Interact CardioVasc Thorac Surg 2008;7:126-129. doi:10.1510/icvts.2007.160192
© 2008 European Association of Cardio-Thoracic Surgery
Coronary bypass surgery in young adults. A long-term survey
Aquilino Hurlé*,
Eduardo Bernabeu,
Rafael Gómez-Vicente and
Jack Ventura
Department of Cardiac Surgery, Hospital General Universitario de Alicante, Alicante, Spain
Received 28 May 2007;
received in revised form 8 August 2007;
accepted 15 October 2007
 Presented at the 56th International Congress of the European Society for Cardiovascular Surgery, Venice, Italy, May 17–20, 2007.
*Corresponding author. Servicio de Cirugía Cardiaca, Hospital General Universitario de Alicante, C/Pintor Baeza s/n, 03010 Alicante, Spain. Tel./fax: +34 965938329.
E-mail address: hurle_aqu{at}gva.es (A. Hurlé).
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Abstract
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Objectives: There is little information in the literature on the long-term outcome of young patients undergoing coronary bypass grafting surgery. The aim of this study is to analyze the long-term clinical outcome of this technique when performed in young adults. Methods: We included in this retrospective study all patients aged 40 years or younger undergoing coronary bypass surgery in our unit between January, 1989 and December, 2006. Relevant clinical data were retrieved from the patients' clinical records. Follow-up data were obtained by means of personal or telephone interviews with the patients themselves or with their relatives. Results: There were 42 patients (3 females, 39 males), mean age 36.9 years (range 29–40 years). Nineteen of them suffered a previous myocardial infarction. Left ventricular function was impaired (ejection fraction lower than 50%) in six instances. Twenty-two patients underwent surgery in a state of unstable angina. The indication for surgery was 3-vessel disease in 17 patients, 2-vessel disease in 17 patients and single-vessel disease in seven instances, and in six cases the main steam of the left coronary artery was affected. A total of 102 grafts were constructed (mean 2.4 grafts per patient), 56 (54.9%) of them being arterial. There were no hospital deaths. Mean hospital stay was of 8.1 days. Four patients suffered relevant perioperative complications. One patient (2.3%) was lost for follow-up. Cumulative follow-up was 389.1 years, with a mean of 9.5 years per patient. There were five late deaths, all of them of cardiac origin, with an estimated actuarial probability of survival of 81.4%. Thirteen patients suffered 17 major cardiac non-lethal complications, with an estimated actuarial freedom from cardiac morbidity of 43.9%. Major peripheral vascular morbid events occurred in nine patients, the estimated actuarial probability of freedom from peripheral vascular complications being of 62.1%. Overall actuarial freedom from any cardiovascular lethal or morbid event was estimated at 27.7%. Conclusions: Peri-operative mortality and morbidity is low in young patients undergoing coronary bypass surgery. However, these patients present a high risk of suffering major adverse events of cardiovascular origin in the long-term.
Key Words: Coronary disease; Coronary bypass; Ischemic heart disease
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1. Introduction
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Old age has been reported to be a major risk factor for coronary artery disease, thus, surgical myocardial revascularization procedures are most often performed in patients with rather advanced age. Conversely, young adults represent a relatively rare and infrequent subset for ischemic heart disease [1, 2].
The paradoxical consequence of this is that, despite the fact that coronary bypass grafting is probably the most extensively studied of all surgical techniques, the reported data on its outcome when performed in the younger population are relatively scarce [3–6].
We herein report and analyze our long-term experience with patients undergoing surgical myocardial revascularization procedures within their first four decades of life.
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2. Materials and methods
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We included in this retrospective study all patients aged 40 years or younger undergoing isolated coronary bypass surgery in our unit between January, 1989 and December, 2006. Relevant clinical data were retrieved from the patient's medical records.
Follow-up data were obtained by means of personal or telephone interviews with the patients themselves or with their relatives. These data included vital status, causes of death, major cardiac non-lethal events, angina status, cardiac reoperation, postoperative cardiac percutaneous procedures and adverse peripheral vascular events.
