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Ann Thorac Surg 1998;66:60-67
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy

^a Department of Thoracic and Cardiovascular Surgery, Hôpital Henri Mondor, Créteil, France

Accepted for publication January 8, 1998.

Address reprint requests to Dr Loisance, Service de Chirurgie Thoracique et Cardiovasculaire, Hôpital Henri Mondor, 51 Avenue du Mal de Lattre de Tassigny, 94010, Créteil Cédex, France
e-mail: (loisance{at}univ-paris12.fr)

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. With the progressive aging of western populations, cardiac surgeons are increasingly faced with elderly patients.

Methods. We reviewed the records of 191 consecutive patients aged 80 years or older (mean age, 83 ± 2.4 years) who underwent a cardiac surgical procedure at our institution from 1991 through 1996.

Results. Ninety-eight patients were men. Preoperatively, 32% of patients were in New York Heart Association class III or IV, and mean left ventricular ejection fraction was 0.55 ± 0.02. One hundred ten patients (58%) underwent aortic valve replacement, 47 (25%) had coronary artery bypass grafting, 26 (14%) had combined aortic valve replacement and coronary artery bypass grafting, 5 (3%) underwent mitral valve replacement, and 3 (1.6%) had other procedures. Postoperative complications occurred in 69.1% of patients. The hospital mortality rate was 16.2%. Actuarial survival estimates at 1 year, 3 years, and 5 years were 79.2%, 74.9%, and 56.2%, respectively. Multivariate predictors (p < 0.05) of hospital death were preoperative pulmonary hypertension and lower left ventricular ejection fraction. Multivariate predictors of late death were combined aortic valve replacement and coronary artery bypass grafting and female sex. Sixty-four percent of long-term survivors were fully autonomous, and female sex was the only independent predictor of impaired autonomy. Eighty-three percent of survivors were satisfied with their present quality of life.

Conclusions. Cardiac operations can be performed in octogenarians with a favorable long-term outcome. Earlier referral and intervention is mandatory to improve results in this patient population.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The major reduction in natality and, to a lesser extent, the reduced mortality in all age groups have contributed to the progressive aging of western populations [1]. More recently, this trend has been accentuated mainly because of an increase in the life expectancy of the very elderly [1]. In France, 2.1 million persons are aged 80 years or older (3.7% of the overall population), and these numbers are expected to rise dramatically at the beginning of the next century [2, 3]. Life expectancy at 80 years of age is 6.9 years for men and 8.7 years for women [1]. Cardiovascular disease is extremely prevalent in this subgroup of the population [4], with approximately 40% of octogenarians having symptomatic cardiovascular disease [5]. These patients constitute an increasing pool of potential candidates for cardiac surgical procedures [6].

Major improvements in surgical, anesthesia, cardiopulmonary bypass, and postoperative management techniques have contributed to the excellent survival results reported after open heart operations in increasingly older patients [7–11]. Moreover, as surgical success can no longer be evaluated by survival alone, several studies [12–14] have shown substantial improvement in functional capacity and quality of life after cardiac operations in the very elderly. Further improvement in surgical results in this high-risk patient population necessitates the identification of perioperative risk factors for mortality or suboptimal functional outcome after cardiac surgical procedures.

Our early experience with this high-risk group of patients has been reported previously [15]. However, that series was restricted to patients with severe aortic stenosis and comprised only a limited number of patients, thus precluding multivariate risk-factor analysis. Therefore, we undertook the present study to describe our more recent experience with a larger series of 191 consecutive patients aged 80 years or older and to identify risk factors for early and late postoperative mortality, impaired autonomy, and reduced quality of life.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
Between January 1, 1991, and December 31, 1996, 191 consecutive patients aged 80 years or older underwent cardiac surgical procedures with cardiopulmonary bypass at Henri Mondor University Hospital, Créteil, France.

