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Early neurological complications after coronary artery bypass grafting and valve surgery in octogenarians

Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire, United Kingdom

Received 1 September 2007; received in revised form 10 January 2008; accepted 11 January 2008.

^_* Corresponding author. Address: Department of Cardiothoracic Surgery, Castle Hill Hospital, Kingston-Upon-Hull, East Yorkshire HU16 5JQ, United Kingdom. Tel.: +44 1482 623256; fax: +44 1482 623257. (Email: dngaage{at}yahoo.com).

Objective: To determine the incidence and risk factors for neurological events complicating cardiac surgery, and the implications for operative outcome in octogenarians. Methods: Of 6791 who underwent primary on-pump CABG and/or valve surgery from 1998 through 2006, 383 were aged 80 years. Neurological complications, classified as reversible or permanent, were investigated by head CT scan in patients who did not recover soon after an event. Results: There were more females (47% vs 26%, p < 0.0001) among octogenarians (n = 383, median age 82 years) than among younger patients (n = 6408, median age 66 years). Controlled heart failure, NYHA class III/IV and chronic obstructive pulmonary disease were more prevalent in octogenarians while preoperative myocardial infarction was predominant in younger patients. Octogenarians were at higher operative risk (median EuroScore 6 vs 2, p < 0.0001). Operative procedures differed between octogenarians and younger patients (p < 0.0001); respective frequencies were 45% vs 77% for CABG, 26% vs 10% for AVR, and 23% vs 6% for AVR + CABG. Mortality was higher for octogenarians (8.9% vs 2.1, p < 0.0001). Early neurological complications observed in 3.9% of the entire study population were mostly reversible (3.2%). Age 80 years (odds ratio [OR] 2.82, 95% confidence interval [CI] 1.89–4.21, p < 0.0001), prior cerebrovascular disease (OR 2.23, 95% CI 1.56–3.18, p < 0.0001), AVR + CABG (OR 2.92, 95% CI 1.60–5.33, p < 0.0001) and MVR + CABG (OR 4.77, 95% CI 2.10–10.85, p < 0.0001) were predictive of neurological complications. More octogenarians experienced neurological events (p < 0.0001): overall 12.8% vs 3.4%, reversible 11.5% vs 2.8%, permanent 1.3% vs 0.6%. Among octogenarians, neurological complication was associated with elevated operative mortality (18% vs 8% for those without neurological complication, p = 0.03), and prolonged ventilation, intensive care stay and hospitalisation. Predictors of neurological complications in octogenarians were blood and/or blood product transfusion (OR 3.60, 95% CI 1.56–8.32, p = 0.003) and NYHA class III/IV (OR 7.6, 95% CI 1.47–39.70, p = 0.02). Conclusion: Octogenarians undergoing on-pump CABG and/or valve repair/replacement are at higher risk of neurological dysfunction, from which the majority recover fully. The adverse implications for operative mortality and morbidity, however, are profound. Blood product transfusion which has a powerful correlation with neurological complication should be reduced by rigorous haemostasis with parsimonious use of sealants when appropriate.

Key Words: Octogenarian • Cardiac surgery • Mortality • Neurological complications