Coronary Artery Bypass Surgery in the Septuagenarian

Transcription

1 Coronary Artery Bypass Surgery in the Septuagenarian Jerry B. Gooch, M.D., H. Edward Garrett, M.D., J.T. Davis, Jr., M.D., and Robert L. Richardson, M.D. Analyzed during a 3 -year period wvere 86 patientsfrom 70 to 80 years of age who underwent coronary artery bypass grafting without other cardiac procedures. The series included 57 men (66%) and 29 women (34%). The average follow-up period was 27 months. The early mortality rate for the men was 5.2%, and the overall mortality was 8.7%. This compared with an age-adjusted nationally expected death rate of 12.17% for this age group during this period of time. The early mortality ratefor the women was 6.9%, with ani overall mortality rate of 13.9%. This compared with an 8.7% age-adjusted nationally expected death rate. Factors which did not affect mortality in this particular series included smoking, hypertension, diabetes, and ejection fraction. Factors which did affect mortality included peripheral vascular disease (29% mortality), and postoperative complications (38% mortality). Of the 86 patients operated on from 1978 through 1980, ages 70 to 80, 88% are alive (76 of 86 patients). Of the patients living, 60.5% have no chest pain, and 26.3% describe their chest pain as significantly improved. When medical treatment alone fails, coronary artery bypass grafting is possible in the older age group to relieve disablinig angina and improve the quality of life, with very acceptable mortality rates. T HE EXACT role of coronary artery bypass grafting in the elderly has been questionable.'2 The suspected increase in mortality rates and the possibility of less than optimum results in this age group3 have led to some reluctance in the recommendation of surgery. Our impression has been that this is a viable therapeutic option to pursue regardless of age. This study, along with others,4 points out the fact that both mortality rates and quality of life can be improved in this age group, although the problems may be greater. Patient Selection Technical changes that took place in 1976 and 1977 caused us to pick the beginning date of January 1, 1978 for this rev%iew. All Caucasian patients between the ages of 70 and 80 were reviewed. To have a minimal follow-up of at least 18 months, From the Surgical Group for Thoracic and Cardiovascular Diseases, Mlemphis, Tennessee. Presented at the Ninth Annual Scientific Symposium of the Denton A. Cooley Cardiovascular Surgical Society, Sept , 1982, Athens, Greece. Address for repnrnts: Surgical Group for Thoracic and Cardiovascular Diseases, P.C., 1325 Eastmoreland Avenue, Suite 340, Memphis, Tennessee Texas Heart Institute Journal 137

2 the study was stopped December 31, There were 57 males and 29 females in this group. Follow-up was 100%. Life Expectancy A review of the data (Table I) indicates that bypass grafting in the male, aged 70 to 80, may actually increase the life expectancy slightly, although the numbers are not large enough to be statistically significant. With an average follow-up of 24 months, the percentage of those who died was 8.8%, contrasted with an expected rate of 11%. The majority (5.3%) of the postoperative deaths occurred early and were related to the operative procedure. This seems to indicate improvement in longterm survival rates that could continue to increase with time. Women in their seventh decade did not fare as well as their male counterparts. Although fewer in number, the mortality rates for women were quite different. The expected mortality rate of 7.3% was considerably lower than the observed rate of 14%. The perioperative death rate was satisfactory (6.9%), but increased significantly with time. This factor was especially apparent in the more elderly women. Predictive Factors Certain preexisting conditions and operative occurrences served to predictably influence end results. Patients in this age group who had had previous vascular surgery were more at risk than their first-time counterparts. Although the number was small, it supported our impression that patients with proven, preexisting arteriosclerotic disease did not generally fare as well. This includes those patients who had undergone surgery for aneurysm, carotid stenosis, or peripheral vascular lesions (Table II). Patients with any perioperative problem had increased mortality (Table III). Reexploration of the mediastinum for bleeding carried with it a 66% death rate. The development of complete heart block, necessitating the implantation of a permanent pacemaker, was also significant. Other factors, such as intraaortic balloon removal and sternal dehiscence, were rather infrequent. Interestingly, all five patients who had had an intraaortic balloon inserted at the time of surgery did very well. The number of bypasses per patient showed an increase in risk in both the lower and upper ranges. Those patients having three or four distal anastomoses exhibited only a 3.9% mortality rate. Patients having more grafts were much more at risk (Table IV). The immediate postoperative status was an important factor. Of the 69 patients who were asymptomatic (other than incisional pain), only one experienced an early death, and to date there have been only three additional deaths. Average follow-up of this group is 25.8 months. Symptomatic patients have exhibited a 35% mortality rate over an average follow-up time of 14.5 months (Table V). The presence of hypertension, diabetes and pulmonary disease did not influence the outcome. We did not attempt to analyze the preexisting cardiac status, as these factors are well known to all and were taken into consideration when making the surgical decision. The development of Dressler's syndrome increased the length of hospital stay, but did not influence the outcome. Follow-Up Seventy-seven of the 86 patients were alive at the time of follow-up contact: Forty-seven are asymptomatic and are able to carry on their usual life styles. Thirty are symptomatic with angina pectoris. Half of these patients have had to restrict their activity level, even though 66% stated that their pain pattern is improved compared to the preoperative status (Table VI). Discussion Age must influence the decision for coronary artery bypass grafting. The effect of variables present in the older age groups has been studied by several observers Vol. 10, No. 2, June 1983

