Coronary artery surgery in octogenarians

BRIEF REPORTS

Coronary Artery Surgery in Octogenarians William S. Weintraub, MD, Stephen D. Clements, MD, John Ware, MD, Joseph M. Craver, MD, Caryn L. Cohen, MN, Ellis L. Jones, MD, and Robert A. Guyton, MD oronary surgery is being performed increasingly in older patients who may have more extensive diseaseas well as other factors that may lead to more frequent complications and death.1-3Severalstudies haveshownthat the rate of complicationsand mortality in elderly patients are higher than in younger ones.4-7 Advanced age has also beenshown to correlate with late mortality after cardiac surgery.* Becauseof these data, there has beenuncertainty asto useof cardiac surgery in older patients, especially in those aged 280 years. This report presentsresults of coronary artery bypassgrafting both in hospital and at follow-up in patients aged 280. The study population comprised all patients aged 280 years who underwent isolatedfirst coronary bypass surgery at Emory University Hospital or Crawford W. Long Hospital between 1978 and 1989. Patients with coexisting valve, congenital heart and primary myocardial diseases,those needing aneurysmectomy, and those undergoing coronary surgery in the setting of unsuccessful angioplasty were excluded from the study. In all, there were 154patients included in the study. Coronary arteriography was performed with multiple right and left anterior oblique projections using the Judkins technique. All angiograms were interpreted by 22 experienced angiographers. Contrast left ventriculograms were obtained in the 30” right anterior oblique projection. Extracorporeal circulation was instituted by standard techniques,9 and perfusion was maintained at 2.0 to 2.4 liters/min/m2. Systemic (30 to 25’C) and topical hypothermia, and cold potassium cardioplegia were usedfor myocardial protection. Cardioplegic solution was reinfused at 20 to 30 minute intervals to maintain an intramyocardial temperature <2O”C. Distal anastomoses wereformed with the aid of optical magnification. Grafts were createdfrom either internal mammary arteries or vein grafts. Patients were then weaned from cardiopulmonary bypass, and chests were closed using standard techniques. Patients were then transferred to the surgical intensive care unit. Angina class was defined by the Canadian Cardiovascular Society classification.tO Variables of previous myocardial infarction, diabetes mellitus and hypertension were gathered from the patient’s history.

C

From the Divisions of Cardiology and Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia 30322. Manuscript received July 16, 1991; revised manuscript received and accepted July

Emergent surgery was defined by the operator. A vessel was considered stenotic if there were 150% diameter narrowing of the main coronary artery or of any major branch. The number of vessels diseased was determined by a set algorithm that has been used in this institution.” The number of grafts was determined by the number of distal anastomoses.Myocardial infarction after surgery was determined by the development of new Q waves.A neurologic event was a persistent change in neurologic function, including persistent disorientation, after thejirst several days in the intensive care unit. All data were prospectively collected and entered into a computerized clinical database. Data are presented as a percentage or mean f standard deviation, where appropriate. For purposes of analysis, prolonged stay was defined as 210 days after coronary surgery. Categorical variables were compared by Pearson’s chi-square. Multivariate correlates of inhospital death were determined by stepwise logistic regression analysis. Statistical testing was performed with BMDP. Patients werefollowed up by telephone survey. Events occurring during subsequent hospitalizations were obtained from the clinical database. Survival was determined by the Kaplan-Meier method.t2 Differences in survival betweengroups were determined by the Mantel-Cox method.t3 Multivariate correlates of survival were determined by Cox model analysis. Mean age of the patients was 82 f 2 years (range 80 to 89); 98 (64%) were men, 73 (47%) had a prior myocardial infarction, 76 (49%) had hypertension, 26 (I 7%) had diabetes mellitus, 130 (84%) had class III or IV angina, I9 (12%) had history of congestiveheart failure, 103 (67%) had 3-vessel or left main coronary artery disease and 46 (32%) had an ejection fraction X.50%.Procedural characteristics and complications TABLE I Operative

No. Emergent Grafts Internal mammary Exploration for bleeding lntraaortic balloon pump Q-wave myocardial infarction Stroke Hospital death Length of stay

29, 1991.

