Jan 12, 2011 - Operative procedures included on-pump Coronary Artery. Bypass Grafting (CABG) (47), Off-Pump Coronary Artery. Bypass Grafting (OPCABG) ...
Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:15–19 DOI 10.1007/s12055-010-0076-y
ORIGINAL ARTICLE
Contemporary perioperative results of cardiac surgery in the elderly- our experience Nikhil Prakash Patil & Prashant Sevta & Nilanjan Dutta & Vishal Vikas Khante & Akshay Balbir Sharma & Deepak Kumar Satsangi
Received: 21 October 2010 / Accepted: 1 December 2010 / Published online: 12 January 2011 # Indian Association of Cardiovascular-Thoracic Surgeons 2011
Abstract Objective With progressive aging of population in developing nations, cardiac surgeons increasingly face elderly patients. These patients are usually symptomatic, yet at high risk for intervention. This study aims to review our experience in elderly Indian patients. Methods We reviewed the records of 128 elderly patients (mean age 74.6 years; range 70–84) operated at our institution from 2005 to 2009. Postoperatively, patients were followed-up in the out-patient-department. Results Surgery was performed on 10 as an emergency and 41 on an urgent (on the day of referral or the following day) basis. Mean left ventricular ejection fraction was 44%± 9.5. Early mortality (during current admission or within 30 days of discharge from the hospital) was 12 (9.3%). Mean New York Heart Association functional class was improved from 3.0±0.8 preoperatively to 1.5±0.7 postoperatively. Median Intensive Care Unit and in-hospital stay was 4 days (range 1–17) and 12 days (range 4–37), respectively. Postoperative complications included pneumonia (6.3%), stroke (5.5%), reoperation for bleeding (4.6%) and intra-aortic balloon pump requirement (4.6%). Emergency surgery was significantly associated (P48 h Pneumonia
1 1 1 1 0 1 3 0
4 3 2 1 1 1 11 2
0 0 1 0 1 1 3 1
1 0 1 0 0 0 2 1
2 0 0 0 0 0 2 1
3 2 1 0 0 0 4 1
1 1 1 0 0 0 4 2
12 (9.3%) 6 (4.6%) 7 (5.5%) 2 (1.6%) 2 (1.6%) 3 (2.3%) 29 (22.7%) 8 (6.3%)
IABP Hospital Stay >14 days
0 4
3 12
1 4
0 2
0 2
1 7
1 3
6 (4.6%) 34 (26.6%)
AVR Aortic Valve Replacement, CABG on-pump Coronary Artery Bypass Grafting, DVR Double Valve Replacement, IABP Intra aortic balloon pump, MVR Mitral valve replacement, MI Myocardial Infarction, OPCABG Off-Pump Coronary Artery Bypass Grafting Numbers in parentheses indicate percentage of total cases
Discussion Combining the bona fide documentation of a retrospective analysis with the merits of a postoperative follow-up, this series clearly demonstrates that for elderly patients greater than 70 years of age cardiac surgery can attain useful results. Operative mortality and morbidity, ICU and in-hospital stay Based on the results of our study and studies by others, we conclude that the elderly have a great chance of being cured from heart disease after successful open-heart surgery [9– 15]. However, a price has to be paid in terms of morbidity, as 67.1% of the patients experienced postoperative complications, which has also been documented previously [7]. This high rate of complications is related to a prolonged stay in ICU and hospital. Unlike other studies [16–18], the type of operative procedure was not shown to be a significant risk factor for mortality. This may be attributable to the fact that due to the limited numbers of a small study, the confidence intervals are wide and P values do not reach Table 4 Factors affecting early mortality
ACC Aortic Cross Clamp, CPB Cardiopulmonary Bypass, NYHA New York Heart Association
Variable
P value
Age Gender NYHA class ACC time CPB time Operative procedure Emergency surgery
0.62 0.36 0.17 0.24 0.45 0.05 0.04
the 0.05 level of significance. Emergency surgery was significantly associated with an increased risk of mortality. This has been shown in previous studies in the elderly population [5, 16]. In our experience this group includes patients with post-infarct VSD’s and acute aortic dissection, a subset of patients known to fare poorly more often than not. We therefore do not believe that emergency status alone is a contraindication to surgery in these patients but where possible delays in surgery are best avoided. Unless an indication for anti-coagulation is present, most surgeons favour implantation of a biological prosthesis in
Fig. 2 Change in mean functional NYHA class. AVR: Aortic Valve Replacement; CABG: on-pump Coronary Artery Bypass Grafting; DVR: Double Valve Replacement; IABP: Intra aortic balloon pump; MVR: Mitral valve replacement; MI: Myocardial Infarction; NYHA: New York Heart Association; OPCABG: Off-Pump Coronary Artery Bypass Grafting
Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:15–19
these patients. To comment on valve related complications when a limited number of patients receive a variety of different implants is not ideal, though in our series no patients with biological valves have required reoperation for structural dysfunction of the implanted valve. Quality of life The effectiveness of open-heart surgery in terms of improved quality of life is high. Complete and adequate filling-out of quality-of-life questionnaires again appeared troublesome [19]. However, we had no strong reasons to believe that this additional information would significantly influence the outcome of 82% of the survivors being free of angina and 63% being free of dyspnoea on exercise, in addition to 76% of the patients subjectively reporting an “improved” quality of life after the surgery, which indicate that postoperative survival includes a very acceptable quality of life.
Conclusion We believe that elderly patients with severely limiting cardiac disease can benefit from cardiac surgery with an acceptable early mortality. Operative procedures and cardiopulmonary bypass times are not risk factors for early mortality. Postoperatively, patients attain an excellent and improved quality of life. Emergency surgery in this group of patients is less rewarding.
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