Heart and Vessels

, Volume 27, Issue 6, pp 559–567

Coronary artery surgery in octogenarians: evolving strategies for the improvement in early and late results

  • Francesco Nicolini
  • Alberto Molardi
  • Danilo Verdichizzo
  • Maria Cristina Gallazzi
  • Igino Spaggiari
  • Flavio Cocconcelli
  • Alessandro Maria Budillon
  • Bruno Borrello
  • Davide Rivara
  • Cesare Beghi
  • Tiziano Gherli
Original Article

Abstract

The purpose of this study was to investigate retrospectively early and late outcomes of coronary artery bypass grafting (CABG) in a large series of octogenarians. We retrospectively reviewed the data of 241 octogenarian patients who underwent CABG between April 2002 and April 2009 at our institution. Mean age was 84.7 ± 1.8 years. Patients affected by concomitant coexistent organic aortic, mitral, or tricuspid valve disease were excluded from the study. Patients with functional secondary ischemic mitral incompetence were included in the study. The majority of the patients were male. Angina pectoris functional class III/IV accounted for 164 patients (68%). Left ventricular ejection fraction ≤35% was diagnosed in 38 patients (15.8%). Early mortality rate was 5.8% (14 patients). Causes of death were cardiac related in 10 patients. Preoperative independent predictors of in-hospital mortality obtained with multivariate analysis were extracardiac arteriopathy, New York Heart Association class III/IV, and previous percutaneous transluminal coronary angioplasty (PTCA). The overall mean follow-up was 41.6 ± 25.9 months (range 1–87.6 months). Among the 222 contacted survivors, there were 16 (7.2%) deaths during the follow-up. The actuarial survival was 91.9% at 1 year and 83.5% at 5 years. On multivariate analysis, time to late death was adversely affected by preoperative extracardiac arteriopathy and previous PTCA. Advanced age alone should not be a deterrent for CABG if it has been determined that the benefits outweigh the potential risk. A careful selection of optimal candidates, based on the evaluation of their systemic comorbidities, appears mandatory in order to obtain the greatest benefit for these high-risk patients.

