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Ann Thorac Surg 1997;63:606-607
© 1997 The Society of Thoracic Surgeons
Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, Springfield, Massachusetts
Ott and associates [1] have reviewed their experience in an expedited recovery protocol after coronary artery bypass grafting to determine its efficacy in an elderly population. They have clearly shown that early discharge is feasible in a substantial proportion of patients 70 years of age or older (19% discharged in <5 days after operation and 88% in <10 days). As emphasized by Ott and associates, a carefully defined protocol is required that is based on an uncomplicated operation and an anesthetic approach permitting early extubation.
The expedited recovery protocol by Ott and associates primarily employs the fast-track principles as described by both Krohn and associates [2] and Engelman and associates [3] with some significant modifications that deserve editorial comment. First and foremost is the decision to promote as a major goal of their approach a reduction of operative time with cardiopulmonary bypass limited to less than 75 minutes and ischemic time to less than 45 minutes. This, by necessity, limits the number of coronary bypass grafts performed and is justified by the statement: "We believe that unnecessary overrevascularization should be discouraged because it leads to a prolonged operation with an increased risk of perioperative complications." The issue as I see it is not "unnecessary overrevascularization" but whether complete revascularization is necessary or even advisable in the elderly.
These issues have been previously addressed in the literature. Specifically, a review of the original Coronary Artery Surgery Study clearly showed that the completeness of revascularization and specifically performing three or more versus two bypass grafts was associated with improved long-term and event-free survival [4]. However, the number of grafts alone does not adequately address the issue as raised by Ott and associates. Are three or four grafts sufficient if the bulk of myocardium at risk is perfused, or should additional grafts be placed if branch coronary arteries greater than 1.0 mm are jeopardized? Ott and associates are clearly convinced that too many grafts or "unnecessary over-revascularization" is not indicated because it increases operative time and the attendant risk. The data to support this contention are not provided, however, and in fact may not have even ever been addressed. Suffice it to say that the majority of surgeons do not hold to a limiting criterion of cross-clamp time, but to completeness of revascularization as a principle. Despite this statement, clearly, interventional cardiologists routinely use incomplete revascularization with great success and whether surgeons perform complete revascularization or unnecessary revascularization is a matter of clinical judgement.
Another principle used by Ott and associates with great success is the liberal indication for intraaortic balloon pumping. The indications are failed percutaneous transluminal coronary angioplasty requiring urgent or emergent operation; emergency reoperation; left main coronary artery disease of 70% or greater, considered critical; left ventricular dysfunction with an ejection fraction of 0.40 or less; or unstable angina refractory to treatment. These guidelines necessitated intraaortic balloon pump placement in 47% of patients less than 70 years of age and 53% of patients 70 years of age or older. This very high percentage in any reported coronary artery bypass grafting series is probably near twice the incidence of most centers. Remarkably, the intraaortic balloon pump complication rate was only 1.4% in younger patients and 2.2% in the elderly. This is true despite symptomatic vascular disease in 13% and 20%, respectively, and is significantly less than that of other reported series, which have vascular complication rates near 10% [5]. The most likely explanation for these excellent results as defined by Ott and associates is the advantage of controlled, elective placement of the intraaortic balloon pump. Nonetheless, the paucity of complications is commendable, particularly in the elderly.
The other fast-track approach unique to Ott and associates is the use of intravenous triiodothyronine at the initiation of cardiopulmonary bypass followed by intravenous thyroid hormone administration for the first 2 days after operation. Ott and associates admit the data are not clear that thyroid hormone administration alters outcome or expedites recovery, but a single recent report by Klemperer and associates [6] documents how triiodothyronine administration lowers the incidence of atrial fibrillation after cardiac operations. Indeed, Ott and associates report a very low incidence of new onset atrial fibrillation at 8.2% for patients aged less than 70 years and 10.6% for those 70 years old or older, or an overall incidence of 9.4%.
The message to be delivered from this report concerns the appropriate use of an expedited recovery protocol in the elderly bypass patient. Indeed, the data presented clearly support this conclusion. The uniform aspects of the protocol are (1) uncomplicated operations, (2) early extubation, (3) vigorous rehabilitation beginning the day after operation, (4) active participation with social service, and (5) intensive postdischarge follow-up. Age should not be a consideration in expediting recovery, and the use of ancillary measures such as triiodothyronine, intraaortic balloon pumping, or even short cardiopulmonary bypass is not necessary for fast track to succeed.
Footnotes
Address reprint requests to Dr Engelman, Division of Cardiac Surgery, Baystate Medical Center, 759 Chestnut St, Springfield, MA 01199.
References
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  N. Charokopos, P. Antonitsis, M. Toumbouras, J. Konstantinopoulos, and E. Rouska Influence of Fast-Track Recovery after Coronary Artery Bypass in the Elderly Asian Cardiovasc Thorac Ann, April 1, 2007; 15(2): 144 - 148. [Abstract] [Full Text] [PDF]
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