Data collection
Hospital records were reviewed retrospectively for patient demographic characteristics, preoperative status, preoperative comorbidity, intraoperative course, and postoperative course. Perioperative variables included in the study were as follows:

Preoperative

Age

Sex

New York Heart Association classification

Left ventricular ejection fraction (LVEF)

Tobacco use

Systemic hypertension

Obesity

Diabetes mellitus

Peripheral vascular disease

Cerebrovascular disease

Chronic bronchopulmonary disease

Pulmonary hypertension

Preoperative renal insufficiency

Intraoperative

Procedure

Timing of operation

Cardiopulmonary bypass time

Aortic cross-clamp time

Postoperative

Stay in intensive care unit

Cardiogenic shock

Congestive heart failure

Myocardial infarction

Supraventricular arrhythmia

Conduction disorder

Pulmonary complication

Renal insufficiency

Cerebrovascular accident

Gastrointestinal complication

Infection

Transfusion requirements

Reexploration

Left ventricular ejection fraction was assessed by cardiac catheterization and was performed selectively in patients referred for coronary artery bypass grafting (CABG) or patients with strong clinical indications of coronary artery disease (ie, history of angina or cardiovascular risk factors). Hypertensive patients were defined as patients receiving antihypertensive treatment. Patients with cerebrovascular disease included those with a history of stroke, transient ischemic attacks, or both. Peripheral vascular disease was considered present in patients with a history of intermittent claudication, peripheral vascular operation, or both. Pulmonary hypertension was assessed by Doppler echocardiography and defined as a resting pulmonary artery pressure higher than 20 mm Hg. Preoperative renal insufficiency was determined by serum creatinine levels higher than 1.5 mg/dL (130 µmol/L).

Operation was considered elective if the patient was admitted to the cardiac surgery department electively on the day preceding the operation. Urgent operations were defined as operations performed on the day of referral or the following day. Emergent operations were defined as immediate surgical intervention in critically ill patients. The operative technique was similar in all patients. After standard anesthesia, a median sternotomy was performed followed by routine aortic and right atrial cannulation. Cardiopulmonary bypass was carried out using membrane oxygenators, nonpulsatile perfusion, and moderate systemic hypothermia (28°C). Myocardial protection was achieved by cold hyperkalemic crystalloid cardioplegia (Assistance Publique-Hôpitaux de Paris solution) and topical cooling with cold saline solution. Cardioplegia was administered in an antegrade fashion in all patients, and reinfusion was not employed routinely during operation. Bioprostheses were used preferentially for valve replacement unless systemic anticoagulation was required because of an associated condition; then a mechanical prosthesis was used. Coronary artery bypass grafting was performed using reversed saphenous vein in most instances.

Hospital death was defined as death occurring within 30 days of operation. All postoperative complications were recorded. Infection included any postoperative infectious complication requiring antibiotic therapy. Pulmonary complications comprised all those leading to prolonged mechanical ventilation. Intraabdominal complications included only those requiring operative intervention. Postoperative vasodilatation was defined as a high cardiac output state associated with low systemic vascular resistance and requiring vasopressor support.

Follow-up information was obtained during February 1997 by telephone interview of the patient, the patient’s relatives, or the referring physician. Questions were asked in regard to cause and date of death, patient’s autonomy, and subjective appreciation of his or her quality of life. Late death was defined as death occurring more than 30 days after operation. Fully autonomous patients were defined as those able to live on their own and handle their daily routine.

Statistical analysis
Statistical analysis was performed using SPSS statistical software (SPSS Inc, Chicago, IL). Continuous variables were expressed as the mean ± 1 standard deviation and were compared using an unpaired two-tailed t test. Categoric variables, expressed as percentages, were analyzed with a ² test. A two-tailed p value of less than 0.05 was taken to indicate statistical significance.

Survival data were analyzed with standard Kaplan-Meier actuarial techniques for estimation of survival probabilities. To identify risk factors for hospital mortality, univariate analysis of preoperative, intraoperative, and postoperative variables was performed by comparing two or more independent subsets of patients using the log-rank test (Mantel-Cox test). To evaluate independent risk factors for hospital mortality, preoperative and intraoperative variables were examined by multivariate analysis by forward stepwise logistic regression. Coefficients were computed by the method of maximum likelihood. In a subsequent analysis, significant preoperative or intraoperative variables and all postoperative variables were introduced into the logistic model. Analysis of preoperative, intraoperative, and postoperative factors influencing long-term survival (survival longer than 1 month) was performed by multivariate proportional hazard regression analysis (Cox model).

To identify risk factors for impaired autonomy among long-term survivors, univariate analysis of perioperative variables was performed by comparing two groups of patients, patients with impaired autonomy (group 1) and fully autonomous patients (group 2). Independent predictors of impaired autonomy were subsequently determined by forward stepwise logistic regression analysis.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patient characteristics and operative details
Figure 1 shows the percentage of operations performed on octogenarians during the 6-year study period. Mean patient age was 83 ± 2.4 years (range, 80 to 91 years). The series comprised 98 men and 93 women. Mean preoperative functional status as assessed by New York Heart Association functional classification was 2.15 ± 1.0. Preoperative coronary arteriography was performed in 127 patients (66.5%). Left ventricular ejection fraction was evaluated in 121 patients (63%) and averaged 0.55 ± 0.02. Selected patient characteristics and associated comorbidity are shown in Table 1. Operative data are presented in Table 2.

