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Interact CardioVasc Thorac Surg 2009;9:441-445. doi:10.1510/icvts.2009.204156 © 2009 European Association of Cardio-Thoracic Surgery
Is urgent coronary artery bypass grafting a safe option in octogenarians? A developing country perspectiveDepartment of Surgery, The Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan Received 1 February 2009; received in revised form 8 May 2009; accepted 17 May 2009
*Corresponding author. Tel.: +92-21-4864708; fax: +92-21-4934294.
Life expectancy has increased during recent decades leading to a growing number of older population. The objective of this study was to evaluate the outcomes of coronary artery bypass grafting (CABG) in octogenarians and to compare the outcomes of the emergent CABG with elective surgery. Prospectively collected data from 31 consecutive octogenarian patients who underwent CABG between 1 January 2006 and 31 December 2008 were analyzed. Main outcomes of interest included mortality, length of ICU stay, length of hospital stay, priority of surgery, postoperative complications and functional status on follow-up. Fifteen patients were operated on an urgent basis. Patients operated on an urgent basis were in NYHA class III or IV preoperatively (P=0.0016). There were no significant differences in operative and postoperative variables. There were three in-hospital deaths and 23 patients (82%) were alive on follow-up and 19 were in functional class I or II. Quality of life assessment was performed using Seattle Angina Questionnaire and patients reported remarkable improvement in quality of life. Overall, 90% patients were not or slightly disabled in their daily activity. Satisfaction with their current quality of life was reported by 95% of patients. CABG may be performed in octogenarians with remarkable outcomes and improvement in quality of life.
Key Words: Octogenarian; Coronary artery bypass grafting; Elderly; Aging
Life expectancy has increased during recent decades leading to an older growing population [1]. By 2020, the number of elderly people is projected to reach >1000 million, with 70% living in developing countries like Pakistan [2]. Cardiovascular diseases are functionally limiting in >25% of octogenarians [1]. The expected benefit of an intervention should not be viewed in terms of prolonging life only, but also in terms of improving the quality of life. Decision-making and timing of surgery is an important variable when operating on elderly. It has been shown that surgery performed on an urgent basis is a predictor of adverse outcomes [3]. Open heart surgery is an infrequently performed procedure in octogenarians in our country and the outcomes have not been reported. We report our institutional outcomes of performing coronary artery bypass grafting (CABG) in octogenarians.
To evaluate the outcomes of CABG in octogenarians and to compare the outcomes of the urgent CABG with elective surgery.
This is a prospective cohort study of all consecutive patients 80 years or older who underwent CABG between 1 January 2006 and 31 December 2007 at The Aga Khan University Hospital, Karachi, Pakistan. Data were collected prospectively and entered into a computerized database and were subjected to analysis. Main outcomes of interest included mortality, length of hospital stay, timing of surgery, postoperative complications, functional status and quality of life on follow-up. Priority of surgery was assessed by the operating surgeon and was defined using definitions described by O'Connor et al. [4]. Operation was considered emergency if the medical factors relating to the patient's cardiac disease dictated that surgery should be performed within hours to prevent morbidity or death. Operation was considered urgent if the medical factors required the patient to stay in the hospital for an operation before discharge, and elective, if clinical situation allowed discharge from the hospital with readmission at a later date. Patients were divided into two groups on the basis of the timing of operation i.e. emergent/urgent group and elective group.
Left ventricular (LV) dysfunction was categorized on the basis of ejection fraction (EF) and considered severe, moderate, mild, or normal if EF was <30%, 30–44%, 45–54%, A standard operative technique utilizing nonpulsatile perfusion and moderate systemic hypothermia with myocardial protection by antegrade cold intermittent blood cardioplegia was used in all patients. Operative mortality was defined as death occurring within 30 days of operation. All postoperative complications were recorded. Follow-up information on quality of life of surviving patients and causes of death were obtained via telephone interviews. The surviving patient himself was questioned in the first line; relatives served to acquire additional information. Quality of life assessment is based on a validated Seattle Angina Questionnaire [6]. Statistical analysis was performed using SPSS statistical software (SPSS Inc, Chicago, IL). Data were presented as absolute numbers, mean±S.D. and percentages where appropriate. Frequencies and crosstabs were run to know the data distribution. To compare the two groups of octogenarians on the basis of mode of admission, 2 or Fisher exact test was applied for categorical variables. Student's t-test was used to analyze normally distributed variables and Kruskal–Wallis was applied for the ones having skewed distribution. A P-value of <0.05 was taken to indicate statistical significance.
