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(Chest. 2000;117:1262-1270.)
© 2000 American College of Chest Physicians

Coronary Artery Bypass Grafting in the Elderly*

Hitoshi Hirose, MD FICS; Atushi Amano, MD; Shigehiko Yoshida, MD; Akihito Takahashi, MD; Naoko Nagano, MD and Takushi Kohmoto, MD

* From the Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Chiba, Japan.

Correspondence to: Hitoshi Hirose, MD, Department of Cardiovascular Surgery, Shin-Tokyo Hospital, 473-1 Nemoto, Matsudo City, Chiba, 271-0077, Japan; e-mail: genex{at}idt.net


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background and methods: The incidence of coronary artery bypass grafting (CABG) in elderly patients has been increasing. We retrospectively analyzed the results of CABG performed at Shin-Tokyo Hospital between January 1, 1991, and December 31, 1998. Preoperative, perioperative, and follow-up data of patients >= 75 years old (group E, n = 190) were collected, and compared with those of patients < 75 years old (group Y, n = 1,380).

Results: Female gender, emergent CABG, preoperative balloon pumping use, cardiogenic shock, hypertension, and preoperative cerebral vascular accident were significantly more frequent in group E (p < 0.05). CABG was completed without any significant differences, except for less frequent use of the bilateral internal mammary artery (p < 0.01), more frequent use of the saphenous vein (p < 0.005), and a greater incidence of blood transfusion in group E (p < 0.0001). The postoperative course required longer intubation, ICU stay, and postoperative hospital stay in group E (p < 0.001), and was more frequently associated with major complication (p < 0.0001) and in-hospital death (p < 0.05). During the mean follow-up of 2.7 years (maximum 6.9 years), the actuarial 5-year survival of groups E and Y were 84.3% and 92.5% (p < 0.01), respectively, excluding in-hospital mortality. The actuarial 5-year cardiac event-free rates were 79.9% in group E and 79.7% in group Y, showing no significant difference.

Conclusions: CABG in the elderly carries certain surgical risks. However, the long-term cardiac event-free rate after CABG in the elderly was almost the same as that of younger patients. Inferior long-term survival in the elderly was most likely due to the biological nature of aging.

Key Words: aging • coronary artery bypass • ischemic heart disease


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The elderly population has been continuously growing throughout most of the Western world. With the increase in the older population, the number of patients referred for coronary artery bypass grafting (CABG) has also increased.1 2 Published data from the Society of Thoracic Surgeons (STS) national database indicates a gradual increase of the mean age of patients undergoing CABG in the United States.3 The STS database of patients receiving the first and elective CABG shows a significant increase in surgical mortality in the elderly. In this study, we retrospectively analyzed in-hospital and long-term data in patients who underwent CABG at Shin-Tokyo Hospital, especially focusing on patients >= 75 years old.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Between January 1, 1991, and December 31, 1998, 1,730 patients underwent CABG at Shin-Tokyo Hospital. Records of 1,570 consecutive patients were retrospectively reviewed, after excluding 160 patients (9.2%) who were lost to follow-up. The subjects were classified into two groups: one group >= 75 years old (group E), and the other group < 75 years old (group Y).

The following parameters were collected: patient age, gender, results of preoperative angiography, cardiac profiles, preoperative risk factors, graft material, surgical data, postoperative complications, and mortality. Outpatient follow-up was completed by the referring cardiologist or hospital outpatient clinic. Each incidence of postoperative angiography, cardiac events, and/or death were reported.

Preoperative risk factors and postoperative complications were defined according to STS criteria.