View larger version (18K): [in this window] [in a new window]   Fig 1. Percentage of cardiac operations performed on octogenarians each year of study.

View larger version (15K): [in this window] [in a new window]   Fig 2. Actuarial survival for entire patient population. Error bars represent ± 1 standard error of the mean.

View larger version (13K): [in this window] [in a new window]   Fig 3. Actuarial survival curves for patients with a preoperative left ventricular ejection fraction (LVEF) of 0.50 or less compared with those with an LVEF of greater than 0.50. Error bars represent ± 1 standard error of the mean.

View larger version (16K): [in this window] [in a new window]   Fig 4. Actuarial survival for patients with preoperative pulmonary hypertension compared with those without this condition. Error bars represent ± 1 standard error of the mean.

View larger version (16K): [in this window] [in a new window]   Fig 5. Actuarial survival for patients with combined coronary artery bypass grafting (CABG) and valve replacement compared with those having isolated CABG or isolated valve replacement. Error bars represent ± 1 standard error of the mean.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This report reviews the long-term results for 191 patients 80 years old or older having a cardiac operation at a single institution. During the study period of 6 years, the number of operations performed on octogenarians more than doubled (25 patients in 1991 to 57 patients in 1996). Similar increases in cardiac surgical procedures involving the very elderly have been reported by other groups [16], and this finding underscores the importance of a regular reappraisal of the results of cardiac operations on this subgroup.

The hospital mortality and the late survival probability in our patient population were similar to those reported by others [9–11, 17–20]. Overall hospital mortality in the present study was lower than in a previous report by our group [15] about aortic valve replacement in 60 patients aged 80 years or older and having operation between 1981 and 1989 (16.2% versus 28%). However, in the former study, more patients were in New York Heart Association functional class III or IV (78% versus 32%), and preoperative renal insufficiency was more prevalent (28% versus 8%). On the other hand, mean patient age increased from 82 ± 3 to 83 ± 2.4 years, and combined procedures tended to be performed more frequently in recent years (14% versus 8%). These observations mainly reflect earlier patient referral and better patient selection. However, multifactor improvement in anesthesia, surgical, and cardiopulmonary bypass techniques and better postoperative management have probably also contributed to the improvement in early survival.

More than two thirds of the hospital deaths in our study were cardiac related. Preoperative pulmonary hypertension and reduced preoperative LVEF appeared to be significant and independent predictors of hospital mortality in our study. Preoperative pulmonary hypertension or an LVEF of strictly less than 0.50 resulted in excessive hospital mortality rates of 29% and 17%, respectively. Similarly, McGrath and associates [21] reported that increased preoperative pulmonary artery diastolic pressure is a multivariate risk factor for overall mortality, and several other studies have shown that impaired preoperative LVEF is a significant predictor of early mortality after CABG [22–24] or aortic valve replacement [25, 26] in the elderly. Thus, decreased left or right functional reserve or a combination of both appears to be a major determinant of hospital mortality in the elderly. Therefore, elderly patients should be referred and have operation early before severe myocardial dysfunction is present. Further, optimal myocardial protection is mandatory in this subgroup of patients. In our series, cardioplegia has always been administered in an antegrade fashion, but associated coronary artery disease might impair adequate cardioplegia delivery. Retrograde cardioplegia has been proposed to circumvent this problem [27]. Combined antegrade and retrograde cardioplegia has been shown to improve myocardial recovery after cardioplegia in pediatric and adult patients and therefore might be beneficial in the setting of the very elderly cardiosurgical patient [28–30].

The prevalence of coronary artery disease increases dramatically with age. Hancock [31] reported a 33% incidence of severe coronary artery disease in patients 40 to 49 years old, a 38% incidence in patients between 50 and 59 years old, a 64% incidence in patients between 60 and 69 years old, and a 76% incidence in those older than 70 years. Therefore, the association of valvular heart disease and coronary artery disease is a common finding in elderly patient populations [4]. In the present series, this association occurred in 25.3% of patients with valvular heart disease. However, preoperative coronary arteriography was not performed routinely in patients referred for valvular heart disease but was limited to those with a history of angina or cardiovascular risk factors. Although the absence of angina or cardiovascular risk factors has a poor negative predictive value for coronary artery disease and most certainly omits some patients with coronary pathology [32], we could not find a significant difference in postoperative survival between patients who underwent preoperative coronary angiography and those who did not. On the contrary, patients without preoperative coronary angiography tended to perform better after operation. Thus, our experience does not support the systematic use of coronary angiography in the very elderly patient. A refined screening method like the one proposed by Ramsdale and co-workers [33] would optimize patient selection for invasive preoperative testing.

