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Eur J Cardiothorac Surg 2001;20:1152-1156
© 2001 Elsevier Science NL

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients

Harefield Hospital, Harefield, Middlesex UB9 6JH, UK

Received 13 March 2001; received in revised form 19 July 2001; accepted 22 August 2001.

Corresponding author. Tel.: +44-1895-828-550; fax: +44-1895-828-992
e-mail: mr.amrani{at}rbh.nthames.nhs.uk

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Objective: There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time. Methods: Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5±3.5 years) and 87 consecutive CPB patients (age 77.2±2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4±4.4 (OPCAB) versus 16.6±5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques. Results: The length of stay in the intensive therapy unit (ITU) was 35.4±52.9 h for OPCAB patients and 77.6±144.9 h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011. Conclusions: Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.

Key Words: Off-pump coronary artery bypass • Elderly

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
As the number of elderly patients in the general population increases, the number of these patients being referred for coronary artery bypass grafting (CABG) has also increased [1,2]. The introduction of cardiopulmonary bypass (CPB) and the successive improvements in the results of CABG in the second half of the last century have led to an increasing number of elderly patients being considered for this operation [3]. Elderly patients have always been thought of as a higher risk group while undergoing operative procedures. Consequently, they are often referred later for surgery with advanced disease [2]. The elderly are a challenging group of patients undergoing surgical procedures. Their functional reserve capacity is diminished compared with younger patients [4]. In addition, elderly patients are more likely to have preoperative co-morbid conditions [5].

A number of studies investigated in detail the relative significance of operative morbidity and mortality in elderly patients undergoing CABG and attributed this to the use of CPB in addition to the preoperative risk factors associated with advanced age [2,6]. They also studied the degree of functional recovery and quality of life postoperatively to conclude that surgical revascularisation is a justified and a cost-effective approach to achieve, or at least maintain, a reasonable and meaningful quality of life for elderly patients. This is in spite of the fact that considerable health-care resources are being expended on the growing minority of elderly patients.

Recent studies have indicated the advantages of operating using the off-pump coronary artery bypass (OPCAB) particularly in the elderly patients. The aim of this retrospective analysis is to assess whether OPCAB has actually improved the postoperative outcome compared to conventional CABG in the elderly patients.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
2.1. Data collection
The records of 143 consecutive patients, aged 75 years and older, who underwent isolated CABG by three different surgeons in Harefield Hospital between January 1998 and October 2000, were reviewed retrospectively. Registry database, medical notes and charts were studied for preoperative and postoperative data of the patients. Fifty-six patients were operated on using OPCAB technique (age at surgery 78.5±3.5 years) and 87 patients were operated on using CABG technique with CPB (age at surgery 77.2±2.4 years, P=0.01), which meant that OPCAB patients were significantly older than CPB patients (P<0.05). The mean number of diseased coronary vessels was 2.78±0.41 for the CPB group and 2.8±0.7 for the OPCAB group (P=0.23). The Parsonnet scores for the OPCAB and CPB groups were high 17.4±4.4 and 16.6±5.2, respectively, P=0.19. The selection of the patients for either surgical technique (whether OPCAB or CPB) was done by the individual surgeons, and was completely based on their experience and preference. No randomisation was involved and this cohort of patients was reviewed retrospectively.

There was no significant statistical difference between the two groups with respect to any of the preoperative variables as listed in (Table 1). Renal problems included: renal impairment (creatinine200 µmol/l), previous acute or chronic renal failure and renal transplants. Cerebro-vascular problems included: transient ischaemic attacks (TIA) and cerbro-vascular accidents (CVA). Peripheral vascular disease included: acute and chronic ischaemia of the upper and lower limbs and deep venous thrombosis (DVT). Inotropes, nitrates and intra-aortic balloon pumps (IABP) indicate whether they were used before surgery.

2.2.1. OPCAB
Anticoagulation was achieved using 150 U/kg of heparin. The activated clotting time was maintained above 250 s. Heparin was reversed by protamine at the end of the procedure. The operation was performed through median sternotomy using Octopus 3^® (Medtronic Inc., Minneapolis, MN). Blood pressure was optimised during the procedure by means of repositioning the heart and selective use of vasoconstrictors. Other measures to improve cardiac output such as elevation of feet and increasing the heart rate were used as appropriate. A standby perfusionist with bypass circuit primed was available for all cases.

2.2.2. CPB
Anticoagulation was achieved using 250 U/kg of heparin. The activated clotting time was maintained above 480 s. Heparin was reversed by protamine at the end of the procedure. The operation was performed through median sternotomy. CPB was instituted with a single right atrial cannula and an ascending aorta perfusion cannula. Standard bypass management included membrane oxygenators, arterial line filters, non-pulsatile flow of 2.4 l/min/m², with a mean arterial blood pressure greater than 50 mmHg. Myocardial protection was achieved with intermittent cold blood cardioplegia (4:1 blood to crystalloid ratio).

2.3. Statistical analysis
Non-parametric Mann–Whitney test was used whenever the data did not appear to have normal distributions. Numerical variables are presented as mean±standard deviation for CPB and the OPCAB patients. A P-value of less than 0.05 indicates a significant difference.

For ordinal variables, we calculated the frequencies of each value (and percentages of each value) for each group. The P-value (based on a Mann–Whitney test) indicates whether the distribution of values is the same for the two groups; small values of P <0.05 indicate significant difference.

For binary variables, we studied the sample sizes for each group, along with the numbers of patients possessing the characteristic. The P-value (based on a Fisher Exact Test) indicates whether the percentages are the same for the two groups; small values of P <0.05 indicate significant difference.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
3.1. Operative technique
There was no significant difference in the number of grafts between both the groups. The OPCAB patients received 2.71±0.76 grafts while CPB patients received 2.87±0.57 grafts, P=0.18. For the CPB patients, the cumulative bypass time was 80.15±26.01 min and the cumulative aortic cross clamp time 29.89±21.88 min.