1530

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68

Characteristics

DECEMBER 1, 1991

41 3.3 16 7 9 4 8 16 11

(27%)

zk 1.0 (l-6) (10%) (4.5%) (5.8%) (2.6%) (5.2%)

(10%) -c 8 (O-59)

are listed in Table I. Surgery was emergent, as defined TABLE II Correlates of In-Hospital Mortality by the surgeon, in 41 patients (27%). Only ldpatients Total Deaths (%) p Value (10%) had had an internal mammary graft. Reexplo26 0.02 Diabetes mellitus 6 (23) ration for bleeding was needed in 7 patients (4.5%). 128 Diabetes absent 10 (8) The intraaortic balloon pump was neededin 9patients Ejection fraction < 50 46 9 (20) 0.03 (5.8%). A Q-wave myocardial infarction in the hospiElection fraction 2 50 96 7 (7.3) tal occurred in 4 patients (2.6%), a stroke in 8 (5.2%) and in-hospital mortality in 16 (10%). The length of hospital stay after surgery averaged 11 f 8 days (range 0 to 59). Clinical variables were analyzed as correlates of survival, both in the hospital and after discharge. Only diabetes mellitus and left ventricular ejection mellitus, 4 died (29%). In the 44patients with ejection fraction emerged as significant correlates. In-hospital mortality occurred in IO of 128 (7.8%) patients with- fractions <50% or diabetes mellitus, 7 died (16%). In out diabetes mellitus, and in 6 of 26 (23%) with diabe- the 85 patients with ejection fractions 250% and no tes (Table II). Eight of the 26 diabetics were receiving diabetes mellitus, 5 died (5.9%). Five-year survival (Figure 1) was 0.62, and 5-year insulin, and 2 (25%) died. Diabetics receiving insulin myocardial infarction-free survival was 0.57. Twodid not have a higher mortality than those not receiving insulin. In-hospital mortality occurred in 9 of 46 year survival was 0.85 without and 0.54 with diabetes (20%) patients with ejection fractions <50%, and in 7 mellitus (Figure 2). Five-year survival without diabeof 96 (7.3%) with ejectionfractions 150%. In the 14 tes mellitus was 0.64. Two-year myocardial infarcpatients with ejection fractions GO% and diabetes tion-free survival was 0.81 without and 0.54 with

0.7 -

t ---------+-->\ \-

--_

0.6 -

-_

-_

-_

Freedom From 0.5 Events 0.4 03-

Survival

02-

-

MI Fmesuwival

0.1 0 0

I 0.5

I 1

I 1.5

I 2

I 2.5 Time in Years

I 3

I 3.5

I 4

I 4.5

5

Death NRemainiq

1st

129

119

99

a2

61

53

42

30

25

19

Survival

1

a6

as

33

a0

.I8

.78

.77

.I2

.65

.62

N Events

0

21

23

25

29

30

30

31

33

36

37

Death or Ml 152

I24

114

94

77

64

so

40

2s

23

17

Survival

N Remaining

1

a3

.a2

a0

.76

.7s

.I5

.72

.68

.60

57

N Events

0

26

28

30

34

35

3s

37

39

42

43

FIGURE 1. Fine-year freedom from events in 152 pathts. MI = myocardial infarction.

Curves

survival represent

and myocardial

infarction-free

survival.

BRIEF REPORTS 1531

diabetes mellitus (Figure 3). Fiue-year myocardial months after surgery. At the time of follow-up, 87 infarction-free survival was 0.60 without diabetes patients (82%) were free of angina. There was no signijkant difference in angina status at follow-up mellitus. Presenceor absenceof angina at follow-up was available in 106patients at an average of 35 f 22 between patients with no or mild angina and those

0.9 -

I

I I

oallt -.

---__

0.7

0.6 4

\

\

-11 I

--__

-_ I1

0.3

FlGURE 2. Five-year survival in patknts with and without diabetes.

