Bypass surgery after 80 boosts quality of life. (Benefits Tracked in 1,000 Patients).
This new finding from a long-term follow-up study of 1,000 consecutive octogenarians who underwent on-pump coronary artery bypass graft (CABG) at the Miami Heart Institute and Mount Sinai Medical Center in Miami Beach during 1982-2000 has important implications. Octogenarians are the fastest growing segment of the U.S. population. And over 40% of them have cardiovascular disease, noted Dr. Kurlansky, director of research at the Miami Heart Research Institute.
Octogenarians now account for more than 12% of all CABG procedures performed at the two study institutions.
In-hospital mortality was 9%, higher than the rate seen in younger patients, but preoperatively this elderly cohort was quite sick. Their mean age was 83 years, 96% were Canadian Cardiovascular Society class III or IV, 66% had hypertension, 25% were diabetic, 59% had one or more prior MIs, 83% had unstable angina, and 10% were having a repeat CABG. Patients received a mean of 3.6 grafts.
In-hospital mortality has steadily declined over time in these elderly patients, from a peak of 14.5% in 1989-1991 to 6.1% in 1998-2000. But in-hospital complications remain relatively high at 30%. Among the significant complications were disabling stroke in nearly 4% of patients, renal dysfunction in 10%, pulmonary insufficiency in 18%, MI in nearly 2%, low cardiac output in 16%, and reoperation for bleeding in 3%.
Study participants were followed for a mean of 3.6 years and for a maximum of 18.4 years. Among patients who survived their hospitalization, actuarial survival was 6.8 years, rivaling the 7-year life expectancy for 83-year-olds in the population.
The most impressive findings in this study involved the marked improvements in functional status and quality of life.
While 96% of patients were class III or IV before CABG, all but 1.8% of survivors were class I or II at follow-up. And patients scored as good or better than the age-adjusted norms for seven of the eight categories of the SF-36 quality of life assessment tool.
"Sure, mortality rates are going down. But the meat of the matter is these patients feel they're doing as well as anybody in their age group. It makes a strong case for the long-term benefit of working with these patients," Dr. Kurlansky said.
This database didn't permit scrutiny of any subtle changes in measures of neurocognitive function associated with CABG in the very elderly. But Dr. Kurlansky is participating in a multicenter study in which such measures are being compared in CABG performed either on or off the cardiopulmonary bypass machine.
"The general experience around the country suggests high-risk patients such as the very elderly may have more to gain from off-pump surgery. That hasn't been proven, though," he said.
Another unresolved issue concerns the relationship between the type of conduit used for grafting and mortality. Patients who received saphenous vein grafts had higher in-hospital and long-term mortality than did recipients of internal mammary artery grafts. Either vein grafts are intrinsically inferior conduits and have a direct impact upon mortality, or the surgeon may base conduit selection on the patient's anticipated longevity and reserve internal mammary artery grafts for those judged to have the best prospects. Another ongoing study is addressing that issue, Dr. Kurlansky said.
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|Publication:||Internal Medicine News|
|Article Type:||Brief Article|
|Date:||Aug 1, 2002|
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