Eur J Cardiothorac Surg 2007;32:58-64. doi:10.1016/j.ejcts.2007.03.030
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Being an elderly woman: is it a risk factor for morbidity after coronary artery bypass surgery?
Murat Basaran*,
Ozer Selimoglu,
Hamiyet Ozcan,
Halide Ogus,
Eylul Kafali,
Cuneyt Ozcelebi,
Temucin Noyan Ogus
Cardiovascular Surgery Clinic, Goztepe Safak Hospital, Istanbul, Turkey
Received 24 January 2007;
received in revised form 12 March 2007;
accepted 19 March 2007.
* Corresponding author. Address: Fahrettin Kerim Gokay Caddesi, Goztepe Safak Hastanesi, Kadikoy, Istanbul, Turkey. Tel.: +90 216 565 44 44; fax: +90 216 565 85 85. (Email: dr_murat_basaran{at}yahoo.com).
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Abstract
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Objective: Despite the refinements in surgical techniques and postoperative care, elderly women still have a higher prevalence of postoperative morbidity. Methods: The outcomes of 112 elderly women (>80 years) who underwent an elective CABG procedure were compared with those of males operated during the same time interval (n, 164). Results: Median age of female and male patients were 82 and 83 years, respectively. Mean number of grafts did not differ significantly (3.7 ± 0.8 vs 3.9 ± 0.3, p
= 0.4) between groups. Overall early operative mortality rate was 8.6% (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p
= 0.1). Postoperative complications including prolonged ventilation time (13.4% in females vs 8.5% in male, p
< 0.01), atrial fibrillation (40% in females vs 33% in males, p
= 0.01), sternal reclosure (8% in females vs 4.2% in males, p
= 0.01), pneumonia (5.3% in females vs 3% in males, p
= 0.03), leg wound infection (11.7% in females vs 2.4% in males, p
< 0.001), renal dysfunction (10.7% in females vs 7.3% in young patients, p
= 0.02) have been found to be significantly higher in elderly women. Mean intensive care unit (3.2 ± 1.1 days in females vs 1.6 ± 0.4 in males, p
= 0.03), and hospital stays (13.6 ± 2.1 days in females vs 9.1 ± 1.2 in males, p
= 0.02) were also longer in female patients. Five-year survivals including all deaths for female and male patients were 57% and 62%, respectively. Conclusions: In elderly women, revascularization procedures can be done with acceptable mortality rates; but these patients are still associated with a higher prevalence of postoperative morbidity when compared with the male counterparts. Therefore, these patients have to be very carefully evaluated preoperatively and their postoperative care should be more comprehensive to reduce the incidence of postoperative complications.
Key Words: Elderly woman • Octogenarians • Coronary artery bypass grafting • Postoperative mortality • Postoperative morbidity
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1. Introduction
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With the increase in life expectancy, cardiac surgeons are currently confronted with an increasing number of octogenarians requiring coronary artery bypass grafting (CABG) surgery [1–4]. On the other hand, the increased use of percutaneous interventions by invasive cardiologists have led to a decrease in the number of less risky patients and this aggressive approach further increased the percentage of octogenarians referred for cardiac surgery. Various studies documented that myocardial revascularization procedure can be done with an acceptable mortality rate in this patient group [5,6]. Refinements in myocardial protection, minimally invasive cardiac surgery, and postoperative care have all contributed to these improved outcomes. However, in contrast to a significant decrease in mortality rates, the presence of multiple comorbid risk factors still places these patients at higher risk for developing postoperative complications which in turn increases the morbidity and mortality rates of each cardiovascular surgeon and hospital cost of patients.
Previous studies have identified female gender as a predictive of an increased incidence of postoperative complications [7–9] and we therefore believe that especially elderly women deserve a specific word of caution and remain as a significant challenge for physicians. Although the feasibility and applicability of open heart surgery in either octogenarians or female patients have been widely examined previously [10,11], there are limited data about the clinical outcomes obtained in elderly patients having a female gender. Despite the reported satisfactory outcomes, the most important limitation of these studies is the heterogenous nature of patient populations which confuses the data analysis. In this retrospective study, we aimed to assess the short- and long-term results in elderly women (>80 years) undergoing an elective CABG procedure and compare their results with those of male counterparts.