Keywords

Coronary artery bypass grafting Elderly patient Surgery 

References

  1. 1.
    Chee JH, Filion KB, Haider S, Pilote L, Eisenberg MJ (2004) Impact of age on hospital course and cost of coronary artery bypass grafting. Am J Cardiol 93:768–771PubMedCrossRefGoogle Scholar
  2. 2.
    Graham MM, Ghali WA, Faris PD, Galbraith PD, Norris CM, Knudtson ML, Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) Investigators (2002) Survival after coronary revascularization in the elderly. Circulation 105:2378–2384PubMedCrossRefGoogle Scholar
  3. 3.
    TIME Investigators (2001) Trial of invasive versus medical therapy in elderly patients with chronic symptomatic coronary artery disease (TIME): a randomized trial. Lancet 358:951–957CrossRefGoogle Scholar
  4. 4.
    Shirasawa K, Hwang M, Sasaki Y, Takeda S, Inenaga-Kitaura K, Kitaura Y, Kawai C (2011) Survival and changes in physical ability after coronary revascularization for octa-nonagenarian patients with acute coronary syndrome. Heart Vessels 26:385–391PubMedCrossRefGoogle Scholar
  5. 5.
    Baskett R, Buth K, Ghali W, Norris C, Maas T, Maitland A, Ross D, Forgie R, Hirsch G (2005) Outcomes in octogenarians undergoing coronary artery bypass grafting. CMAJ 172:1183–1186PubMedCrossRefGoogle Scholar
  6. 6.
    Gopaldas RR, Chu D, Dao TK, Huh J, Lemaire SA, Coselli JS, Bakaeen FG (2009) Predictors of surgical mortality and discharge status after coronary artery bypass grafting in patients 80 years and older. Am J Surg 198:633–638PubMedCrossRefGoogle Scholar
  7. 7.
    Kozower BD, Moon MR, Barner HB, Moazami N, Lawton JS, Pasque MK, Damiano RJ Jr (2005) Impact of complete revascularization on long-term survival after coronary artery bypass grafting in octogenarians. Ann Thorac Surg 80:112–117PubMedCrossRefGoogle Scholar
  8. 8.
    Filsoufi F, Rahmanian PB, Castillo JG, Chikwe J, Silvay G, Adams DH (2007) Results and predictors of early and late outcomes of coronary artery bypass graft surgery in octogenarians. J Cardiothorac Vasc Anesth 21:784–792PubMedCrossRefGoogle Scholar
  9. 9.
    Likosky DS, Dacey LJ, Baribeau YR, Leavitt BJ, Clough R, Cochran RP, Quinn R, Sisto DA, Charlesworth DC, Malenka DJ, MacKenzie TA, Olmstead EM, Ross CS, for the Northern New England Cardiovascular Disease Study Group (2008) Long-term survival of the very elderly undergoing coronary artery bypass grafting. Ann Thorac Surg 85:1233–1238Google Scholar
  10. 10.
    Rohde SL, Baker RA, Tully PJ, Graham S, Cullen H, Knight JL (2010) Preoperative and intraoperative factors associated with long-term survival in octogenarians cardiac surgery patients. Ann Thorac Surg 89:105–111PubMedCrossRefGoogle Scholar
  11. 11.
    Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R (1999) European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 16:9–13PubMedCrossRefGoogle Scholar
  12. 12.
    Grigioni F, Enriquez-Sarano M, Zehr KJ, Bailey KR, Tajik AJ (2001) Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 103:1759–1764PubMedCrossRefGoogle Scholar
  13. 13.
    Badwar V, Bolling SF (2002) Mitral valve surgery in the patient with left ventricular dysfunction. Semin Thorac Cardiovasc Surg 14:133–136CrossRefGoogle Scholar
  14. 14.
    Huang J-H, Lin Y-Q, Pan N-H, Chen Y-J (2010) Aging modulates dispersion of ventricular repolarization in the very old of the geriatric population. Heart Vessels 25:500–508PubMedCrossRefGoogle Scholar
  15. 15.
    Scott BH, Seifert FC, Grimson R, Glass PSA (2005) Octogenarians undergoing coronary artery bypass graft surgery: resource utilization, postoperative mortality, and morbidity. J Cardiothorac Vasc Anesth 19:583–588PubMedCrossRefGoogle Scholar
  16. 16.
    Wolfe RR (2006) Optimal nutrition, exercise, and hormonal therapy promote muscle anabolism in the elderly. J Am Coll Surg 202:176–180PubMedCrossRefGoogle Scholar
  17. 17.
    Fried L, Walston J (2003) Frailty and failure to thrive. In: Hazzard WR, Blass JP, Ettinger WH Jr, Halter JB, Ous-lander J (eds) Principles of geriatric gerontology, 5th edn. McGraw Hill, New York, pp 1487–1502Google Scholar
  18. 18.
    Maggio M, Ceda GP, De Cicco G, Cattadori E, Visioli S, Ablondi F, Beghi C, Gherli T, Basaria S, Ceresini G, Valenti G, Ferrucci L (2005) Acute changes in circulating hormones in older patients with impaired ventricular function undergoing on-pump coronary artery bypass rafting. J Endocrinol Invest 28:711–719PubMedGoogle Scholar
  19. 19.
    Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, Benussi B, Spina A (2009) Early and late outcomes of cardiac surgery in octogenarians. Ann Thorac Surg 87:71–78PubMedCrossRefGoogle Scholar
  20. 20.
    Kurlansky PA, Williams DB, Traad EA, Carrillo RG, Schor JS, Zucker M, Singer S, Ebra G (2003) Arterial grafting results in reduced operative mortality and enhanced long-term quality of life in octogenarians. Ann Thorac Surg 76:418–427PubMedCrossRefGoogle Scholar
  21. 21.
