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Eur J Cardiothorac Surg 1999;15:809-815
© 1999 Elsevier Science NL

Cardiac reoperations in octogenerians

Probal Ghosh, David Holthouse, Ian Carroll, Robert Larbalestier, Mark Edwards

The Cardiothoracic Surgical Unit, Royal Perth Hospital, Perth, Australia

Received 9 December 1998; received in revised form 22 February 1999; accepted 11 March 1999.

Corresponding author. Harav Zinger 8, Rishon Le Zion 75255, Israel; Tel.: +972-3-964 7843
e-mail: probalg{at}hotmail.com


   Abstract
Top
 Abstract
1. Introduction
2. Methods
3. Results
4. Discussion
References
 
Objective: In recent years, satisfactory outcome of primary cardiac operation in octogenerians and increased ageing of cardiac surgical population in western hospitals have led to increased expectations and referrals for reoperation. Outcome of reoperation in this aged subset was analysed. Methods: Consecutive 18 octogenerians (mean age 81.2 years, 10 men, eight women) undergoing cardiac reoperations from November 1989 through August 1998 were retrospectively reviewed. Results: They represented 6.2% of all octogenerian cardiac surgical patients and 2.7% of all reoperations during the same period. Mean preoperative NYHA class was 3.4 and Parsonnet score was 29.4. The interval to reoperation was 114.5±11.96 (4–188) months. Priority was urgent in 11 and elective in seven patients. The procedures included four AVRs, five MVRs (including two associated TVAs), six CABGs and one each of MVR with CABG, AVR with CABG and AVR, MVR and CABG. Average graft/patient was 2.3. Mean ICU stay was 4.6±1.5 (1–28) days. There was one hospital death (5.5%) on 18 pod after MVR in an 83-year-old woman. Mean postoperative stay was 20.2±5.13 (8–93) days. There were three late deaths (17.6%) – at 32 months after MVR, at 44 and 63 months after CABG. Long-term survivors were 90% among men and 50% among women who were followed up for 42.7±6.9 (9–93) months. Mean Karnofsky score in survivors at 1 year of follow-up was 78.5±2.9. Despite continued medication in all survivors, mean current NYHA is 1.9 and most have improved lifestyle. Conclusions: Satisfactory outcome may be expected after cardiac reoperations in highly selected octogenerians. However, increased procedural risks, complications, hospital stay and slower convalescence during early follow-up may be anticipated, and will indicate very careful screening. These results indicate a need to reconsider the treatment policy in primary operation with regard to choice of graft conduits and prosthetic valves in other elderly patients.

Key Words: Reoperations • Aged • Aged 80 and over • Heart diseases/surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
3. Results
4. Discussion
References
 
Ageing of the population is a current global phenomenon. US bureau of census reported 6.9 million octogenerians in 1990. The population >80 years is expected to rise to 6.2% of US population by 2000 AD and to 25 million by 2050 AD, making one in 12 Americans an octogenerian. Life expectancy in USA at age of 80 years exceeds 8 years. Significant cardiovascular disease would affect 40% of that elderly population [1,2] including 18% with ischemic heart disease. In France, 2.1 million persons (3.7% of population) were >80 years of age in 1990. In France, life expectancy at 80 years of age is 6.9 years for men and 8.7 years for women [3]. In 1995 in Australia, life expectancy varied from 6.99 years at the age of 80 years to 3.79 years at the age of 90 years. In 1997, an Australian man at the age of 80 years had expected life span of 7.4 years while it is 8.92 years for women. There are more than 503 000 persons aged 80 years or more and they represent 2.7% of Australia's total population of 18.532 million[4].

During the last 15 years, several series [1–3,5–31] reported acceptable outcome of cardiac operations in octogenerians and satisfactory quality of life in long-term survivors. Although some series have included reoperation in anecdotal patients aged >80 years, none has focussed on this subgroup separately. However the octogenerians requiring reoperations are fraught with double jeopardy of attendant risks and complications of reoperation coupled with the ageing changes. In this perspective, we reviewed our experience with this subset at Royal Perth Hospital.