3.2. Postoperative morbidity
Postoperative myocardial infarction (MI) was decided to be present when one of the following was observed: (1) new Q waves in the electrocardiogram (ECG); (2) creatine kinase-MB (CK-MB)>50 with ECG changes or (3) CK-MB>70 without ECG changes. Low cardiac output (LCO) was said to be present when the systolic arterial blood pressure was persistently <90 mmHg; or the mean arterial blood pressure was persistently below <50 mmHg despite appropriate fluid management and requiring inotropic or vasoconstrictor therapy. Atrial fibrillation was identified by cardiac monitoring and confirmed by 12-lead ECG.

We defined the term ‘serious complications’ to include: pulmonary oedema or adult respiratory distress syndrome (ARDS), septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis. Only one (2%) OPCAB patient had pulmonary oedema, while 11 (13%) CPB patients (P=0.028) developed serious complications. Six (55%) out of these 11 CPB patients developed more than one serious complication at the same time. Five (6%) had pulmonary oedema or ARDS, four (5%) had permanent stroke, two (2%) had septicaemia and six (7%) had renal dysfunction requiring haemofiltration or haemodialysis. Postoperative insertion of IABP was also significantly higher in the on-pump group. Only one (2%) OPCAB patient required IABP while ten (12%) CPB patients (P=0.05) did so.

Nine (11%) CPB patients were re-operated on for bleeding while no OPCAB patients (0%) were re-operated on, P=0.011. This is showing a significantly higher incidence of bleeding requiring re-operation in the CPB patients.

There was no statistically significant difference between the two groups with regard to other complications, although the incidence was always higher in the CPB patients as evident from the information presented in Table 2.

3.3. Postoperative mortality
We defined the ‘30-day mortality’ as death within the 30 days following the operation. There was no death in the OPCAB patients compared to ten (11%) deaths in the CPB patients (P=0.0066) within 30 days. Out of the ten deaths, three patients (30%) died within 6 h after operation. Therefore, we did not include them in the analysis of some postoperative complications because of the early incidence of death following surgery. The ten deaths included: two (20%) died due to multi-organ failure, two (20%) died due to permanent stroke and six (60%) died due to cardiac reasons including peri-operative MI or pulmonary oedema.

The patients were operated on by three surgeons with different techniques and preferences, all patients who died had preoperative ejection fraction<30%. Five (50%) of them underwent emergency CABG and four out of these five patients had MI within 4 weeks prior to surgery, had IABP inserted preoperatively and were on intravenous nitrates (vasodilator therapy).

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
This retrospective study has shown that using OPCAB technique in elderly patients significantly reduces the incidence of IABP insertion, ITU stay, serious complications, re-operation due to bleeding and mortality. This better outcome of OPCAB patients was evident, despite the fact that the mean age of the OPCAB group was significantly higher than the CPB group.

The elderly are a challenging group of patients increasingly presenting to cardiac surgeons. These patients have diminished functional reserves and are more likely to have preoperative co-morbid conditions. Although the advances in CPB, myocardial protection and critical care have improved the outcome in this group; morbidity and mortality rates stayed significantly higher than that of younger age groups [2]. This leads to considering other alternatives to surgical revascularisation for these patients, with the chance of presenting late for surgical treatment. Achieving or maintaining an acceptable quality of life for this group of patients without burdening the health system with regard to the cost of their surgical treatment and then the management of their postoperative problems, has been a challenge.

It has been shown that bypass pump time is an independent predictor of hospital mortality in patients aged 70 years or older, in addition to age and preoperative angina status [2]. Furthermore, it has also been shown that following a rapid recovery protocol for CABG patients aged 80 years and older, emphasising reduced CPB time in addition to other things; could achieve excellent results in terms of postoperative morbidity, mortality and ITU and hospital stays [6]. Therefore, it has been concluded that operative strategies concerning elderly patients should be centred on minimal CPB time, as this group of patients are at extreme risk to the hazards associated with prolonged CPB.

Beating heart surgery is becoming more widely adopted and continues to be explored as an alternative to conventional CABG surgery in many cardiac units worldwide [7,8]. It has recently been shown that beating heart surgery is associated with a significant reduction in the cost of treatment in high-risk and elderly patients [9].

Our data suggest that elderly patients can undergo safe surgical myocardial revascularisation by OPCAB technique that is associated with a significantly lower postoperative morbidity and mortality than conventional CABG using CPB. The apparently high mortality (11%) in the control group could be explained by the fact that they were high-risk patients as reflected by the high Parsonnet score. Interestingly, the OPCAB group had a similar risk score but with significantly lower mortality, which may suggest some benefit of the OPCAB technique. Furthermore, our mortality rate in this high-risk group of patients compares favourably to other series (Edmunds et al. 24% [10], Houser et al. 15.2% [11], Mullany et al. 10.7% [3], Gersh et al. 13.8% [12,13], Talwalkar et al. 8% [14] and Horneffer et al. 9.3% [2]).

There are few limitations in our study. Firstly, the patients have been operated on by different surgeons with different techniques and preferences and the choice of the surgical technique was completely the judgement of the individual surgeon. Therefore, there might be a hidden selection bias not seen in the variables analysed. Secondly, two out of the three surgeons used the CPB for the high-risk emergency and salvage cases, and this has probably caused the high mortality in that group.

Although, our retrospective analysis has shown important differences in the outcome between both the techniques in elderly patients, we believe that a prospective randomised clinical trial would strengthen the findings of this present study.

	Acknowledgments

 
We thank Dr Derek Robinson from Sussex University, UK for his assistance in the statistical analysis.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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