The study was closed for a one-month period between the 1st and the 31st of December, 2006. One patient was lost for follow-up, so the study was 97.6% complete.
Statistical analysis was carried out with an SPSS 11 (SPSS Inc., Chicago, IL) computer package. Continuous variables were expressed as mean value±S.D. Actuarial analysis was performed with the Kaplan–Meier method.
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3. Results
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There were 42 patients (3 females, 39 males), with a mean age of 36.9±2.8 years (range 29–40 years). Nineteen of them (45.2%) suffered a previous myocardial infarction and left ventricular systolic function was impaired (ejection fraction below 50%) in six subjects (14.3%). Risk factors for coronary artery disease identified in these patients included cigarette smoking (n=37), overweight, defined as a body mass index >26 kg/m2, (n=32), dyslipemia (n=33), systemic hypertension (n=17), diabetes mellitus (n=9) and renal failure (n=2).
The indication for surgery was isolated left main coronary artery stenosis in one patient, single-vessel disease in seven patients, two-vessel disease in 17 patients (associated to left main coronary artery stenosis in four instances) and triple-vessel disease in 17 patients (associated to left main coronary artery stenosis in one case). No significant heart valve dysfunction was demonstrated in any patient. Surgery was conducted on an urgent or emergency basis in 22 instances.
The surgical intervention was carried out with extracorporeal circulation and cardioplegic arrest of the heart in 40 cases and off-pump in the remaining two cases. A total of 102 grafts (41 with left internal thoracic artery, 9 with right internal thoracic artery, 6 with radial artery and 46 with saphenous vein) were constructed, with a mean of 2.4±1.1 grafts per patient (range 1–5 grafts). All patients received an arterial graft to their left anterior descending coronary artery (pedicled left internal thoracic artery in 41 cases and radial artery in one case). All five remaining radial artery grafts were anastomosed distally to marginal branches of the circumflex artery. In all nine cases in which the right internal thoracic artery was used, this graft was anastomosed proximally to the left internal thoracic artery graft (y-graft) and distally to marginal branches of the circumflex artery. All saphenous vein grafts were anastomosed distally, either to marginal branches of the circumflex artery or to the right coronary artery system.
There were no hospital deaths. Mean hospital stay was 8.1±4.5 days (range 3–27 days). Four patients (9.1%) suffered relevant postoperative complications. These included respiratory infection (n=2), upper gastro-intestinal tract bleeding (n=1) and superficial wound infection (n=1).
Cumulative follow-up was 389.1 years, with a mean of 9.5±5.3 years per patient (range 1.1–17.6 years).
Five patients died late at follow-up. Among these patients, one had been operated on urgent basis. Preoperative left ventricular function was preserved and a complete surgical myocardial revascularization was achieved at the time of surgery in all five cases. The causes of death were sudden domiciliary death in four cases and death at reoperation (cardiac transplant) in one case. All these deaths were considered to be cardiac-related. Actuarial probability of survival (freedom from death of cardiac origin) was estimated in 81.4% (Fig. 1).
Thirteen patients suffered 17 major cardiac non-lethal events: recurrent angina (n=9), acute myocardial infarction (n=1), recurrent angina and myocardial infarction (n=2) and recurrent angina with myocardial infarction and ventricular tachycardia requiring implantation of a permanent internal defibrillator (n=1). None of these 13 patients suffering late non-lethal cardiac events required reoperation for ischemic heart disease. However, cardiac catheterization and coronariography was repeated in nine of them and percutaneous angioplasty was performed in six instances.
Actuarial probabilities of freedom from non-lethal cardiac complications and from morbi-mortality of cardiac origin were estimated in 43.9% and 33.8%, respectively (Figs. 2 and 3).
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Fig. 3. Actuarial probability of freedom from morbi-mortality of cardiac origin at 16.6 years follow-up.