4.1. Preoperative data A total of 1206 CABG operations were carried out at our institute during the study period. Thirty-one octogenarians underwent CABG during the study period. There were 22 males (69%) and 9 females (31%). Mean age of the patients was 81.3 years. Median length of hospital stay was 12.5 days (9–17 days). Fifteen patients were operated on an urgent basis. Comparison of demographic features of the two groups is shown in Table 1. There was one redo CABG in the elective group. Two patients had undergone recent PCI in the elective group.
Seven patients in the urgent CABG group had recent myocardial infarction (  7 days). The P-value for 2 for trends was significant (0.035). Patients operated on an emergent basis were in New York Heart Association (NYHA) class III or IV preoperatively (P=0.0016). Mean additive EuroSCORE for patients operated on an elective basis was 10.6 and 12.5 for patients operated on an urgent basis (Fig. 1). The cause of urgent CABG was left main disease with intractable pain requiring intraaortic balloon pump (IABP) support in six cases, acute myocardial infarction (AMI) with intractable pain in four patients, AMI with congestive cardiac failure in three patients and cardiogenic shock in two patients.
4.2. Operative data The operative characteristics of the two groups are shown in Table 2. There was no significant difference in left main coronary artery disease and number of diseased coronary arteries. Mean cardiopulmonary bypass time and mean aortic cross-clamp time were not different in the two groups (P=0.42). Elective and emergent patients received almost the same number of distal coronary anastomoses (P=0.7).
Median duration of postoperative ventilatory support was 19.5 h. Median duration of ICU stay was 3.4 days in the elective group and 3.9 days in the urgent group. Eight patients in the urgent CABG group and four in the elective group required prolonged ventilatory support. The postoperative complications are shown in Table 3. There were no significant differences in postoperative complications. There were three in-hospital deaths. One patient in elective group succumbed to pulmonary complications and two in the urgent group died due to cardiac and pulmonary causes.
4.4. Follow-up Mean follow-up was 663±198 days. Twenty-eight patients were discharged from the hospital and follow-up was available in 26 (93%) of patients. Twenty-three patients (82%) were alive on follow-up (Table 4). Three patients died during the follow-up period. Cause of death was pulmonary in two and noncardiac in one patient. Nineteen (83%) were in NYHA class I or II. NYHA class was not significantly different between the groups (P=0.68).
4.5. Quality of life Quality of life assessment was done based on a validated Seattle Angina Questionnaire [1, 6] and is 100% complete. This instrument examines mobility and activity, cardiac symptoms perception, disease perception, treatment satisfaction as well as emotional well-being and enjoyment of life. There was considerable improvement in quality of life after CABG. Overall, 90% of patients were not or slightly disabled in their daily activities and there was considerable decrease in symptom perception (Fig. 2). There was no requirement of nitroglycerin in 90% of patients and there was 100% satisfaction to take prescribed medications. Patient satisfaction with their treatment, interference of cardiac disease with daily enjoyment of life, optimism conserving their present activity of life and worries about recurrence of heart disease or sudden cardiac death are shown in Fig. 3 (a) and (b).
