Ann Thorac Surg 1997;63:1314
© 1997 The Society of Thoracic Surgeons
Invited Commentary
Invited Commentary
Neal W. Salomon, MD
The Heart Center at Sinai, Johns Hopkins Cardiac Surgery Associates, Weinberg Building, Suite 502, 2411 W Belvedere Ave, Baltimore, MD 21215
See also page 1309.
This retrospective review by Katz and Chase from Georgetown University Medical Center provides a state-of-the-art general review of current results to be expected from coronary artery bypass grafting, valve operations, and combined coronary artery bypass grafting and valve procedures in the general population. These results are clearly attributable to good surgical technique, excellence in postoperative care, and reasonable patient selection, particularly in the elderly age group. Over the 5-year course of this study, inevitable modifications of technique evolved including the more common use of epiaortic echocardiography to examine the ascending aorta, more liberal use of antegrade and retrograde cardioplegic techniques, use of renal protective measures, modification of anesthesia and early extubation protocols, and a variation of retrosternal dissection methods in redo operations. It is not possible to quantitate the contribution of any of these individual techniques to the excellent overall results.
Criticism could be raised in that perhaps age 70 years was not a stringent enough criterion to dichotomize the patient population into a higher chronologic age risk category, but examination of the data reveals only a 2% mortality rate for patients older than 80 years with similar risk-stratification criteria. The concomitant use of two indices of perioperative mortality may be a bit confusing in that the 30-day mortality rate for the group of patients 70 years old and older was 1.8%, but the overall hospital mortality for this group was actually 3.2% (9/285) compared with a hospital mortality rate for patients less than 70 years old of 2.5%. Multiple logistic regression analysis negated both patient age greater than 70 years and patient sex as significant risk factors. In this study, age greater than 80 years might also have been eliminated as a risk factor. Clearly, these are very commendable results.
My only potential criticism is the rather long overall length of stay, although comments are made that the length of stay decreased significantly in the last year of this retrospective study. In addition, both groups seemed to have a rather high rate of return to the operating room of 6% to 7%. With the current heavy interest in expansion of minimally invasive as well as off-pump operation for both high- and low-risk patients, perhaps studies such as this provide a reasonable benchmark to which comparison can be made, particularly in regard to neurologic and renal complications, cost, and length of stay. Obviously, completeness of revascularization may be the most important issue, and we must assess our techniques to see what shortcuts actually make not only short-term but more importantly long-term sense.
I believe this report is appropriately subtitled "Reduction of the Age Factor" rather than "Elimination of the Age Factor." Perhaps with improvements in patient selection criteria, chronologic age will continue to fade as a risk factor, thereby leaving true "physiologic age" the critical variable.
Related Article
-
Risks of Cardiac Operations for Elderly Patients: Reduction of the Age Factor
- Nevin M. Katz and Gary A. Chase
Ann. Thorac. Surg. 1997 63: 1309-1314.
[Abstract]
[Full Text]
