Canging profilie of elderl patmients undergoing coronary bypass surgery

E.C.W. Cloin, L. Noyez

Objective. Are elderly patients now undergoing CABG at higher risk than several years ago? Methods. 1536 patients, aged between 70 and 77 years, who underwent CABG between January 1987 and December 2001, were analysed. Group A 1987-1989 (n=177); group B 1990-1992 (n=243); group C 1993-1995 (n=362); group D 1996-1998 (n=418); and group E 1999-2001 (n=336). The Euroscore evaluated operative risk. Results. There was an increase in the percentage of the study population from 12.5 to 24.1% (p=0.000). Mean age increased from 72.1±1.8 to 73.2±1.9 years (p=0.047). The percentage of patients with neurological (p=0.002), renal (p=0.013) and lung disease (p=0.04), a previous PTCA (p=0.000), left main stenosis (p=0.003), impaired ventricular function (p=o.ooo) and reoperations (p=0.01) increased. Emergency/ urgent operations (p=0.001) decreased. Hospital mortality decreased from 7.3 to 5.7% (p=0.34). Only neurological problems increased significantly (p=0.03). The calculated operative risk by Euroscore remained stable (p=0.28). To eliminate the influence of the urgent/emergency situation, the Euroscore was recalculated, supposing that all patients were elective. At that moment a significant increase in the operative risk was seen (p=0.02). Conclusion. Over the last few years there has not only been an increase in the number of older patients undergoing CABG, but even in this older population there is an increasing number of highrisk patients. (NethHeartJ2005;13:132-8.) Key words: coronary bypass surgery, elderly, Euroscore, morbidity, mortality, risk E.C.W. Cloin L Noyez Department of Thoracic and Cardiac Surgery, Heart Centre, St Radboud University Medical Centre, Nymegen

Correspondence to: L. Noyez Department of Thoracic and Cardiac Surgery 414, Heart Centre, St Radboud University Medical Centre, 6500 HB Nijmegen E-mail: [email protected]


Today, elderly people make up an important part of our society and consequently more and more older patients are undergoing cardiac surgery.' Not only the percentage ofolder patients is increasing over the years, but also the age of the 'elderly' patients. In 1983, patients aged 65 years or older were described as elderly, in 1986 this was the over 70 year olds and nowadays even patients aged 80 years and older are presenting and being accepted for cardiac surgery.2-4 Where ten years ago a patient of 72 years was considered an 'old patient', he is now a routine patient. We can suppose that in the beginning only older patients in a good condition were being referred for surgery, but with the increasing number of these patients and experience gained there is not only a further increase in the age of the presenting patients but also an increase in the comorbidity ofthis patient population. The main purpose of this study was to evaluate whether at this moment elderly patients undergoing cardiac surgery are in a worse condition and at a higher risk for mortality and complications than previously treated patients of their age group. If yes, a second question is, is this perceptible in the postoperative results?

Material and methods Patients With the aid of the Coronary Surgery Database Radboud Hospital (CORRAD), a registry that stores pre-, peri-, and postoperative data on all patients undergoing isolated CABG, 7474 myocardial revascularisations were identified that had been performed between January 1987 and December 2001. This period was subdivided into five cohorts based on the operation date: group A 1987-1989, group B 19901992, group C 1993-1995, group D 1996-1998 and group E 1999-2001. For this study we selected patients aged between 70 and 77 years. The studied variables and their definitions are presented in table 1. Risk evaluation The Euroscore was used for analysis of the operative risk.5 This risk stratification system is simple, objective and up-to-date for assessing heart surgery, based on

Neth1reands Heart Journal, Volume 13, Number 4, April 2005

Changing profile of elderly patients undergoing coronary bypass surgery

Table 1 Variables and definitions. Sex Age Diabetes Hypertension Neurological disease Renal disease Lung disease Peripheral vascular disease PTCA Myocardial infarction Valve disease (mild) Left main Reoperation Left ventricular function

Operative status

Postoperative Ml Wound infection Renal problems Neurological problems

Pulmonary problems

Male, female Years Diet-controlled, oral therapy, or insulin-dependent diabetes Systolic blood pressure >160 mmHg, or diastolic pressure >100 mmHg, or antihypertensive medication Cerebrovascular accidents and/or transient ischaemic attack Renal failure (creatinine .150 gmol /1) preoperative dialysis, renal transplantation Chronic obstructive pulmonary disease and/or history of previous lung disease Peripheral or abdominal vascular pathology or operation History of previous percutaneous transluminal coronary angioplasty History of a previous myocardial infarction Combined valve disease, not requiring surgical intervention Left main stenosis >70% Previous cardiac surgery Left ventricular ejection fraction, otherwise surgeons peroperative evaluation. Three groups: good (>50%), poor (>30,5.

Surgical technique All patients were operated using standard cardiopulmonary bypass technique, aortic and right atrial cannulation and hypothermia (28-32°C). Myocardial protection during aortic cross-clamping was performed with infusion of cold (4°C) St Thomas' Hospital cardioplegia until asystole occurred and was maintained by reinfusion of 100 ml/i2 of the solution every 25 to 30 minutes or earlier as needed; in redo-surgery cold blood cardioplegia has been used since 1992.6 In group E, 37 patients (12%) were operated off-pump. Statistical analysis The characteristics of the patients in the different cohorts are presented as percentages for dichotomy variables and as mean SD for the results of the Euroscore. Differences between the groups were tested with the F test (one-way analysis of variance) or with the x2 test. Statistical significance was assumed at p>O.05 (p=O.OOO means p200 imol/l preoperatively 3 Active endocarditis Critical preoperative state 3 (ventricular fibrillation, reanimation, shock) Cardiac-related factors 2 Unstable angina LV dysfunction 30-50% //

Changing profile of elderly patients undergoing coronary bypass surgery.

Are elderly patients now undergoing CABG at higher risk than several years ago?...
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