In the last two decades survival in octogenarians, after cardiac surgery, has steadily increased to become highly acceptable nowadays [7]. Patients who are 80 years and older represent a very distinct population from younger cardiac surgical patients. Cane et al. have shown actuarial survival for octogenarians undergoing CABG that is comparable to that of the age-matched population with the expectation of reasonable results and late survival that parallels their demographic group [8]. Persons aged 80 or above constitute only 0.5% of the Pakistani population. Cardiac surgery in octogenarians is infrequently performed in our part of world. This is a single institutional report of performing CABG in octogenarians. A few studies have reported the results of cardiac surgery in elderly Asians, but most of the studies are about septuagenarians [9, 10]. Our finding of a cumulative mortality rate of 9.7% is similar to other reports [3, 11]. An interesting finding in our study was that almost half of our population comprised of patients who were operated on an urgent or emergent basis. In this group mortality rate was 13.3%, which shows a higher mortality trend in urgently operated patients but did not reach statistical significance. A higher mortality rate in urgently operated octogenarians has been reported by other investigators as well. Kolh et al. reported that urgency of surgery was an independent predictor of mortality [3]. Ishikawa et al. reported a 4-fold increase in operative mortality in the urgent or emergency operation group compared to the elective cases [12]. Our findings were different from these studies and although the mortality was higher in urgently operated patients but it still was in acceptable range. Another study reported results similar to our study and found no difference in operative mortality between elective and urgent cases [13]. Patients operated on an urgent basis in our study had a poorer NYHA status, lower preoperative EF and recent history of myocardial infarction. The reason for having better outcome in this group of patients could be the multifactor improvements in the anesthesia, surgical technique, myocardial protection and postoperative care. We adhered to our policy of complete revascularization in these patients with the principle of the internal thoracic artery as the graft of choice in CABG as reported earlier [1]. Most of the elderly patients in our study were men, although women have a higher life expectancy. This may be due to the gender differences in seeking healthcare, as has been reported from other parts of the world [14]. Most octogenarian cardiac surgery candidates in our part of the world are deemed to be at high risk due to their comorbidities. This partly reflects the reluctance to operate on functionally more independent elderly, and an inclination towards more conservative management. The balance tilts more in favor of conservative management in acute settings. These patients either are managed medically or undergo attempts of percutaneous coronary intervention (PCI). Longevity is not the primary goal in these patients and good outcomes in these patients translates into daily comfort and improvement in quality of life. The appreciation of importance of preserving quality of life in octogenarians is still not as much as in developed countries. There is relative dearth of information regarding outcomes of CABG in octogenarians and this may be the reason for a ‘psychological barrier’ to surgery for both older patients and their clinicians. In our study, there was remarkable improvement in NYHA class and quality of life of our patients. They demonstrated considerable increase in emotional well-being and functional recovery. Improvement from a dependant to self-caring patient is very well appreciated in our patient population. Chronologic and physiologic age may not always match [7]. The answer to the question ‘should cardiac surgery be performed in the octogenarian?’ is complex, and must take into account several elements, such as lack of synchronism between physiological age and chronological age, quality of life, risk/benefit ratio, and augmentation of health care costs, an element that is gaining more and more importance [3]. With increase in aging population, an increasing number of elderly patients will be referred for surgery. Octogenarians show a remarkable quality of life and a considerable increase in their emotional well-being as well as increased functional status after cardiac surgery.
Our study suffers from the limitations common to all non-randomized, and retrospective analyses. The small sample size was a major study limitation. Cardiac surgery in octogenarians is still not a widely accepted procedure in Pakistan. Our study was performed in a single institute with a single surgical group. Another limitation was combining the emergent and urgent patients, but the number of emergent patients was small and therefore a meaningful analysis was not possible. The use of an 11-item shorter Seattle angina questionnaire as opposed to SF–36 was motivated by the increased age, specific disease and treatment characteristics of the analyzed population. The lower number of questions and the nature of the questions were found to be more adequate to the very old patient population.
Cardiac operations may be performed in octogenarians with acceptable morbidity and mortality and remarkable improvement in quality of life. Urgent surgery does increase the operative risk but it should not be a contradiction per se to offer surgery in such patients.
We would like to acknowledge the assistance provided by Ms Shumaila Furnaz in collection of data for this study.
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Abstract
1. Introduction
55%, respectively 