   2. Methods
Top
 Abstract
 1. Introduction
2. Methods
3. Results
4. Discussion
References
 
Consecutive 18 patients in the 80th year of life or older underwent cardiac reoperations from November 1989 though to August 1998. They represented 6.2% of all octogenerian cardiac surgical patients and 2.7% of all cardiac reoperations during the same period. Reoperation was defined as subsequent operation with cardiopulmonary bypass (CPB) in patients whose previous operation(s) employed CPB. Clinical notes were reviewed retrospectively.

Indications for reoperation included hemodynamically significant failure of mitral valve (MV) repair in one patient, prosthetic valve endocarditis (PVE) in three patients, degenerative changes in previously implanted bioprosthesis/homograft in six patients, progressive senile aortic valve disease in two patients and disabling angina with graft occlusion/stenosis and/or progression of native coronary artery disease (CAD). Left internal thoracic artery (LITA) graft was not used in a previous operation in any patient. Percutaneous transluminal coronary angioplasty (PTCA), with or without stents, had failed to improve graft dysfunction and clinical status in two patients prior to reoperation. Thrombolysis was attempted preoperatively in two patients. Nine patients were on intravenous (IV) nitroglycerine and heparin. Previous coronary artery bypass grafting (CABG) was deemed ‘complete’ revascularization in 10 out of 11 patients with previous CABG. Reoperation was indicated by progression of native CAD in two and graft failure in seven patients. No referral from cardiologists was denied reoperation on basis of age or comorbidity.

2.1. Surgical management
Pulmonary artery (Swan–Ganz) catheters were inserted in all patients. Propofol was used in anaesthesia in the recent patients. All procedures were performed through sternal reentry, standard CPB with membrane oxygenator, centrifugal pump and moderate hypothermia up to 26°C. Intermittent multidose cold blood cardioplegia (antegrade or retrograde according to surgeon's choice) provided myocardial protection. Topical hypothermia with ice slush was used to augment and maintain myocardial cooling. Femoral artery was not cannulated routinely before sternal reentry, but both groins were kept prepared. Femoral perfusion was used in two patients after sternal reentry. Aprotinin was available and used in the latter part of the series in 13 patients.

In repeat coronary artery bypass grafting [CABG], existent grafts were mobilized carefully during dissection to minimize manipulation and possible embolization.

2.2. Follow-up
All survivors were followed up by direct interview, whenever possible, or by telephone. All final assessments were done and the Karnofsky performance score was assigned by the same observer (DH).

2.3. Data management
All values are expressed as mean±standard error. A P value <0.05 was considered significant.


   3. Results
Top
 Abstract
 1. Introduction
2. Methods
3. Results
4. Discussion
References
 
Table 1 details the demographic data and the preoperative cardiologic status. Ten patients were moderately anaemic. Nutritional status was normal. Nine patients (50%) were in NYHA class IV. Parsonnet score was in the high-risk category (score 15–19) in two patients, while all others were in the very high-risk category (score 20–148). Associated comorbidities included diabetes mellitus (1), chronic renal dysfunction with azotemia (8), hypertension (6), hypothyroidism (2) and osteoporosis (2). Treated rectal carcinoma and coexistent abdominal aortic aneurism was present in one patient each. Peripheral vascular disease was present in ten patients.


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  		Table 1. Demographicsa

 
Varying grades of congestive heart failure (CHF) was present in 13 patients. Pulmonary oedema had been documented in three patients. Previous myocardial infarction (MI) was noted in six patients. Severe chronic airway disease (COAD) was present in two, while seven were ex-smokers. Silicosis was present in one.

Interestingly, left main coronary artery disease (LMCAD) was present in only one patient. Significant carotid artery stenosis or prior carotid endarterectomy was not noticed in this group of patients.

Interval to reoperation was >5 years in 15 and >10 years in nine patients. Only one 80-year-old woman had required reoperation within 1 year (at 4 months) because of failed MV repair. No correlation of outcome was noticed to the interval to reoperation.

Eleven patients (61%) were operated urgently (Table 2). Preoperative cardiac index (CI) was <2 L/M2 in 11 patients. Pulmonary hypertension was present in five patients. LITA was grafted to left anterior descending coronary artery (LAD) in four reoperations. Seven bioprostheses and one homograft were replaced with new bioprostheses in seven patients, while mechanical prostheses were used in five cases. Three patients required intra-aortic balloon pump (IABP) for weaning off CPB. LITA-LAD graft were used in two of them. The third patient had undergone repeat mitral valve replacement (MVR), 8 years after previous MVR with CABGx2.


