Coronary Artery Bypass Grafting in Octogenarians - Outcome with and without Extracorporeal Circulation

Abstract

Octogenarians are increasingly considered for coronary artery bypass grafting (CABG), but still represent a high-risk patient group with increased mortality and morbidity. In recent years off-pump surgery has been successfully established in CABG. The avoidance of extracorporeal circulation (ECC) seems to be of particular benefit for this patient group. We retrospectively analyzed our experience with CABG surgery with and without ECC in octogenarians to define the potential benefit of these different approaches in this high-risk group of patients. We analyzed the outcome after isolated CABG of 344 consecutive patients (219 male, 125 female, age: 82 ± 2.4 years) who were aged 80 or older. Patients were divided into two groups according to the use of ECC. The on-pump group consisted of 237 patients (151 male, 86 female, 82 ± 2.8 years) and the off-pump group consisted of 107 patients (68 male, 39 female, 82 ± 1.9 years). The predicted EuroSCORE and EuroSCORE mortality risk were similar for both patient groups. The overall hospital mortality rate was 5.5 % (n = 17): 14 patients (5.9 %) in the on-pump group (n = 237, 100 %) and five patients (4.6 %) in the off-pump group (n = 107, 100 %). The average number of grafts in the on-pump group was 2.8 ± 0.4 and it was 2.4 ± 0.6 in the off-pump group (p = 0.05). Morbidity was comparable in both groups. Significant variables in multivariate regression were preoperative atrial fibrillation (p = 0.03; RR = 2.7), COPD (p = 0.0001; RR = 6.5) and prolonged intubation (p = 0.005; RR = 4.1). Isolated CABG in octogenarians can be performed with good clinical results, although a substantial mortality remains. The results of coronary surgery in this patient group with and without ECC are comparable with respect to mortality and morbidity.

coronary bypass surgery - octogenarians - extracorporeal circulation - off‐pump

References

• 1 Gummert J F, Funkat A, Beckmann A. et al . Cardiac surgery in Germany during 2005: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.  Thorac Cardiovasc Surg. 2006;  54 362-371
• 2 Van Dijk D, Nierich A P, Jansen E WL. et al . Early outcome after on-pump coronary artery bypass surgery.  Circulation. 2001;  104 1761-1766
• 3 Arom K V, Flavin T F, Emery R W. et al . Safety and efficiency of off-pump coronary artery bypass grafting.  Ann Thorac Surg. 2000;  69 704-710
• 4 Magee M J, Jablonski K A, Stamou S C. et al . Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients.  Ann Thorac. 2002;  73 1196-1202
• 5 Calafiore A, Di Mauro M, Conti M. et al . Myocardial revascularization with and without cardiopulmonary bypass in multivessel disease: impact of the strategy on early outcome.  Ann Thorac. 2001;  72 464-468
• 6 Akpinar B, Guden M, Saisoglu I. et al . Does off-pump coronary artery bypass surgery reduce mortality in high risk patients?.  Heart Surg Forum. 2001;  72 2020-2025
• 7 Mack M, Bachand D, Acuff T. et al . Improved outcomes in coronary artery bypass grafting with beating-heart techniques.  J Thorac Cardiovasc Surg. 2002;  124 598-607
• 8 Tugtekin S M, Alexiou K, Kappert U. et al . Coronary reoperation with and without cardiopulmonary bypass.  Clin Res Cardiol. 2006;  95 93-98
• 9 Demaria P, Cartier M, Fortier S. et al . Reduced mortality and stroke with off-pump coronary artery bypass grafting surgery in octogenarians.  Circulation. 2002;  106 (Suppl I) I5-I10
• 10 Stamou S C, Dangas G, Dullum M K. et al . Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups.  Ann Thorac Surg. 2000;  69 1140-1145
• 11 Demers P, Cartier R. Multivessel off-pump coronary artery surgery in the elderly.  Eur J Cardiothorac Surg. 2001;  20 908-912
• 12 Smith K M, Lamy A, Arthur H M, Gafni A, Kent R. Outcomes and costs of coronary artery bypass grafting: comparison between octogenarians and septuagenarians at a tertiary center.  CMAJ. 2001;  165759-165764
• 13 Nagpal A D, Bhatnagar C A, Cutrara. et al . Early outcomes of coronary artery bypass with and without cardiopulmonary bypass in octogenarians.  Can J Cardiol. 2006;  22 849-853
• 14 Kirsch M, Guesnier L, LeBesnerais P. et al . Cardiac operations in octogenarians: perioperative risk factors for death and impaired autonomy.  Ann Thorac Surg. 1998;  66 60-67
• 15 Wilson M F, Baig M K, Ashraf H. Quality of life in octogenarians after coronary artery bypass grafting.  Am J Cardiol. 2005;  95 761-764
• 16 Hoff S J, Ball S K, Glassford D M. et al . Coronary artery bypass grafting in patients 80 and over: is off-pump the operation of choice?.  Ann Thorac Surg. 2002;  74 S1340-S1343
• 17 Kilo J, Baumer H, Cerny M. et al . Target revascularization without cardiopulmonary bypass in elderly high-risk patients.  Ann Thorac. 2001;  71 537-542
• 18 Osswald B R, Blackstone E H, Tochtermann U. et al . Does the completeness of revascularization affect early survival after coronary artery bypass grafting in elderly patients?.  Eur J Cardiothorac Surg. 2001;  20 120-125
• 19 Ricci M, Karamanoukian H L, Abraham R. et al . Stroke in octogenarians undergoing coronary artery bypass grafting with and without cardiopulmonary bypass.  Ann Thorac Surg. 2000;  69 1471-1475
• 20 Hirose H, Amano A, Takahashi A. Off-pump coronary artery bypass grafting for elderly patients.  Ann Thorac. 2001;  72 2013-2019
• 21 Murphy G J, Angelini G D. Side effects of cardiopulmonary bypass: what is the reality?.  J Card Surg. 2004;  19 481-488
• 22 Lev-Ran O, Braunstein R, Sharony R. et al . No-touch aorta off-pump surgery: the effect on stroke.  J Thorac Cardiovasc Surg. 2005;  129 307-313
• 23 Kim K B, Kang C H, Chang W I. et al . Off-pump coronary artery bypass with complete avoidance of aortic manipulation.  Ann Thorac Surg. 2002;  74 1377-1382
• 24 Peterson E D, Cowper P A, Jollis J G. et al . Outcomes of coronary artery bypass graft surgery in 24 461 patients aged 80 years or older.  Circulation. 1995;  92 (Suppl) II85-II91
• 25 Craver J M, Puskas J D, Weintraub W W. et al . 601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups.  Ann Thorac Surg. 1999;  67 1104-1110