Interact CardioVasc Thorac Surg 2009;8:104-107. doi:10.1510/icvts.2008.183244
© 2009 European Association of Cardio-Thoracic Surgery
Early results of off-pump coronary artery bypass graft surgery using bilateral internal thoracic artery grafts in octogenarian patients during ten years
Mohammad El Diasty*,
Jose Antonio Gonzalez,
Javier Perez,
Francisco Cid,
Victor Mosquera,
Jose Cuenca and
Alberto Juffe
Servicio de Cirugía Cardíaca, Hospital Juan Canalejo, Las Jubias 84, La Coruña, 15006, Spain
Received 16 May 2008;
received in revised form 5 October 2008;
accepted 7 October 2008
 Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.
*Corresponding author. Tel.: +34 655 41 22 31; fax: +34 981 176 144.
E-mail address: doctoreldiasty{at}yahoo.com (M. El Diasty).
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Abstract
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Objective: The aim of this study is to review the outcome of OP-CABG using bilateral internal thoracic artery (BITA) grafts in these patients in terms of morbidity and mortality. Patients and method: Retrospective data from consecutive 64 octogenarian patients who underwent this surgery in the period between April 1998 and December 2007 were taken. Demographic data, risk factors, and details of surgical intervention and postoperative complications were analysed. Results: The mean age was 81.8±1.8 years (males=78.1%). Expected mortality calculated by additive EuroSCORE was 7.1±1.9%. The mean of left ventricular ejection fraction was 57.3±12.3%. Unstable angina was the main presenting symptom in 70.3% of patients and 18.7% had recent acute myocardial infarction. Hospital morbidity and mortality rates were 60.9 and 6.2%, respectively. The most frequent complications were: respiratory (25%) and atrial fibrillation (17.2%). The means of stay in intensive care unit and total hospital stay were 2.4±1.9 and 7.6±3.7 days, respectively. Conclusion: Realizing OP-CABG using BITA grafts had a high rate of postoperative morbidity, however, the mortality rate was low.
Key Words: Off-pump coronary artery graft surgery; Octogenarian
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1. Introduction
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Cardiac surgery in octogenarian patients has become more frequent during the last few years as this subgroup of the population is rapidly increasing. According to risk scales, this group of patients has an elevated expected surgical mortality rate. Various studies reviewed the outcome of different types of cardiac surgery in this population. To our knowledge, there has not been published any article that analyzed in depth the results of OP-CABG using bilateral internal thoracic artery (BITA) grafts in octogenarian patients. It is probable that this surgical technique might reduce perioperative morbidity and mortality due to the non-aortic touch method and the absence of inflammatory response associated with cardiopulmonary bypass.
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2. Objectives
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This study was designed to review and present our experience in performing OP-CABG using BITA grafts in octogenarian patients. We analyzed the early outcome of surgery in terms of morbidity and mortality in order to find out whether it had a higher incidence of postoperative complications or not.
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3. Criteria for inclusion
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We included all octogenarian patients who underwent OP-CABG using BITA grafts in the period between April 1998 and December 2007 at the Hospital Juan Canalejo, La Coruña, Spain. We excluded patients in whom the procedure was intentionally performed under cardiopulmonary bypass and those who underwent surgery for a single graft CABG.