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  		Table 2. Operative dataa

 
Priority of reoperation influenced the postoperative course (Table 3). Average ICU and postoperative hospital stay was 6.1 days and 26.2 days, respectively, after urgent reoperations, against 2.1 days and 9.7 days after elective reoperations. However, preoperative NYHA class, body mass index, Parsonnet score, CPB time or aortic cross-clamp time did not correlate with ICU stay and postoperative length of stay.


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  		Table 3. Perioperative dataa

 
Only one patient had uncomplicated postoperative course. Postoperative complications included reexploration for bleeding/tamponade in four, complete heart block requiring permanent pacemaker implantation in one, temporary/incomplete heart block in three (needing temporary pacing in two), postoperative pulmonary oedema in seven, renal failure in three, CHF in three and chest infection in three patients.

Atrial fibrillation was the preoperative rhythm in five patients which persisted postoperatively in two but reverted to sinus rhythm in three patients. On the other hand, denovo AF developed and persisted in six patients.

3.1. Survival
There was one hospital death (5.5%). An 83-year-old woman in NYHA class IV and Parsonnet score of 33 had undergone urgent reMVR with #29 St Jude bileaflet prosthesis 103 months after CABGx2 (to LAD, RCA) and MVR with #31 Carpentier–Edwards porcine bioprosthesis. She required IABP to be weaned off CPB and developed septicemia and renal failure. She succumbed on the 18th postoperative day (Go).


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  		Table 4. Death analysisa

 
All 17 hospital survivors were followed up at 42.7±6.9 (9–93) months. There were three late deaths (17.6%) (Table 4). The overall survival rate was 90% among men but 50% among women. All survivors are on regular medications, but have improved quality of life. Average Karnofsky score at 3 months after discharge was 81.8±2.6 which marginally changed to 78.5±2.9 at 1 year into follow-up. Currently two are at nursing care facilities, three live in retirement hostels and the remaining nine live at home. Average NYHA class is 1.9 among the long-term survivors (Fig. 1) . Actuarial survival trend approximates the expected life span of their Australian cohorts (Fig. 2) .



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  		Fig. 1. Changes in NYHA functional class.

 


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  		Fig. 2. Actuarial survival after cardiac reoperation compared with normal Australian octogenerians.

 

   4. Discussion
Top
 Abstract
 1. Introduction
2. Methods
3. Results
4. Discussion
References
 
Feasibility of an operative procedure per se does not confer generic safety for the procedures. Mere acceptability of outcome may not make the procedure worthwhile. Good surgical care may convert ‘a poor surgical risk’ subset into an operable group. In other words, surgery may convert a lethal disease into a prolonged terminal illness in the aged group. In the era of lengthening waiting lists, limited resources and increasing surgical audit, the rationale for redo cardiac surgery in the octogenerians calls for critical rethinking. Paucity of information in the subject may make the present conclusions tentative. There are only 16 reports during the last 9 years which have anecdotally mentioned about 145 reoperations in octogenerians (Table 5). Reoperations represented 6% of all cardiac operations in octogenerians in the cumulative experience.


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  		Table 5. Literature review of Redo OHS >=80 yearsa

 
Increased risk of reoperation at >80 years are due to several factors. These are related to sternal reentry complications, inconsistent myocardial protection, atheroembolization from old grafts and aorta, comorbidities leading to diminished reserve of subsystems and tissue fragility. Predicted operative mortality at >70 years of age is 12% for reCABG and 17% for redo valve cases by the Parsonnet scoring system [32]. Even after primary cardiac operations in octogenerians, high early mortality and increased complications rates are commonly observed. Our hospital mortality of 5.5% in octogenerian reoperation group is quite similar to overall hospital mortality of 5.8% in all cardiac operations at >80 years of age and compares very favourably with all series on octogenerians. Increased age also contributes to higher prevalence (10–41%) of postoperative atrial fibrillation (AF) and flutter above the age of 70 years [16,33] which may be aggravated by coexistent airway disease, chronic renal dysfunction and preoperative use of beta blockers. Preoperative AF, atrial flutter and heart block in these very old patients may indicate a severe degree of left ventricular (LV) dysfunction.