    Onorati F, Santarpino G, Leone MA, Impiombato B, Mastroroberto P, Renzulli A (2008) Intraoperative behavior of arterial grafts in the elderly and the young: a flowmetric systematic analysis. Heart Vessels 23:316–324PubMedCrossRefGoogle Scholar
  22. 22.
    Santarpino G, Onorati F, Scalas C, De Gori M, Cristodoro L, Zofrea S, Renzulli A (2009) Radial artery achieves better flowmetric results than saphenous vein in the elderly. Heart Vessels 24:108–115PubMedCrossRefGoogle Scholar
  23. 23.
    Emmert MY, Salzberg SP, Theusinger OM, Rodriguez H, Sündermann SH, Plass A, Starck CT, Seifert B, Baulig W, Hoerstrup SP, Jacobs S, Grünenfelder J, Falk V (2011) Off-pump surgery for the poor ventricle? Heart Vessels (Epub ahead of print). doi:10.1007/s00380-011-0146-0
  24. 24.
    Kleisli T, Cheng W, Jacobs MY, Mirocha J, Derobertis MA, Kass RM, Blanche C, Fontana GP, Raissi SS, Magliato KE, Trento A (2005) In the current era, complete revascularization improves survival after coronary artery bypass surgery. J Thorac Cardiovasc Surg 129:1283–1291PubMedCrossRefGoogle Scholar
  25. 25.
    Sharony R, Saunders PC, Nayar A, McAleer E, Galloway AC, Delianides J, Schwartz CF, Applebaum RM, Kronzon I, Colvin SB, Grossi EA (2004) Semirigid partial annuloplasty band allows dynamic mitral annular motion and minimizes valvular gradients: an echocardiographic study. Ann Thorac Surg 77:518–522PubMedCrossRefGoogle Scholar
  26. 26.
    Chee T, Haston R, Togo A, Raja SG (2008) Is a flexible mitral annuloplasty ring superior to a semi-rigid or rigid ring in terms of improvement in symptoms, survival? Interact Cardiovasc Thorac Surg 7:477–484PubMedCrossRefGoogle Scholar
  27. 27.
    Nicolini F, Beghi C, Muscari C, Agostinelli A, Budillon AM, Spaggiari I, Gherli T (2003) Myocardial protection in cardiac surgery: current options and future challenges. Eur J Cardiothorac Surg 24:986–993PubMedCrossRefGoogle Scholar
  28. 28.
    Enc Y, Karaca P, Ayoglu U, Camur G, Kurc E, Cicek S (2006) The acute cardioprotective effect of glucocorticoid in myocardial ischemia-reperfusion injury occurring during cardiopulmonary bypass. Heart Vessels 21:152–156PubMedCrossRefGoogle Scholar
  29. 29.
    Abelha FJ, Botelho M, Fernandes V, Barros H (2009) Determinants of postoperative acute kidney injury. Crit Care 13:R79PubMedCrossRefGoogle Scholar
  30. 30.
    Presta P, Onorati F, Fuiano L, Mastroroberto P, Santarpino G, Tozzo C, Andreucci M, Renzulli A, Fuiano G (2009) Can pulsatile cardiopulmonary bypass prevent perioperative renal dysfunction during myocardial revascularization in elderly patients? Nephron Clin Pract 111:c229–c235PubMedCrossRefGoogle Scholar
  31. 31.
    Landoni G, Biondi-Zoccai GG, Marino G, Bove T, Fochi O, Maj G, Calabrò MG, Sheiban I, Tumlin JA, Ranucci M, Zangrillo A (2008) Fenoldopam reduces the need for renal replacement therapy and in-hospital death in cardiovascular surgery: a meta-analysis. J Cardiothorac Vasc Anesth 22:27–33PubMedCrossRefGoogle Scholar
  32. 32.
    Salzberg SP, Emmert MY, Vassalotti J, Nandiwada DR, Adams DH (2009) Impact of preoperative nesiritide on renal function after mitral valve surgery. Heart Surg Forum 12:E217–E218PubMedCrossRefGoogle Scholar
  33. 33.
    Ejaz AA, Martin TD, Johnson RJ, Winterstein AG, Klodell CT, Hess PJ Jr, Ali AK, Whidden EM, Staples NL, Alexander JA, House-Fancher MA, Beaver TM (2009) Prophylactic nesiritide does not prevent dialysis or all-cause mortality in patients undergoing high-risk cardiac surgery. J Thorac Cardiovasc Surg 138:959–964PubMedCrossRefGoogle Scholar
  34. 34.
    Haase M, Bellomo R, Devarajan P, Ma Q, Bennett MR, Mockel M, Matalanis G, Dragun D, Haase-Fielitz A (2009) Novel biomarkers early predict the severity of acute kidney injury after cardiac surgery in adults. Ann Thorac Surg 88:124–130PubMedCrossRefGoogle Scholar
  35. 35.
    Bridges CR, Edwards FH, Peterson ED, Coombs LP, Ferguson TB (2003) Cardiac surgery in nonagenarians and centenarians. J Am Coll Surg 197:347–356PubMedCrossRefGoogle Scholar
  36. 36.
    Akins CW, Daggett WM, Vlahakes GJ, Hilgenberg AD, Torchiana DF, Madsen JC, Buckley MJ (1997) Cardiac operations in patients 80 years old and older. Ann Thorac Surg 64:606–614PubMedCrossRefGoogle Scholar
  37. 37.
    Kirsch M, Guesnier L, LeBesnerais P, Hillion ML, Debauchez M, Seguin J, Loisance DY (1998) Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy. Ann Thorac Surg 66:60–67PubMedCrossRefGoogle Scholar

Copyright information

© Springer 2011

Authors and Affiliations

  • Francesco Nicolini
    • 1
  • Alberto Molardi
    • 1
  • Danilo Verdichizzo
    • 1
  • Maria Cristina Gallazzi
    • 1
  • Igino Spaggiari
    • 1
  • Flavio Cocconcelli
    • 1
  • Alessandro Maria Budillon
    • 1
  • Bruno Borrello
    • 1
  • Davide Rivara
    • 1
  • Cesare Beghi
    • 1
  • Tiziano Gherli
    • 1
  1. 1.Heart Surgery SectionUniversity of Parma Medical SchoolParmaItaly

Personalised recommendations