NODLbde _-_-_-_

0.2

Diabetes

1

4c,,,,_0

0.5

1

2

1.5

2.5 Time in Years

35

3

4.3

4

No Diabetes l26

111

107,

86

12

64

41

29

28

22

17

Sunival

1

a9

an

a7

a9

a.3

.82

..a

.I6

*(I

.64

N EvenIs

0

14

15

16

1s

19

19

20

22

29

26

N Rmuining

Diabem 24

18

1,

l2

10

SWVM

1

.69

.6s

.65

.54

N EW,IIS

a

a

9

9

11

N Remaining

-.---___ * -_ ’ it---_ --__ --_ II----__ ----

oaOS0.7 0.6 Ezl

05-

-

0.4 03-

-

P-m

FlGURE3.Five-yearmyocardial infarction-free survival in patients with and without diabetes. Ml = myocardial infarction.

No-

030.1 O-

NO Diabeies NRepahi~ Survival

NEments

I

I

I

I

I

I

1

15

2

25 rime in Years

3

3.6

I 4

.-I

0

I 0.5

l24

1OS

97

81

4

97

44

27

24

21

15

1 e

a9 u

a4 20

a3 21

81 23

.m ?A

39 24

37 26

113 27

Y 26

.60 31

26

1* .6, 0

17 .65 ,

l2 .69

10 .94

1 54

‘ 54

2 .41

9

11

11

11

I2

4.5

Dillbdes Nlbmalninp stmivd N RWdS

1532

1 .

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68

DECEMBER 1, 1991

with severe angina originally. Thus, 7.5of 101 (82%) patients with severeangina at the time of surgery were without chest pain at follow-up. The in-hospital and long-term results of coronary bypass surgery in octogenarians are reviewed in this study. In-hospital mortality was lo%, and ejection fraction and presenceof diabetes mellitus were correlates. Diabetes mellitus was also a correlate of mortality and the combined end point of mortality and myocardial infarction over the several years after the procedure. Patients without diabeteshad lower in-hospital mortality and remarkably high 5-year survival for octogenarians. In addition, 82% of the patients were pain-free during follow-up. Old age has been shown to be a risk factor for inhospital and long-term mortality.4-7 The results of the current study are consistent with reports on geriatric patients from other centers.14-14Fdmunds et all4 reported a 90-day mortality in 10 of 41 (24%) patients aged > 80 years undergoing coronary surgery. Subsequentseries have shown improved results. Naunheim et all5 reviewed the results of coronary and valve surgery in 103 patients aged 280 years. As in the presentstudy, symptomatic improvement was noted. Perioperative predictors of mortality were use of the balloon pump before surgery, history of congestiveheart failure, and mitral valve replacement.In-hospital mortality occurred in 9 of 7 1 (13%) patients undergoing coronary bypasssurgery. Tsai et al 16reported results of coronary bypasssurgery in 64 patients aged >80 years. Within 30 days, 2 patients (3.1%) died. Of the surviving patients, 60% were symptomatically improved. Percutaneoustransluminal coronary angioplasty has also been reported in octogenarians.i7-18Jeroudi et all7 reported impressiveresults in 54 patients, with angiographic successin 49 (91%) and 2 deaths(3.7%) in the hospital. Survival was 8 1%at 1 year and 78% at 3 years. Restenosisand the need for repeat angioplastyor coronary surgerywere limitations. Kern et all8 cautioned that angioplasty in patients aged >80 years is a high-risk procedure. Selection of appropriate caseslimits the ability to compare patients undergoing angioplasty with those treated surgically. Selection of the appropriate form for therapy in patients aged 280 years may be complicated by higher adverseevent ratesthan thosein younger ones.Although the influence of age on the cost of surgery is not known, older patients do have a longer mean length of hospital stay.l9 Complications including stroke and wound infections are more frequent in older patients and can result in dramatically longer hospital stays in some patients.19 The criteria for operating on patients aged > 80 yearsare likely to be different than for those who are decades younger, with the severity of angina being more important in the decisionto operateon octogenarians.There is

almost certainly a tendency to avoid surgery in patients aged 280 years. Factors that were not available for this study, such as detailed assessmentof the diffusenessof the coronary artery diseaseon angiographic review, and considerationof how robust or frail the patient is, may further improve selection of appropriate cases. With careful caseselection,the probability of successfulsurgery in octogenariansis increased.Thus, the probability is that selectedpatients aged 280 yearswill havesuccessful surgerydespitehigher risks and almostcertainly higher costs. It is of interest to note that 5-year survival in 1987 in the United States for all personsaged 80 to 85 yearswas 66%,20which is quite closeto the 62% found in this study. Whether life is prolonged and whether coronary surgery can be cost-effectivein patients aged 280 years cannot be answered from the current literature. Although the current crisis in health care costs may result in attemptsto deny certain proceduresto the elderly, this report suggeststhat coronary artery bypasssurgery should not be denied to patients on the basisof age alone.