Advanced age has been cited as a risk factor for inadequate treatment. Semantically inadequacy is a relative term. Expected outcomes differ in different age groups. Cardiac reserve required in a 50-year-old man to fulfil his commitments is different from that in an octogenerian. Higher level of associated comorbidities, later stage of disease, increased hazard of subsequent reoperation and altered perception of quality of life in the sunset years should all play a role in deciding the details of the surgical procedure. CPB time >150 min and aortic cross-clamp time >100 min in the aged patients contribute to increased mortality and morbidity [25]. Thus, an optimal procedure rather than an over-enthusiastic maximal procedure may be in the best interest of these elderly patients. Moreover ‘complete’ revascularization may possibly have a different connotation in primary and reoperations at >80 years of age, because of diffuse progression of CAD. At the same time, it should be emphasized that there is always an inherent selection bias in referral of patients >80 years for cardiac surgery. Anyone surviving cardiac surgery is possibly above a certain threshold of frailty commonly noticed among the aged. The octogenerians are biologically more heterogeneous than the younger patients. Extrapolation of assumed age-group characteristics to an individual octogenerian may be misleading in elective patients.

Conventional wisdom has favoured the use of bioprostheses in the elderly. Such practice owes its origin to the belief that structural deterioration of tissue valves is limited in the elderly patients [34]. Tissue valves have been used in 24–92% of octogenerians.[5,16,18,23,26]. However, current generation of mechanical prostheses not only provide minimal gradients, specially in small aortic roots, acceptable flow pattern and LV mass regression, but also have a much lower hazard of thromboembolism and anticoagulant – related bleeding. INR in these very old patients after AVR can safely be kept at 1.5–2.0. Mechanical prostheses are preferred in the octogenerians by some centres if the aortic annulus is less than 23 mm [5]. Moreover, McGrath et al. [23] noted that bioprosthetic degeneration necessitated three out of four redo cases in their experience. In a large series of 528 octogenerians (including 225 valve operations) over a decade, degeneration of prostheses was noticed in 29 cases and 20 patients underwent valve reoperations [16]. In the present study, valve reoperation became necessary in six out of 12 patients, due to degeneration of bioprostheses implanted in the primary operation performed in their 70s. As the hazard of reoperation above 80 years of age is more than the possible hazard of thromboembolism – bleeding after mechanical valve prostheses implantation – there may be a case for a durable mechanical valve in septuagenerians and octogenerians in primary operations. In the reoperations in the septuagenerians, Awad et al. [32] observed a mortality of 14% in reMVR after previous MVR, but no death after MVR if following failed MV reconstruction and recommended conservative MV surgery in middle-aged patients in order to improve potential for a better outcome after reoperation when needed in the elderly.

A very high rate of postoperative complications in these patients was not unexpected. Similar high rates (57–92%) have been observed after primary operations [6,9,10]. Lower body weight has been correlated with increased rate of complications. However, higher rate of non-fatal postoperative events do not affect quality of long-term survival [25]. Interestingly, common postoperative complications of the elderly viz., sternal wound problems [6] or perioperative CNS events [3,12] was not noticed in these patients. Reexploration for bleeding was rather high (22%) in this group. but a varied rate (3-37%) of reexploration after primary operation has been reported in octogenerians [1,6,7,20,25].

Our study population may have represented a rather selective substrate. Unlike general octogenerian population, this group of patients did not have cartotid disease, coexistent malignancy, nutritional impairment, severe motor and cognitive deficit, orthopaedic disability, haematological disorder, pacemaker-dependence, or tissue trophic problems. LMCAD and diabetes was present in one patient each only. Usually LMCAD is noted in 28–70% of octogenerians [7,12,20]. This may be the result of attrition due to natural ageing and unnatural history of previous operation. In a way, all surgical reports on octogenerians reflect such an inherent selection up to a certain extent.