In patients with combined aortic valve disease and severe coronary artery disease, aortic valve replacement and myocardial revascularization should be performed during the same surgical intervention [34]. Indeed, when severe coronary artery disease is left untreated, patients have a lower postoperative survival than those who undergo concomitant CABG [35]. Some groups [26, 36–39] have reported that combined aortic valve replacement and CABG is an independent predictor of hospital mortality. Culliford and colleagues [36] observed a hospital mortality rate of 5.7% for isolated aortic valve replacement and 19.4% for aortic valve replacement plus CABG. Fiore and coauthors [37] reported an early mortality rate of 9% for isolated valve replacement but a 28% early mortality rate after single-valve replacement combined with CABG. This increased hospital mortality after combined procedures is probably a consequence of prolonged operative times and suboptimal myocardial protection secondary to impaired cardioplegia delivery.

In contrast, we found that despite significantly increased cardiopulmonary bypass time and aortic cross-clamp time, patients with combined procedures had a hospital mortality similar to that of patients undergoing isolated CABG or isolated valve replacement. Adkins and associates [40] also reported excellent results after combined procedures in the octogenarian. The more rapid and less aggressive transmyocardial laser revascularization technique might be an interesting alternative in the setting of myocardial revascularization associated with valve replacement in the very elderly patient [41]. Combined valve replacement and CABG appears to be a significant predictor of late mortality. Similar results have been reported by Bessone and co-workers [42]. Late outcome after operation is more dependent on the extent of myocardial damage as a result of the primary disease than on the myocardial insult during operation. These findings favor earlier intervention at a time when myocardial tissue can still be salvaged.

In the general population, the life expectancy for women is significantly longer than that for men [1, 2]. This explains the high proportion of female patients and the sex ratio close to 1 in our study. Several studies have shown that as for younger patients, female sex is a significant risk factor for hospital mortality in the elderly after aortic valve replacement [25, 43] or combined procedures [38]. In contrast, Glower and colleagues [44] found a trend for elderly women to have a lower in-hospital mortality, but the results did not achieve significance. In the present study, hospital mortality was similar for male and female patients. However, female sex appeared to be a significant independent predictor of late mortality. Women have smaller coronary arteries, thus making myocardial revascularization technically more demanding with probably poorer long-term results. Further, female patients are more likely to have a small aortic root and therefore to require smaller prostheses. The high profile of the stent-mounted heterograft bioprosthesis is an additional factor contributing to reduction of the effective valve orifice area [45]. It is possible that the poor late results observed in female patients are the delayed effects of a more or less important residual stenosis caused by the prosthesis. On the other hand, an aortic root enlargement procedure would most certainly increase the operative risk in this elderly and fragile patient population. Finally, recent studies [46] suggest that the late referral pattern of women may contribute to their poor outcome after cardiac surgical procedures.

Assessment of postoperative quality of life revealed that 83% of long-term survivors were satisfied with their present quality of life. Although quality of life was not precisely quantified according to a validated scale, we believe that these subjective results are very encouraging. Further, nearly two thirds of long-term survivors were completely autonomous. By multivariate analysis, only female sex appeared to be an independent predictor of impaired postoperative autonomy. Jaeger and associates [14] also reported that female sex is an independent predictor of less improvement in functional capacity 1 year after cardiac operation. These findings are probably related to the same reasons that make female sex a risk factor for late mortality after a cardiac surgical procedure.

In conclusion, with the progressive aging of western populations, cardiac surgeons and cardiologists will be caring for an increasing number of elderly patients. Despite a high incidence of postoperative complications, cardiac surgical procedures can be performed in octogenarians with an acceptable hospital mortality (16.2%) and gratifying long-term survival results. Most long-term survivors are satisfied with their quality of life, and almost two thirds are fully autonomous. Early referral of patients before severe cardiac dysfunction is mandatory to improve immediate postoperative survival and make possible a long-term benefit for surgical intervention.