1. Weintraub WS, Jones EL, King SP III, Craver J, Douglas JS, Guyton R, Liberman H, Morris D. Changing use of coronary angioplasty and coronary bypass surgery in the treatment of chronic coronary artery disease. Ant J Cardiol 1990;65:183-188. 2. Jones EL, Weintraub WS, Craver JM, Guyton RA, Cohen CL. Coronary bypass surgery-is the operation different today? J Thorac Cardiouasc Surg 1991;101:108-115. 3. Christ&is GT, Ivanov J, Weisel RD, Birnbaum PL, David TE, Salerno TA, and the cardiovascular surgeons of the University of Toronto. The changing pattern of coronary artery bypass surgery. Circukztion 1988;8O(suppl 1): I-151&1-161. 4. Kennedy JW, Kaiser GC, Fisher LD, Fritz JK, Myers W, Mudd JG, Ryan TJ. Clinical and an&graphic predictors of operative mortality from the collaborative study in coronary artery surgery (CASS). Circulation 1981;63:793-802. 5. Cosgrove DM, Loop FD, Lytle BW, Baillot R, Gill CC, Gelding LAR, Taylor PC, Goormastic M. Primary myocardial revascularization: Trends in surgical mortality. J Thor-m Cardiouasc Surg 1984;88:673-684. 6. Montague NT, Kouchoukos NT, Wilson TAS, Bennet AL, Knott HW, Lochridge SK, Erath HG, Clayton OW. Morbidity and mortality of coronary bypass grafting in patients 70 years of age and older. Ann ThoracSurg 1985;39:552-557. 7. Gersh BJ, Kronmal RA, Schaff HV, Frye RL, Ryan TJ, Myers WO, Athearn MW, Gosselin AJ, Kaiser GC, Killip T. Long-term (5 years) results of coronary bypass surgery in patients 65 years old or older: A report from the Coronary Artery Surgery Study. Circulation 1983;68(suppl II):II-190-11-199. 8. Vigilante GJ, Weintraub WS, Klein LW, Schneider RM, Seelaus PA, Parr GVS, Lemole G, Agarwal JB, Helfant RH. Medical and surgical survival in coronary artery disease in the 1980’s. Am J Cardiol 1986;58:926-931, 9. Jones EL, Craver JM, King SB III, Douglas JS, Brown CM, Bone DK, Hatcher CR Jr. Clinical, anatomic and functional descriptors influencing morbidity, survival and adequacy of revascularization following coronary bypass. Ann Surg 1980;192:390~402. 10. Campeau L. Grading of angina pectoris (letter). Circulation 1975;54:

522-523. 11. Talley JD, Hurst JW, King SB Ill, Douglas JS, Roubin GS, Gruentzig AR, Anderson HV, Weintraub WS. Clinical outcome 5 years after attempted percutancous transluminal coronary angioplasty in 427 patients. Circukxtion 1988;77:

820m829. 12. Kaplan EL,

Meier P. Nonparametric estimation from incomplete observations. J Am Star Assoc 1958;53:457-481. 13. Mantel N. Evaluation of survival data and two new rank order statistics arising in its consideration. Cancer Chemother Reports 1966;50:163-170. 14. Edmunds LH JR, Stephenson LW, Edie RN, Ratcliffe MB. Open heart surgery in octogenarians. N Engl J Med 1988;319:131-136.

BRIEF REPORTS 1533

15. Naunheim KS, Dean PA, Fiore AC, McBride LR, PenningtonDG, Kaiser GC, Willman VL, Barrier HB. Cardiac surgery in the octogenarian.Eur J Cardiothorac Surg 1990;41:130-135. 16. Tsai TP, Chaux A, Kass RM, Gray RJ, Matloff JM. Aortocoronary bypass surgery in septuagenariansand octogenarians.J Cardiouasc Surg (Torino) 1989;30:364-368. 17. Jeroudi MO, Kleiman NS, Minor ST, Hess KR, Lewis JM, Winters WL, Raizner AE. Percutaneoustransluminal coronary angioplasty in octogenarians. Ann Int Med 1990;113:423%428.

