Khan JH, McElhinney DB, Hall TS, et al [ Univ of California, San Francisco]
Cardiac Valve Surgery in Octogenarians : Improving Quality of Life and Functional Status
Arch Surg 133 : 887-893, 1998
Open heart surgery can be performed on octogenarians with acceptable mortality but significant morbidity, but no studies have assessed the resulting quality of life and functional status of such patients. Factors that may predict survival, performance status, and medical resources use were retrospectively reviewed.
Between June 1987 and May 1995, medical records of 61 patients [14 women], aged 80 to 89 years, who underwent cardiac valve surgery, were reviewed, and patients were interviewed on telephone. Patients were followed up for 30 months. They had a variety of co-morbid conditions, and all were symptomatic at surgery. Functional status and Karnofsky status were assessed at discharge and at 3 months.
Patients underwent aortic valve replacement [n=47], mitral valve replacement and /or repair [n=14] and coronary artery bypass grafting with other procedures [n=27]. Seven patients [11.4%] died perioperatively, and 20 patients [37%] experienced significant postoperative complications. Hospital stay for those with complications was 25 days versus 12 days for the rest. Of the 54 survivors, 15 were discharged to nursing homes, 9 of them for functional disabilities. There were 12 late deaths. The remaining 42 survivors had 18 hospital re-admissions. Actuarial survivals were 85% at 1 year and 66% at 5 years. Patients with postoperative complications had longer hospital stay and decreased actuarial survival. One months after discharge, New York Heart Association classification had improved a median of two classes; Karnofsky performance had improved to a median of 80%, from a preoperative level of 30%. Results were similar at 8 months.
Heart valve replacement in octogenarians is safe, improves symptoms and functional status, and enhances quality of life but more resources are used, and recovery is complicated and delayed.
Kirsch M, Guesnier L, LeBesnerais P, et al [Hospital Henri Mondor, Creteil, France]
Cardiac Operations in Octogenarians : Perioperative Risk Factors for Death and Impaired Autonomy
Ann Thorac Surg 66: 60-67, 1998
With the aging of the population, cardiac surgeons are more frequently performing surgery on older, higher-risk patients. Records of 191 consecutive patients, aged 80 years or older, who underwent cardiac surgery were reviewed to identify risk factors for early and late postoperative mortality, impaired function, and reduced quality of life.
Between January 1, 1991 and December 31, 1996, 191 patients [ 98 men] aged 80 to 91 years, in New York Heart Association class III or IV and a mean left ventricular ejection fraction of 0.55, underwent aortic valve replacement [n=110], coronary artery bypass [n=47], combined aortic valve replacement and coronary bypass grafting [ n=26], mitral valve replacement [n=5] and other procedures [n=3].
The mean postoperative stay was 6 days, and the mean hospital stay was 9.5 days. Complications occurred in 132 patients [91%]; and included cardiovascular in 82.6%, pulmonary in 32.5% , stroke in 9.4%, intra-abdominal complications requiring surgery in 2.1%, renal failure in 12.0%, and infection in 10%. The in -hospital mortality was 16.2%. Actuarial survivals at 1,3 and 5 years were 79.2%, 74.9% and 56.2% respectively. The over-all mortality rate was 31.0%. The most common causes of death were heart related. In those with in-hospital deaths, preoperative pulmonary hypertension and low left ventricular ejection fractions, were independent predictors of mortality. In those with late deaths, predictors of mortality were female sex and combined aortic valve and coronary artery bypass surgery.
At follow-up, 129 patients [63.6% ] were completely autonomous. Subjective quality of life assessments revealed 83% were satisfied, 8.5% were somewhat satisfied, and 7.8% were dissatisfied.
Thus outcome after cardiac surgery in octogenarians is satisfactory, with majority continuing long-term autonomy and satisfactory quality of life.
Sollano JA, Rose EA, Williams DL. et al [Columbia Univ, New York]
Cost-Effectiveness of Coronary Artery By-pass Surgery in Octogenarians
Ann Surg 228; 297-306, 1998
Survival, quality of life, and economic outcomes are important issues to evaluate when considering the efficacy and cost effectiveness of coronary artery bypass graft [CABG] in octogenarians. Results of a retrospective relative effectiveness, and cost effectiveness analysis of CABG surgery versus medical management in octogenarians were studied.
Two cohorts of patients with significant multi-vessel coronary artery disease, treated by CABG [n=176; 57% male, aged 80 to 90 years] or by medical management [n=48; 75% male, aged 80 to 89 years], were compared, at Columbia Presbyterian Medical Center between 1992 and 1996. Medically managed patients were reasonable surgical candidates. End points were health outcomes, cost, and cost effectiveness.
Surgically and medically managed patients were followed up for 38 and 31 months respectively and 3 year survivals were 80% and 64% respectively. Perioperative mortality was 6.8%. A subgroup of patients, who had refused surgery and were medically managed, had a ten-month survival rate of 50%. The costs for surgical group were $ 41348 as against $ 12467 for those managed medically and $ 15232 for those refusing surgery and opting for medical treatment. The costs when adjusted for quality of life gained, worked out almost same for the two groups.
Thus CABG in octogenarians is cost effective and increases quality of life.
Marcantonio ER, Goldman L, Orav EJ, et al
The Association of Intraoperative Factors with Development of Postoperative Delirium
Am J Med 105 : 380 – 384, 1998
The study included 1341 patients [55 % Women ] above the age of 50 years [ mean age 67 years], who were hospitalized for major elective noncardiac surgery. The investigators collected possible intraoperative risk factors from the patients medical records.These included route of anesthesia, intraoperative hypotension, bradycardia, tachycardia, blood loss, number of blood transfusion, and lowest postoperative hematocrit level. From postoperative day 2 to 5, the patients were assessed daily for delirium with the use of confusion Assessment Record. The medical record and the hospital’s nursing intensity index were also used in assessing the patient’s mental status.