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4. Methods
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We conducted a retrospective review of records of this group of patients. The total number was 64. Data were gathered from an electronic data base storing system. All surgical interventions were performed under general anaesthesia via median sternotomy. Dissection of both internal thoracic arteries (ITA) was done in a skeletonised fashion. A (Y) or (T) shaped anastomosis between in situ left ITA and free graft right ITA was then performed. A non suctioning fixation system was utilized to perform anastomosis and no intracoronary shunts were used. The anterior descending coronary artery was revascularized using the left ITA in all cases while other coronary arteries were anastomosed to the right ITA. Graft patency was verified intraoperatively by a transit time flowmeter. All interventions were initially intended off-pump and conversion to on-pump was considered only in case of hemodynamic instability or any other intraoperative complications. We defined coronary artery disease as occlusion of at least 70% of the vessel diameter, left main coronary trunk lesions as occlusion of at least 50% of the vessel diameter, low cardiac output as cardiac index lower than 2 l/min/m2 or prolonged need for inotropic drugs, preoperative renal impairment as serum creatinine higher than 2 mg/dl [1], postoperative deterioration of renal function as a rise in serum creatinine by 50% of its basal value [1], COPD as irreversible airway obstruction due to chronic bronchitis or emphysema with an obstructive pattern in respiratory function tests, and hospital mortality as any death occurring within the first 30 days of surgery. Expected postoperative mortality risk was calculated by applying both the additive EuroSCORE and Parsonnet 95. All analyses were performed using SPSS® Version 13 software for Windows (SPSS Inc, Chicago, IL, USA, Version 13.0).
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5. Results
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5.1. Preoperative data
The total number was 64 patients with a mean age of 81.8±1.8 years (r: 80–86). Males were 78.1%. The main associated cardiovascular risk factors were: arterial hypertension (64.1%), hypercholesterolemia (54.7%), smoking (34.4%), and diabetes mellitus (31.2%). Other associated risk factors were: peripheral vascular disease (17.2%), chronic renal failure (9.4%), and previous cerebrovascular accidents (6.2%). The means of expected mortality according to the additive EuroSCORE and Parsonnet 95 were 7.1±1.9 and 6.1±2.3, respectively. Significant left main coronary trunk lesions were found in 51.6% of patients. The incidence of one-, two-, and three-vessel disease was 9.4, 10.9 and 79.4%, respectively. The mean of left ventricular ejection fraction (LVEF) was 57.3±12.3. Unstable angina was the main presenting symptom in 70.3% of patients. History of previous myocardial infarction was found in 42.4% and 12 patients (18.7%) had recent acute myocardial infarction within the three weeks prior to surgery. Preoperative data are summarised in Table 1.
5.2. Operative data
Surgery was performed on an urgent basis in 15.6% of patients. In all patients the intervention was initially intended off-pump but in only one patient (1.6%) it was impossible to continue the procedure due to hemodynamic instability and cardiopulmonary bypass was used. The mean number of grafts performed was 2.6±0.6 vessels/patient with a mean total coronary artery occlusion time of 27.9±9.6 min/patient (10.7 min/graft). There was no intraoperative mortality. Intraoperative data are summarised in Table 2.
5.3. Postoperative data
The global morbidity rate was 60.9% (Table 3). The most frequent postoperative complications were respiratory (25%) in the form of prolonged ventilation (14.1%), pleural effusion (4.7%), and neumothorax (3.1%). The second most frequent complication was transient atrial fibrillation (17.2%) that was reverted with pharmacological treatment with amiodarone in all patients. The deterioration of renal function occurred in 15.6% of patients and only one patient (1.6%) needed haemodialysis while the rest of patients recovered with conservative treatment and fluid management. The incidence of neurological complications (14.1%) was mainly as disorientation and prolonged recovery of consciousness level after general anaesthesia. None of the patients developed permanent neurological damage. Sternal wound infection occurred in 4.7% of patients and it was treated with antibiotics and late wound closure. Only one patient (1.6%) needed insertion of an intra-aortic balloon pump due to low cardiac out-put state. Overall mortality rate was 6.2% (four patients). The first patient died due to acute massive myocardial infarction a few hours after surgery while the second patient died due to severe sepsis that resulted from mediastinitis. The third one developed severe respiratory distress and died from respiratory failure. The fourth patient had a perforated duodenal ulcer, although he underwent urgent laparoscopy he died two days later due to severe sepsis. The mean of stay in Intensive Care Unit was 2.4±1.9 (r: 0–9) days while the mean of total hospital stay was 7.6±3.7 (r: 0–25) days.