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				D. Rosborough Cardiac Surgery in Elderly Patients: Strategies to Optimize Outcomes Crit. Care Nurse, October 1, 2006; 26(5): 24 - 31. [Full Text] [PDF]

				M. Shiono, M. Hata, A. Sezai, M. Iida, S. Yagi, and N. Negishi Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians Ann. Thorac. Surg., August 1, 2006; 82(2): 554 - 559. [Abstract] [Full Text] [PDF]

				C. G. Koch, F. Khandwala, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Impact of Prosthesis-Patient Size on Functional Recovery After Aortic Valve Replacement Circulation, June 21, 2005; 111(24): 3221 - 3229. [Abstract] [Full Text] [PDF]

				F. Collart, H. Feier, F. Kerbaul, A. Mouly-Bandini, A. Riberi, T. G. Mesana, and D. Metras Valvular surgery in octogenarians: operative risks factors, evaluation of Euroscore and long term results Eur. J. Cardiothorac. Surg., February 1, 2005; 27(2): 276 - 280. [Abstract] [Full Text] [PDF]

				E. A Black, S. Ghosh, K. Sin, T. Spyt, and R. Pillai Off-Pump Coronary Artery Bypass Surgery Asian Cardiovasc Thorac Ann, December 1, 2004; 12(4): 379 - 386. [Abstract] [Full Text] [PDF]

				B. L. Sandifer, S. Steinbis, E. L. Jones, and C. Lawrence Pharmacologic Management of Pulmonary Hypertension Associated With Mitral Valve Disease Chest Meeting Abstracts, October 1, 2004; 126(4): 972S - 973S. [Abstract] [Full Text] [PDF]

				C.-Y. Ng, M. F. Ramli, and Y. Awang Coronary Bypass Surgery in Patients Aged 70 Years and Over: Mortality, Morbidity, Length of Stay and Hospital Cost Asian Cardiovasc Thorac Ann, September 1, 2004; 12(3): 218 - 223. [Abstract] [Full Text] [PDF]

				A. Sedrakyan, V. Vaccarino, A. D. Paltiel, J. A. Elefteriades, J. A. Mattera, S. A. Roumanis, Z. Lin, and H. M. Krumholz Age does not limit quality of life improvement in cardiac valve surgery J. Am. Coll. Cardiol., October 1, 2003; 42(7): 1208 - 1214. [Abstract] [Full Text] [PDF]

				M.-B. Edwards and K. M. Taylor Outcomes in nonagenarians after heart valve replacement operation Ann. Thorac. Surg., March 1, 2003; 75(3): 830 - 834. [Abstract] [Full Text] [PDF]

				P. Ghosh, M. Djordjevic, R. Schistek, R. Baier, and F. Unger Does Gender Affect Outcome of Cardiac Surgery in Octogenarians? Asian Cardiovasc Thorac Ann, March 1, 2003; 11(1): 28 - 32. [Abstract] [Full Text] [PDF]

				S. C. Stamou, K. A. Jablonski, A. J. Pfister, P. C. Hill, M. K.C. Dullum, A. S. Bafi, S. W. Boyce, K. R. Petro, and P. J. Corso Stroke after conventional versus minimally invasive coronary artery bypass Ann. Thorac. Surg., August 1, 2002; 74(2): 394 - 399. [Abstract] [Full Text] [PDF]

				J. G. Byrne, A. N. Karavas, F. Filsoufi, T. Mihaljevic, L. Aklog, D. H. Adams, L. H. Cohn, and S. F. Aranki Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts Ann. Thorac. Surg., March 1, 2002; 73(3): 779 - 784. [Abstract] [Full Text] [PDF]

				Y. Kawachi, A. Nakashima, Y. Toshima, S. Kimura, and K. Arinaga Outcome of Cardiac and Thoracic Aortic Operation in Patients Over 80 Years Old Asian Cardiovasc Thorac Ann, March 1, 2002; 10(1): 12 - 15. [Abstract] [Full Text] [PDF]

				K. M. Smith, A. Lamy, H. M. Arthur, A. Gafni, and R. Kent Outcomes and costs of coronary artery bypass grafting: comparison between octogenarians and septuagenarians at a tertiary care centre Can. Med. Assoc. J., September 1, 2001; 165(6): 759 - 764. [Abstract] [Full Text] [PDF]

				L.A. Pierard Cardiac surgery in octogenarians: who, when and how? Eur. Heart J., July 2, 2001; 22(14): 1159 - 1161. [PDF]