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2. Materials and methods
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Between April 1997 and May 2006, 3912 consecutive patients underwent a CABG operation, of which 1456 patients (37.2%) were female. Among female patients, 135 (9.2%) were octogenarians (>80 years). Redo and/or emergent cases, patients having concomitant cardiac (CABG + valvular intervention, ascending aorta replacement, etc.) and/or extracardiac (carotid endarterectomy, peripheral vascular arterial reconstruction, etc.) procedures (26 patients) were excluded from the study protocol. In clinical practice, we generally defer myocardial revascularization procedure after an acute myocardial infarction for 4 weeks unless the patient does not require an emergent operation. In cases with critical stenosis in other myocardial territories, an emergent CABG procedure has been carried out; but these patients were excluded from the study cohort. Therefore, 112 remaining patients who underwent an isolated and elective CABG operation represented the study group for all subsequent analysis. The short- and long-term outcomes of this patient cohort were compared with those in male counterparts fulfilling the same criteria and operated during the same time interval (n, 164 patients). This study was approved by the ethical committee of the hospital and informed consent was obtained from each patient and/or family.
2.1 Patient demographics
The preoperative characteristics of all patients are listed in Table 1
. Median ages of female and male patients were 82 and 83 years, respectively. There were no significant differences between groups regarding mean preoperative ejection fraction (EF) and Canadian Cardiovascular Society Anginal Class (CCSAC). The percentage of patients with a renal dysfunction was found to be higher among females; but this difference did not reach a statistical significance (p
= 0.09). Among women, there were 81 patients (72.3%) with stable angina and 31 patients (27.7%) with unstable angina. Preoperative angiogram revealed a single-vessel disease in 14 patients (12.5%), double-vessel disease in 21 patients (18.7%), triple-vessel disease in 77 (68.7%), and left main coronary artery stenosis in the remaining 12 (10.7%). Forty-three patients (38.4%) suffered a remote (>1 month) myocardial infarction and all patients were on a regimen of at least one anti-anginal medication (average number, 2.7 ± 0.4 drugs per patient).
2.2 Surgical technique
All operations were performed using conventional cardiopulmonary bypass (CPB) techniques under moderate hypothermia (28 °C). Briefly, following a median sternotomy, the conduits including left internal thoracic artery (LITA) and autologous saphenous vein were harvested. Myocardial protection was achieved with antegrade or antegrade plus retrograde blood cardioplegia. In forty-two patients (37.5%) in female groups and 67 patients (40.8%) in male group with suitable vessel anatomy and perioperative hemodynamic performance, an off-pump CABG procedure was executed. Fourteen patients in female group (12.5%) and 17 patients (10.3%) in male group underwent the procedure under hypothermic fibrillatory arrest without cross-clamping because of the presence of atheromatous aorta. In these patients, arterial inflow was achieved via femoral or axillary artery.
In patients with a diffusely diseased LAD, a long-segmental LAD reconstruction with LITA or saphenous vein has been performed. Diffuse LAD disease is characterized by the presence multiple stenosis downstream from the first major proximal lesion. This technique has been used in patients having the followings: multisegmental LAD involvement, at least 1 mm LAD diameter at the preoperative angiogram and the presence of critical, but non-stenotic septal and/or diagonal branches along the stenotic segment. In patients with ulcerated and fragile atheromatous plaques, this approach has not been applied to avoid plaque-related complications and alternative techniques including endarterectomy, atherectomy or plaque-fixation have been carried out. The presence of severely limited distal run-off (<1 mm) determined at the preoperative angiogram and/or intraoperatively usually precludes the use of an extended anastomosis technique and such patients underwent a coronary endarterectomy procedure. The long-segmental reconstruction has been described previously [12]. Briefly, a long superficial arteriotomy was made along the diseased LAD and the length of incision was decided at the operation. The tip of the arteriotomy incision was extended to the disease-free distal portion of the vessel. The LAD was also opened proximally and the healthy part of the vessel had been reached. The LAD was not opened at the level of the first proximal lesion. The LITA or saphenous vein was then spatulated longitudinally adjusting its length to the length of the LAD arteriotomy. Long-segmental LAD reconstruction was performed by covering the arteriotomy with LITA or saphenous vein as onlay graft using continuous 7.0 polyprolene suture material. In patients requiring an extended anastomosis to other myocardial territories, the above mentioned technique was applied by using a saphenous vein as onlay graft. All proximal anastomoses were done while aortic cross-clamp on. After the completion of the operation, all patients were transferred to the intensive care unit and anti-platelets agents (aspirin) were started at the first postoperative day.