Prevalence and Significance Coronary Angioplasty

16. Kern MJ, Deligonul U, Galan K, Zelman R, Gabliani G, Bell ST, Bodet J, NaunheimK, VandormaelM. Percutaneoustransluminalcoronary angioplastyin octogenarians.Am J Cardiol 1988;61:457-458. 19. Weintraub WS, JonesEL, Craver J, Guyton R, Cohen CL. Determinantsof prolonged length of hospital stay after coronary bypass surgery. Circulation 198%80x276-284. 20. National Center for Health Statistics. Mortality. Washington,DC.: Public Health Service, 1990.(Vital Statistics of the United States, 1987,vol II, part A, section 6, page 6.)

of ST-Segment

Alternans

During

Ian C. Gilchrist. MD lectrical alternansis a phenomenonof alternating electrocardiographic morphology on an everyother-beat basis. ST-segment alternans is often seenin the animal laboratory with subtotal or transient coronary artery occlusion.l In humans it has been observedin a variety of settings,such as Prinzmetal’s angina and once during percutaneoustransluminal coronary angioplasty (PTCA).2 Although clinically rarely observed, ST-segment alternans has been correlated with subsequentmalignant arrhythmias and may be an important marker of electrically unstable myocardium.3 This study was performed to determine whether PTCAinduced transmural ischemia could reproducibly induce ST-segmentalternans and serveas a model for this syndrome.

E

and, when feasible, intracoronary blood pressure monitoring. More than 90% of the patients had Ll balloon inflation X0 seconds. Each patient’s record was reviewedfor target arteries, number and duration of balloon inflations, presence of ST-segment alternans, and complications. Five patients were observed to have ST-segment alternans. Their records were further reviewed for cardiac history, prior PTCA procedures, coronary anatomy and ventricular function, medications and electrolytes. The records were also reviewed for contrast agent use, angina1 symptoms, hemodynamic changes and sequence of electrocardiographic changes in relation to duration of balloon inflation. Clinical characteristics and pertinent data for the 5 Laboratory records of 407 consecutive patients un- patients with ST-segment alternans are listed in Tadergoing PTCA, with continuous electrocardiographble I. Four of these cases occurred of I95 angioplastic monitoring and recording of 22 standard leads ies of the left anterior descending artery, and 1 of 102 during balloon inflations, were evaluated. Lead selec- angioplasties of the left circumflex artery. No epition was based on the most likely ischemic zone dursodes of ST-segment alternans were seen in 110 aning PTCA. Most procedures were performed using gioplasties of the right coronary artery. ST-segment alternans never developed with C.55 seconds of arteristandard over-a-wire balloon techniques with arterial al occlusion. With repeated dilatations, ST-segment From the Division of Cardiology, The Milton S. Hershey Medical alternans was reproducible at about the same time of Center, PennsylvaniaState University, Hershey, Pennsylvania 17033. Manuscript received May 24, 1991; revised manuscript received and balloon occlusion. RR intervals and QRS morphologies were unchanged during periods of ST-segment acceptedJuly 26, 1991. TABLE

I Clinical Characteristics of Patients with ST-Segment Alternans During Coronary Angioplasty

Age lyr) & Sex

PTCA Artery

Collaterals

Diameter Narrowings in Other Coronary Arteries

1

71 M

2 3 4 5

74 M

LAD LAD LAD LC LAD

0 0 + 0 +

90%-D 1 60%-LC lOO%-LC 0 95%-LC

Pt. No.

71 F 57 M 69 M

*Persisted for 120 seconds, then developed into uniform ST elevation. D = ST-segment depression; Dl = first diagonal branch; E = ST-segment transluminal coronary angioplasty; - = no information available.

1534

elevation;

THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 68

Onset of Alternans Isec)

E E E E D

55

95 60

120* 100 LAD = left anterior

Type of ST Change

descending

DECEMBER 1, 1991

artery;

Inflation Time bed

Angina1 Symptoms Moderate

180 180

Slight

420 360

Severe

180

Slight

LC = left circumflex

artery;

PTCA = percutaneous