Life expectancy of women is significantly longer than men, but female sex is a risk factor for increased mortality after AVR [18]. In contrast, Glower et al. [27] observed a lower hospital mortality in these aged women. Late referrals also contribute to poorer outcome in elderly women after cardiac surgery. Slightly worse procedural outcome has been observed in octogenerian women and non-white patients [2]. In the present study, the women fared worse than the men in early and late deaths. Ninety percent of men but 50% of women were long-term survivors after reoperation. However, the quality of life in Karnofsky score was similar in both sexes among the survivors, and compared favourably with other observers [27,29]. All survivors approached the average Australian societal pattern of expected life span completion with acceptable quality. The majority of the survivors lead an independent life at home or in retirement hostels. Follow-up nursing care facilities were needed in only two patients. Similar need was noted after primary operations in 6-11% patients [25,27]. Rehabilitation may not be as good as might be expected given the extent of symptomatic improvement in these patients. Even symptomatic improvement in survivors of reoperation is not quite as favourable as documented for patients after primary operation. In the Cleveland clinic experience also, only 50% survivors of all coronary reoperations become asymptomatic beyond 5 years postoperatively [35].

Awad et al. [32] considered the mean interval to reoperation as an important indicator of outcome in their study of reoperations in septuagenerians. Their operative mortality was 2% when the reoperative interval was >1 year but it was 0% when the interval was <1 year. In their series, the mean interval was 133 (10 –254) months for reCABG and 92 (8–313) months for valve reoperations. The interval was 38 (6–56) months in Deborrah experience [25] and 9.9 years in Mayo Clinic [12]. The mean interval in our experience was 117.7±12.6 (5–203) months. Only one 80-year-old woman underwent early reoperation for MVR 5 months after MV reconstruction. But she is a long-term survivor with current NYHA class II.

Urgent reoperative procedures predicted overall higher risk of morbidity and mortality in octogenerians. All non-survivors (early and late) underwent urgent operation. Average ICU stay was 6.1 days after urgent procedures compared to 2.1 days after elective reoperations. Similarly, postoperative hospital stay was more prolonged after urgent reoperations (average 26.2 days) against average 9.7 days after elective procedures. Even in primary operations in octogenerians, urgent or emergent CABG carried 4–11 times higher mortality than elective CABG [20,21]. Urgency of the operation at times is precipitated by failure of attempts of cardiological interventions viz., coronary angioplasty, stenting, thrombolysis, balloon valvoplasty, etc. Certain medications viz., abciximab, etc. may further compound the already daunting surgical challenge. Earlier referral would help improve outcome after reoperations in octogenerians.

Contemporary advances and adjuncts may also contribute to improving the results. Principles of fast-tracking viz., propofol and other newer short-acting anaesthetics, aprotinin, measures to reduce systemic inflammatory response of CPB, heparin-coated circuits, surgical glues, warm heart surgery with continuous normothermic blood cardioplegia, accent on earlier extubation, avoidance of prolonged postoperative sedation, early ambulation, etc. may all be utilized in this subset. Similarly, early removal of vascular catheters, chest tubes and urinary catheters would contribute to reduction of morbidities. Use of clenbuterol has been shown to prevent muscle wasting and preserve physical fitness in these elderly patients.

This experience – albeit small – should possibly influence the treatment policy in ‘younger’ elderly patients for the selection of valve prosthesis and choice of conduits in CABG. Concomitant AVR may be undertaken for moderate aortic valve disease in septuagenerians if they are to undergo elective CABG or MVR. Similarly, LITA-LAD graft, when used in a previous operation, prove to be durable during the reoperation and may also be recommended as standard policy in elderly patients, unless otherwise contraindicated.

Thus, very careful screening is indicated in selecting octogenerian candidates for reoperations to achieve a beneficial outcome. Indications for surgery in octogenerians are different from those for younger patients. Indications for reoperation in this aged subset need to be more stringent. Serious associated comorbidities viz., malignancy, renal dysfunction, etc. need be recognized and corrected or improved before cardiac reoperation. Urgent surgery may be avoided whenever feasible. Possible candidates may be recognized for early referral. All patients should be stabilized adequately before reoperations, whenever possible. Similarly, recurrence of disabling angina with severe multivessel disease in presence of non-critical aortic valve disease in an otherwise suitable candidate may indicate CABG alone. Severe cognitive impairment, significant motor deficit, severe renal dysfunction may all detract from possible benefit, and thus contraindicate reoperation. This may amount to rationing of medical care in this vulnerable aged subset, but will ensure definitive benefit in reoperative candidates.


   Acknowledgments
 
Contributions in patient care by all past and present members of the department of cardiothoracic surgery, cardiology, anaesthesiology and intensive care and critical care medicine are acknowledged.


   References
Top
 Abstract
 1. Introduction
2. Methods
3. Results
4. Discussion
References
 

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