2.3 Statistical analysis
Follow-up of each patient was conducted annually by telephone interviews. The primary end points of the study were assessed and all gathered data were entered into the surgical database. The primary outcomes were early morbidity and mortality rates. The secondary outcomes included cardiac- and noncardiac-related mortalities occuring from the time of operation throughout follow-up period. Clinical assessment also included anginal status of each patient and anti-anginal drugs prescribed postoperatively. During the early postoperative period, perioperative myocardial infarction (MI) was defined as the occurrence of new Q wave in the electrocardiogram and a creatine kinase-MB fraction level of >100 U/l postoperatively. Prolonged mechanical ventilation time was defined as the requirement of mechanical ventilatory support formore than 24 h. Other postoperative complications recorded were low cardiac output, revision because of postoperative bleeding, superficial sternal infection, mediastinitis, leg wound infection, pneumonia, renal dysfunction, cerebrovascular accident, and gastro-intestinal system ischemia. Low cardiac output was diagnosed by the presence of hypotension, oliguria, cardiac index of less than 2 l min–1
m–2 and the requirement for intraaortic balloon pump counterpulsation. Superficial sternal and leg wounds infections were defined as the presence of a local infection requiring tissue debridement and antibiotic treatment. Mediastinitis was defined as the presence of sternal infection requiring reoperation, tissue debridement, secondary rewiring and antibiotic treatment. Pneumonia was diagnosed by cultures of sputum and radiographic findings. Postoperative renal dysfunction was defined as an increase in the serum creatinine level of greater than or equal to 0.7 mg/dl from preoperative to maximum postoperative values. A cerebrovascular accident was defined as a central neurologic deficit lasting for more than 48 h. Gastrointestinal ischemia was defined as the presence of abdominal distention and hypo/hypermotility requiring laparotomy and bowel resection.
Results for continuous variables were expressed as median or mean ± standard deviation. Categorical variables were presented as number (percentage). Continuous and categorical data were compared by the paired sample-t and chi-square tests, respectively. Preoperative risk factors were examined as predictors of a single postoperative complication by both univariate and multivariate analysis. The Kaplan–Meier method was used to analyze long-term survival and values of p less than 0.05 were considered significant.
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3. Results
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The percentage of octogenarians operated during the study period is shown in Fig. 1
and an absolute increase was observed in the percentage of octogenarians referred for myocardial revascularization. Operative data are given in Table 2
. Mean number of grafts for female patients was 3.7 ± 0.8 compared with 3.9 ± 0.3 for male patients (p
= 0.4). Within the group of females, 46 patients (41%) had a revascularization procedure exclusively with saphenous vein grafts, whereas this percentage was 36% (59 patients) for males (p
= 0.3). The proportions of LITA in both male and female patients have changed significantly over time. In female patients, the percentage of patients having a LITA anastomosis was 43.3% (13/30) before year 2000; but this percentage was found to be 64.6% (53/82) for patients operated after year 2000. In male patients, a similar trend was observed regarding LITA use (43.1% before year 2000 vs 67.2% after year 2000). The causes for nonuse of a LITA graft for both groups included severe chronic obstructive pulmonary disease, uncontrolled diabetes mellitus, and morbid obesity. In all patients, LAD vessel could be revascularized at the operation and incompletely revascularized myocardial territories included only right coronary and circumflex arterial systems. In patients with a poor run-off, a coronary endarterectomy procedure was carried out (11 patients in female group, 9.8% vs 14 patients in male group, 8.5%, p
= 0.09).