3 TABLE 1. Mortality Results Following Coronary Artery Bypass Grafts in the Age Group Months Sex Number Follow-up Early Total Expected Male Female TABLE II. Relation of Proven Arteriosclerotic Disease to Death Rate Number Early Late Proven present Not present TABLE Ill. Relation of Associated Operations to Death Rate Operation Number Early Total None Pacemaker Reexploration Previous CABG Others CABG = Coronary artery bypass graft. TABLE IV. Relation of Number of Bypasses and Mortality Rates Number Number Total of Grafts of Patients Deaths TABLE V. Relation of Postoperative Angina to Death Rate Status Number Early Deaths Total Deaths Asymptomatic 69 1 ( 1.4%) 3 ( 4.3%) Symptomatic 17 4 (23.5%) 6 (35.3%) TABLE VI. Status of the 77 Patients at Follow- Up Asymptomatic 47 Symptomatic 30 Improved 20 (66%) Same 5 (16%) Worse 5 (16%) Texas Heart Institute Journal 139

4 Certain points have become evident, indicating that the efficiency of the procedure, when properly performed, does not diminish in the geriatric group. In this evaluation, we did not attempt an in-depth study of the cardiac variables that are known to influence outcome.7'8 It is our practice to limit our surgery recommendations to those people with relatively low-risk situations in this age group. The viable, active septuagenarian who does not exhibit other conditions that contraindicate surgery does not benefit from operation with an acceptable risk. The technical improvements that took place in the mid-70s have advanced cardiac surgery into a new era. Improved methods of myocardial preservation were a major factor in our selecting 1978 as the starting date for this study. Since that time, our early mortality rate has been acceptable, and the follow-up data seem to indicate good long-term results. Life expectancy may actually be improved in this select group.9 This study substantiated the long-held theory that "older patients do well as long as nothing goes wrong." Any secondary operative procedure, such as reexploration for bleeding or permanent pacemaker implantation, was indicative of problems that significantly influenced outcome. There was a correlation betwveen increased problems and the preexistence of arteriosclerotic disease. The presence of pulmonary disease, hypertension or diabetes did not seem to affect outcome. Although it is entirely subjective, each postoperative patient's own evaluation of his status proved to be very accurate. An improved long-term survival rate has been observed in those patients who noted that their angina was better immediately following operation. Summary A series of 86 patients, aged years, who had undergone coronary artery bypass grafting without other procedures, was analyzed over a 2-year period. There were 57 men and 29 women in the study. Review of the data indicates that bypass grafting in the male in this age group may actually increase the life expectancy slightly, although the numbers are not large enough to be statistically significant. Women in the group, however, did not fare as well as their male counterparts. Seventy-seven of the 86 patients were alive at the time of follow-up contact, 47 of whom wvere asymptomatic and able to carry on their usual life style. Thirty patients had angina pectoris. The number of bypasses per patient showed an increase in risk in both the lowver- and upper-age ranges. From our analysis, certain points have become evident, indicating that the efficiency of coronary artery bypass surgery when properly performed does not diminish in the geriatric age group. References 1. Ashor GWV, Meyer BWN%, Lindesmith GG, Stiles QR, Walker GH, Tucker BL. Coronary artery disease. Surgery in 100 patients 65 years of age and older. Arch Surg 1973: 107: Hoffmann RG, Blumnleini SL, Andersoni AJ, Barboriak Jj, Walker ja, Rimm AA. The probability of surviving coronary bypass surgery. Fi e-year resuilts from 1,718 patients. JANIA 1980; 243 (13): Kirklin JWV, Kouchoukos NT, Blackstone EH, Oberman A. Researclh related to surgical treatmlent of coronarv arterv disease. Circulation 1979: 60 (7): Knapp WS, Dotiglas JS jr, Craver JM, Jones EL, King SB, Bone DK, Bradf'ord JM, Hatcher CRJr. Efficacy of coronary artery bypass graf'ting in elderly patients with coronary artery disease. Am J Cardiol 1981; 47: ( 5. Meyer J, W'ukasch DC, Seybold-Epting WN', Chiariello L, Reul (j, Sandiford FM, Hallman GL, C(oolev DA. Coronary artery bypass in patients over 70 years of age: Indication and results. J Cardiol 1975; 36: Stephenson LWN', MacVaugh H III, Eddmunds LH. Surgery using cardiopulmonary bypass in the elderly. Circulation 1978; 58 (2): Russell ROJr (with 46 investigators). Unstable angina pectoris: National cooperative study group to compare surgical and medical therapy. II. In-hospital experience and initial follow-up resilts in patients with one, two and three vessel disease. Am (Cardiol 1978: 42: Vol. 10, No. 2, June 1983

5 8. Takaro T, Hultgren HN, Lipton MJ, Detre KM (participants in the study group). The VA cooperative randomized study of surgery for coronary arterial occlusive disease. II. Subgroup with significant left main lesions. Circulation 1976; 54 (Suppl III) (6): Isom OW, Spencer FC, Glassman E, Cunningham JN, Teiko P, Reed GE, Boyd AD. Does coronary bypass increase longevity? J Thorac Cardiovasc Surg 1978; 75 (1): Texas Heart Institute Journal 141