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6. Discussion
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This article is one of the studies that tried to find out the outcome of coronary surgery in octogenarian patients. The results of OP-CABG using BITA grafts in these patients have not been published before. In our institution, we have six adult cardiac surgeons. The technique of choice for all elective coronary interventions is the off-pump with BITA. We accumulated a good experience from more that 2000 patients all over the last 10 years. The total number of octogenarians was 243 of which 104 underwent CABG surgery. The number of patients who complied with the criteria for inclusion in this study was 64.
6.1. Limitations of the study
No mid/long-term follow-up data were available. This can be explained as many patients were derived from other hospitals. Patients were followed up either in their original hospitals or primary health-care centres. It was very difficult to retrieve follow-up data for these patients because there does not exist a unified data base system which links all these centres. The size of sample is small and no control was realized with other patients from different age groups.
6.2. Off-pump or on-pump?
Whether the on-pump technique has an advantage over the off-pump one in elderly patients has been a matter of argument in various articles. It was found that off-pump patients had a higher rate of freedom from complications, lower incidence of stroke, and lower risk-adjusted mortality than on-pump patients, and that the use of cardiopulmonary bypass was correlated independently with increased risk of overall complications [2]. It was also found that lower operative mortality rate was achieved with the off-pump technique in a study of appraxmately 5500 patients [3]. This may be due to the non-aortic touch techniques that avoid manipulating highly calcified vessels. However, transient neurological complications were relatively frequent in our study despite the ascending aorta not being manipulated during the intervention. This may be due to the low cardiac output due to postural manipulation of the beating heart. Other authors reported that it was not possible to achieve a lower incidence of neurocognitive deficits in the off-pump than in the on-pump group [4]. Off-pump surgery can be performed in patients with comorbidities with similar outcome compared to the on-pump surgery [5]. In a previous article published by our group, we found that off-pump surgery reduced both morbidity and public health costs in low-risk patients and morbimortality in high-risk patients [6]. Although the off-pump technique may decrease the operative risk, it may be to the price of worsening late functional results [7]. It could be concluded that the off-pump technique may have some advantages over the on-pump one, although this will remain a matter of debate and more studies will be needed to help find out the answer.
6.3. Arterial or venous grafts?
The outcome of total arterial revascularization using bilateral internal thoracic artery (BITA) grafts over venous grafts has been studied extensively. Arterial grafts had less late failure rate over venous grafts [8]. Excellent low- to mid-term results using BITA and radial grafts were reported by some authors [9] while excellent long-tem clinical outcome, especially in old patients, was also reported in patients with three-vessel disease [10]. It could be assumed that due to the progressive increase in life expectancy, the use of arterial grafts may be justified even in very old patients. A great advantage of arterial grafts is avoiding the manipulation of the ascending aorta. Appraxmately one half of our patients had radiological evidence (chest X-ray or CT-scan) of gross calcification of the ascending aorta. Although this method is as accurate as epiaotric ultrasound, it gives a rough idea regarding the state of the ascending aorta. Many authors linked the degree of atherosclerosis of the ascending aorta to the neurological outcome after surgery. OP-CABG may significantly reduce the incidence of post- operative stroke in patients with at least 50% of the ascending aorta affected by atherosclerotic disease [11].
6.4. Predictors of morbidity and mortality
Despite the downward trend in overall mortality, postoperative morbidity remains high. Five major preoperative risk factors for operative mortality: emergency/salvage procedure, intraaortic balloon pump, renal failure, peripheral vascular disease or cerebral vascular disease and finally mitral insufficiency [12]. At the same time, various methods have been reported in a trial to reduce postoperative complications such as: optimization of pulmonary function [13], prophylactic use of amiodarone to reduce postoperative arrhythmias [14], repair of life-threatening lesions only, maintaining hematocrit above 30%, and applying an aggressive approach to weaning from mechanical ventilation [15].
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7. Conclusion
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Although the postoperative morbidity rate was high, the mortality rate was fairly low. Adequate preoperative selection and optimization of these patients may play an important role in reducing both morbidity and mortality rates. Age alone should not be an absolute contraindication to surgery in these patients. Improving quality of life rather than longevity should be the primary therapeutic aim of surgery.
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Abstract
1. Introduction