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Fig. 1. Percentages of octogenarians referred for myocardial revascularization. During the last 10 years, a total number of 329 octogenarians (135 females, 194 males) underwent CABG procedure (including all elective cases, redo and/or emergent cases, patients having concomitant cardiac and/or extracardiac procedures). This constitutes of 8.4% of all CABG procedures (3912 patients) performed during the same time interval.
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3.1 Early outcomes
Early operative mortality rate was 8.6% in overall (24 of 276 patients); 8.9% (10 of 112 patients) for female and 8.5% (14 of 164 patients) for male patients (p
= 0.1). Of female patients who died postoperatively, five underwent the procedure exclusively with saphenous vein grafts (5/46, 10.8% vs 5/66, 7.5%, p
= 0.03). In female patients, six of deaths were related to low cardiac output. All these patients had an ejection fraction less than 40% preoperatively and could be weaned off CPB by the administration of high doses of inotropic support and intraaortic balloon pump. Two patients with preoperative renal dysfunction (serum creatinine levels of 2.4 and 2.7 mg/dl, respectively) developed acute renal failure postoperatively and died at the end of postoperative days 13 and 17, respectively. In the remaining two patients that could not be weaned off mechanical ventilator, a suspicion of gastrointestinal system ischemia was aroused because of the presence of bowel distention and diarrhea. Subsequent laparotomy confirmed our initial diagnosis and a sigmoid colon ischemia probably having an embolic origin was detected. Both patients underwent a bowel resection procedure, but died because of multiorgan failure. Fourteen patients in male group died during the early postoperative follow-up period. Causes of early death in this group included low cardiac output (six patients), acute renal failure (three patients), multiorgan failure (four patients), and pulmonary embolism (one patient). Of male patients who died postoperatively, six underwent the procedure exclusively with saphenous vein grafts (6/59, 10.1% vs 8/105, 7.6%, p
= 0.03).
Postoperative complications in all patients are listed in Table 2. The incidence of new Q-wave myocardial infarction was similar in both groups (three patients in female group, 2.6% vs four patients in male group, 2.4%, p
= 0.2). In two female patients, with a normal preoperative right coronary artery, right ventricular infarction has been developed because of acute occlusion of this artery. These two patients have been treated conservatively and discharged at postoperative days 16 and 28, respectively. Other postoperative complications reaching a statistical significance included prolonged ventilation time, atrial fibrillation, sternal infection requiring secondary reclosure, pneumonia, leg wound infection, and transient renal dysfunction. Univariate analysis revealed that female gender, preoperative renal dysfunction, ejection fraction of less than 40%, previous myocardial infarction, chronic obstructive pulmonary disease, and history of previous stroke were predictors of at least one postoperative complication. In the multivariate analysis, female gender, and an ejection fraction of less than 40% emerged as independent predictors of at least single postoperative complication. Among these factors, female gender was the strongest factor predicting at least one postoperative complication (odds ratio [OR], 3.12; 95% confidence interval [CI], 2.34–3.51) (Table 3
).
3.2 Late outcomes
Among early survivors (n, 252 patients), 3 patients were lost to follow-up and follow-up included 249 patients (99% complete). Mean follow-up period in all patients was 63.7 ± 15 months (range, 7–108 months). Among females, 46 patients (43%) died during the follow-up period. Causes of late death were cardiac-related in 16 patients (congestive heart failure, 11; new myocardial infarction, 3; ventricular arrhythmia, 2). The remaining 30 deaths were as a result of malignancy in 12 patients, chronic renal failure requiring dialysis treatment in 5 patients, cerebrovascular accident in 7 patients and unknown reasons in 6 patients. Overall survivals including all deaths at 3 and 5 years were 68% and 57%, respectively (Fig. 2
). Among late survivors, 38 patients were symptom-free (67.8%), 12 patients were in CCSAC I-II (21.4%), and 6 were in CCSAC III-IV (10.7%). At the late follow-up period, 21 (37.5%) patients were on a regimen of one anti-anginal drug and 13 patients (23.2%) were on a regimen of two anti-anginal drugs.