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Nine patients suffered relevant adverse peripheral vascular events, none of them resulting in death. These included five cases of intermittent claudication, three cerebrovascular events (two cases of stroke, with no permanent sequelae, and one case of ruptured cerebral aneurysm, successfully treated with percutaneous embolization) and one case of severe lower limb ischemia resulting in foot amputation. Actuarial freedom from peripheral vascular complications was of 62.2% (Fig. 4).
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Fig. 4. Actuarial probability of freedom from peripheral vascular complications at 17.1 years follow-up.
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Overall actuarial freedom from any morbid or lethal event of cardiovascular origin was estimated in 27.7% (Fig. 5).
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Fig. 5. Actuarial probability of freedom from morbi-mortality of cardiovascular origin at 16.6 years follow-up.
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After a mean of 9.5 years follow-up, there were 21 survivors (56.8%) in class I for angina, 11 (29.7%) in class II, 4 (10.8%) in class III and none in class IV. All patients in class II and III and three patients in class I were on some sort of anti-anginal medication (nitrates, calcium antagonists or beta-blockers) at the end of their follow-up.
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4. Discussion
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Ischemic heart disease is an age-related condition and this is probably the reason why most data available in the literature on this subject refer either to the general population (where elder subjects predominate) or, specifically, to an elderly population. However, the management of this disease in younger patients, a particularly relevant issue as they have a longer life expectancy and greater functional requirements for leading a normal life, has been, somehow, overlooked by researchers, perhaps due to the fact that its incidence is relatively low in the younger population (patients below 45 years of age account for only 6–10% of all cases of myocardial infarction) [1, 2].
Current accepted indications for aorto-coronary bypass surgery do not defer substantially between younger and older subjects. So, according to these criteria, we observed some remarkably good early results in our series, with no in-hospital mortality, a very low rate of perioperative complications and a relatively short hospital stay, despite the fact that several factors for increased operative risk [7], such as surgery carried out on urgent or emergency basis, previous myocardial infarction, impaired left ventricular systolic function, female gender or renal failure, could be identified in a substantial number of our patients. Thus, it would appear that youth could play a favorable role in the early postoperative outcome of these patients, as it occurs following an acute myocardial infarction, where young age (<45 years) has been reported to be an independent protective factor against early mortality [2].
Unfortunately, a rather more disappointing panorama can be observed when analyzing their long-term evolution. Arteriosclerosis is a progressive disease and many patients in our series suffered its consequences during their follow-up, either as recurrent heart ischemia, as major peripheral vascular complications, or both.
Late mortality rate is known to be increased in young patients undergoing primary aorto-coronary bypass surgery, with reported 15-year actuarial survival estimates ranging between 50% and 72% in the different series [4, 5]. Our experience, with a late mortality rate close to 12% and an estimated actuarial probability of survival of only 81% at over 17 years follow-up, although not as pessimistic, also evidences a considerable life expectancy reduction in these patients. Furthermore, their quality of life appears to be negatively affected too, as illustrated by the fact that about 40% of all survivors still suffer angina pectoris at different degrees of exertion and, also, that a substantial number of patients in class I require anti-anginal medical therapy in order to remain free of symptoms.
Preventing the disease is probably the best way for improving results. In agreement with the observations reported by other authors, the commonest risk factors for ischemic heart disease identified in our series were a higher proportion of male patients [3], cigarette smoking [1, 3, 5, 8], obesity [1, 8], dyslipemia [1, 3, 5, 8] and, to a lesser extent, systemic hypertension and diabetes [3, 5], all of them, with the exception of gender, potentially avoidable by physical or pharmacological means. Medical treatment with anti-platelet and lipid-modifying therapy becomes essential in order to improve late graft permeability [4, 6]. From the surgical technical point of view, the use of arterial conduits (internal thoracic, radial, etc.), as opposed to saphenous vein conduits, has been reported to improve long-term graft patency [6, 9] and could also help improving late outcome in these patients.
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References
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Abstract
1. Introduction
