, Craver and colleagues [6] reported a mortality rate of 9.1% compared with patients aged 60 to 69 years and only slightly higher when compared with 70- to 79-year-old patients (9.1% versus 6.7%). One observation from reviewing this literature is the appearance that sample size plays a major role in the mortality rate. Reports with increasing numbers of octogenarians convey lower mortality rates. This is encouraging for it suggests that the actual mortality rate has yet to be determined, if only for lack of sample size.

In addition, our results concerning nonfatal complications are comparable to those of recently published reports. Liu and Leung [12] reported that 69% of patients aged 80 years or more had at least one postoperative complication; we report a rate of 61.5%. In addition, the rate of pulmonary complications is similar (Liu and Leung [12], 7% versus 8.2%). However, our second most frequently occurring complication was leg infection. This complication was not reported in the studies of Liu and Leung or Craver and associates. Gurevitch and colleagues [15] reported a sternal complication rate of 2.2% among 92 patients aged 75 years or more. At present, the interpretation of complication rates in the very old is difficult. There are few studies, with each reporting and summarizing reports in different ways.

There are potential limitations to this study. Statistical inference is always tenuous at best when 5% of a sample is compared to 95%. However, we believe this potential limitation is minimized for the following two reasons: (1) the long length of time in which patients accrued (1994 to 2000) and (2) the population-based perspective. As far as changes in surgical procedures, we performed several analyses focusing on short intervals (1994 to 1996, 1996 to 1998, and 1998 to 2000, data not shown) resulting in minimal deviance from the 1994 to 2000 estimates. We have included all octogenarian patients who had a CAB or valve procedure during this period. The Society of Thoracic Surgeons database is a surgical database; thus we collect no information on why an individual was denied a surgical procedure. Patients are evaluated individually based on their quality of life, life expectancy, comorbidities, and the potential for cognitive decline. It is important to note that octogenarian patients are evaluated based on physiologic age not chronologic age. Open-heart operation carries a certain expectation that the patient will return to some level of presurgical functional status. A candidate may be denied an operation if the expected gain in postsurgical functional status is minimal.

Lastly, the lack of available survival data on our part is worth noting. Our participation in the Society of Thoracic Surgeons database is limited to 30 postoperative days; thus survival data beyond this period is not part of our collection process. We recognize that although the accumulation of such data has tremendous appeal, the accumulation of survival data is expensive and time-consuming, and currently we lack such institutional resources. However, we are in the process of exploring extramural funding options to garner the use of such national resources as the National Death Index to further explore this population.

We believe that the strengths of our study are worth noting, namely, our large sample size and stratification by cardiac procedure. Previous studies have had sample sizes of less than 200 patients, with as few as 37. Given our sample size of almost 500 octogenarians, we believe we can more than adequately calculate octogenarian mortality rates among our growing octogenarian community. Additionally, stratification by age and procedure gives other investigators the opportunity to compare their findings with relatively homogeneous subgroups. In previous work, nearly 10% of the study population was comprised of octogenarians. In our study it was only 5%. We have no explanation for this rate difference. However, given the population-based nature of our study, we have attempted to include all patients available for analysis during this time period.

In this retrospective study of patients who had a surgical cardiac intervention, we conclude that the incidence of postoperative complications was significantly greater among octogenarians than nonoctogenarians. Furthermore, the mortality rate among octogenarians was 70% greater than that of their younger counterparts. Given the increasing longevity of the United States population, the very old will become a larger proportion of patients presenting for surgical cardiac intervention. The potential benefits of bringing the patient back to a productive lifestyle will be greater.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Linda S. Halpin Alan M. Speir Robert A. Albus Bechara F. Akl Paul S. Massimiano Nelson A. Burton Lucas R. Collazo Edward A. Lefrak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Barnett, S. D. Articles by Lefrak, E. A. Search for Related Content PubMed PubMed Citation Articles by Barnett, S. D. Articles by Lefrak, E. A. Related Collections Cardiac - other