Follow-up of male patients included 147 cases. In this patient group, there were 57 late deaths, of which 21 (36.8%) were cardiac-related (congestive heart failure, 12; new myocardial infarction, 6; ventricular arrhythmia, 3). The remaining 36 deaths were as a result of malignancy in 14 patients, cerebrovascular accident in 8 patients, chronic renal failure in 7 patients, traffic accident in 1 patient, and unknown reasons in 6 patients. Overall survivals including all deaths at 3 and 5 years were 71 and 62%, respectively (Fig. 3
). Among survivors, 63 patients were symptom-free (70%), 16 patients were in CCSAC I-II (17.7%), and 11 were in CCSAC III-IV (12.2%).
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4. Discussion
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Previous reports have confirmed the safety and efficacy of myocardial revascularization in octogenarians; but these studies generally included both genders into statistical analysis [13,14] which confuses the data interpretation. These studies have also generally focused on crude early mortality rates and the incidence of postoperative complications has been generally underevaluated. In the light of our clinical experience, we observed that the postoperative course of female patients is generally more troublesome and this problem becomes usually more pronounced in ages 80 years or more when compared with their younger counterparts. We therefore aimed to evaluate specifically the short- and long-term outcomes in elderly women and compare their results with those of male counterparts. In this study, we demonstrated that elderly women can undergo a CABG procedure with an acceptable mortality rate; but female gender among octogenarians still remains as a risk factor for developing postoperative morbidity.
Our overall mortality rate of 8.6% in octogenarians compares favorably with those reported by other studies [3,15]. Colon et al. [16] documented a 14.7% and Fruitman et al. [14] reported a 7.9% of mortality rates in octogenarians who underwent a cardiac operation. Previous studies have reported a high incidence of postoperative complications in octogenarians [4,13]. In the present study, the most common complications observed at the early postoperative period included prolonged ventilation time, transient renal dysfunction, atrial fibrillation, sternal dehiscence, respiratory system and leg wound infections. Of these complications, the most prevalent was the development of atrial fibrillation which is probably related to advanced age. At this age group, especially prolonged mechanical ventilation carries a critical importance which has direct impact on mortality. Several published studies documented that incidence of postoperative respiratory insufficiency is higher in female patients as compared with male patients. It has been suggested that this high incidence is related in part to the amount anesthetic agents administered intraoperatively [17]. Barnett et al. [13] reported a postoperative prolonged ventilation rate of 6.7% among octogenarians who had either a CABG or valve replacement and this percentage is lower than our rate. The first reason for this better outcome is the sample size of their studies (8361 patients) which probably plays a major role in the reported rate. Furthermore, in their study, the incidence of COPD among octogenarians was 12.4%, whereas this percentage was found to be 18.5% in our entire cohort. Some authors also stated that postoperative respiratory insufficiency at this age group is related to a significantly higher prevalence of chronic obstructive pulmonary disease (COPD) in female patients [18,19]. However, the presence of similar COPD incidences in our two groups raises some suspicions about this conclusion. Interestingly, of 15 patients requiring prolonged mechanical ventilatory support, only 9 had COPD as a risk factor preoperatively. Furthermore, there was only one patient with a postoperative low cardiac output and in the remaining five patients, there were neither preoperative nor postoperative clear reason explaining the development of respiratory insufficiency. We can therefore speculate that the requirement for prolonged postoperative respiratory insufficiency may be the result of multiple interrelating factors including borderline pulmonary reserve, decreased metabolism of anesthetic drugs and postoperative respiratory muscle weakness.
In our study, transient renal dysfunction requiring medical treatment developed more frequently in the female group. Although not significant, the women had usually much longer times of operation, CPB, and aortic cross-clamping because of the delicate nature of their coronary arteries. This may be the explanation of higher rate of postoperative renal dysfunction in women who were longer exposed to the deleterious effects of extracorporeal circulation.
Several previous studies have demonstrated the beneficial impacts of off-pump CABG surgery on octogenarians [20–22]. In their series of 113 patients, Beauford et al. [23] suggested that off-pump revascularization is associated with excellent outcomes in octogenarians. In their series of 142 octogenarians, 113 (79%) underwent an off-pump procedure and the number of mean graft was 3.3 ± 1 and slightly lower than ours. However, their mean operation time was significantly longer (214 min vs 151 min). At the operation, they attempted to afford myocardial revascularization at the expense of a longer operative time. In another study, Stamou et al. [4] stated that an off-pump procedure can be done with acceptable morbidity and mortality rates. However, mean number of grafts in patients undergoing the operation through a median sternotomy was reported to be 1.6 ± 1.4 which is significantly lower than ours. In another study reporting the results of 2182 consecutive female patients at any age, Bucerius et al. [11] also reported the beneficial effects of off-pump CABG operation. In their study, they compared the results of two groups undergoing either off-pump or on-pump CABG operation. However, in off-pump group, the percentage of patients requiring three or more bypass grafts was only 13.2%. In our female group, the percentage of patients having a triple-vessel disease was found to be 58%. A diffusely diseased LAD is a frequently encountered event at this age group and complete myocardial revascularization may not be always achieved by conventional techniques. These patients may require either a long segmental LAD reconstruction or coronary endarterectomy procedure. Therefore, although we are agree with these authors on the beneficial effects of off-pump procedures, this is not always the case in the clinical practice. At the operation, every attempt has been tried to afford complete revascularization without CPB; but the high prevalence of diffuse coronary artery disease at this age group precluded the use of an off-pump technique in 60.5% of our entire cohort.
Another interesting finding of the study is the observation of a correlation between early mortality and failure to use LITA. In both groups, the mortality rates are found to be significantly higher in patients undergoing the procedure exclusively with saphenous vein grafts. Dabal et al. [24] previously documented that the use of LITA grafts for coronary revascularization is associated with decreased mortality and morbidity. In our series, the causes for nonuse of a LITA graft were severe chronic obstructive pulmonary disease, uncontrolled diabetes mellitus and morbid obesity. Although the numbers are small and out of the scope of this study, we recommend the use of at least a LITA graft in octogenarians also to decrease the early morbidity and mortality rates.
The most important limitation of our study is its retrospective design. Another limitation is the inclusion of both off-pump and on-pump procedures into the analysis. Because of the small numbers of groups, we did not perform a subgroup analysis within both genders. In this study, we did not aim to compare the results of off-pump and on-pump techniques in octogenarians. The decision to proceed with off-pump CABG was made on the basis of underlying coronary artery disease and the presence of comorbidities. At the operation, every attempt has been tried to execute the procedure by an off-pump technique. However, since our primary goal at the operation was to afford complete revascularization, we did not hesitate to use extracorporeal circulation in patients with an unfavorable anatomy for an off-pump procedure. Additionally, the percentages of patients undergoing an off-pump operation were similar in both groups and we therefore believe that reliable conclusions can be raised from our results.
In conclusion, although CABG operation can be done with an acceptable early mortality rate in elderly women, this patient subset is still associated with a higher prevalence of postoperative morbidity when compared with those of male counterparts. These patients have to be carefully evaluated preoperatively and a decision requires weighing specific benefits and risks of cardiac surgery for each patient. A successful surgical intervention requires a successful operation on one hand; but on the other hand, a multidisciplinary approach is strongly needed during both pre- and postoperative periods to achieve the ultimate goal. Lastly, despite the guidelines, we all know that an overlap is currently present between the limits of cardiovascular surgery and cardiology because of the increased use of invasive cardiologic techniques. This may cause a nice debate between us and our cardiologist colleagues for some patients. However, it would be interesting to know whether better results could be obtained if some patients would be referred for surgery at younger ages when the operative risk is lesser.
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Abstract
1. Introduction