Statistical analysis was performed using Student’s t tests for continuous variables or {chi}2 tests (Fisher’s Exact Tests if n < 5) for categorical variables. Results were expressed as mean ± SD. Postoperative patient survival and event-free rate were constructed by the Kaplan-Meier method and compared using Mantel-Cox’s log rank tests. Cox’s risk hazard ratio was calculated by logistic regression analysis and expressed with 95% confidence interval (CI). A p value < 0.05 was considered significant. Significant variables by univariate comparisons were further analyzed by multivariate logistic regression analysis. All statistical analyses were performed using Statview version 5.0 (SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Group E consisted of 190 patients (122 men and 68 women; mean age, 77.4 ± 2.2 years), and group Y consisted of 1,380 patients (1,090 men and 290 women; mean age, 62.4 ± 8.2 years). The preoperative data are described in Table 1 . History of congestive heart failure, emergent CABG, preoperative use of intra-aortic balloon pumping (IABP), cardiogenic shock, hypertension, and cerebral vascular accident significantly more frequent in group E.


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  		Table 1. Preoperative Risk Factors*

 
Operative data are shown in Table 2 . The total number of grafts were almost the same in both groups; however, the bilateral internal mammary arteries (IMAs) were more often utilized in group Y, and a saphenous vein graft was more often utilized in group E. Clamp time, pump time, and operative time were not significantly different between the two groups.


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  		Table 2. Operative and Postoperative Data*

 
Postoperative course is also displayed in Table 2 . Group E required longer intubation, longer ICU stay, and longer postoperative hospital stay. The overall in-hospital mortality of groups E and Y were 3.2% and 0.9%, respectively (p < 0.05). Major complications were more frequently observed in group E (27.4%) than in group Y (14.1%), with p < 0.0001. Univariate logistic analysis revealed that group E carried 2.3 times (95% CI, 1.6 to 3.3; p < 0.0001) greater risk of major complication than group Y, as well as 3.4 times (95% CI, 1.3 to 9.1; p < 0.05) greater risk of in-hospital death after CABG. Other significant preoperative variables influencing in-hospital mortality by univariate analysis are depicted on Table 3 . Further multivariate analysis of these significant variables demonstrated that advanced age (> 75 years old) was not a significant predictor of in-hospital death. Significant independent predictors of in-hospital death by multivariate analysis included the following: history of congestive heart failure, preoperative atrial fibrillation, coexisting valvular disease, emergent surgery, and cardiogenic shock.


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  		Table 3. Preoperative Factors Influencing Postoperative Death*

 
Postoperative angiography was performed in selected patients. Late coronary angiography was performed in a total of 45 patients, with 139 anastomoses in group E and 565 patients with 1,795 anastomoses in group Y, after a mean interval of 18 months. The overall graft patency rates in groups E and Y were 94.2% and 95.2%, respectively (p = not significant [NS]). The graft patency rates of each graft material did not differ between the two groups, analyzed with the Kaplan-Meier method.

Excluding perioperative mortality, collection of long-term data was completed, with a mean follow-up period of 2.9 ± 1.8 years (longest follow-up period of 8.0 years). Late death was observed in 17 patients (9.3%) in group E, which was significantly greater than that in group Y (70 patients; 5.1%). The details of long-term death are displayed in Table 4 . Noncardiac death was more frequent in group E than in group Y (p < 0.005), although the incidence of the cardiac death was similar in both groups. The risk hazard of late death in group E compared with group Y, calculated by univariate analysis, was 2.0 (95% CI, 1.2 to 3.4; p < 0.01). Other preoperative risk factors influencing long-term survival are listed in Table 3 . Multivariate survival analysis failed to demonstrate advanced age as a independent predictor of late death. Independent predictors of late death included the following: previous congestive heart failure, poor left ventricular function (ejection fraction < 40%), peripheral vascular disease, renal dysfunction, and malignant neoplasm on admission. The survival curve of each group is shown in Figure 1 . The respective actuarial 1-, 3-, and 5-year survival rates were 97.8, 94.9 and 84.3% in group E, and 99.0, 97.7 and 92.5% in group Y, respectively, which was significantly different (p < 0.01).


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  		Table 4. Long-term Mortality and Morbidity*

 


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  		Figure 1. Long-term survival curve, constructed by the Kaplan-Meier method. The gray line indicates patients < 75 years old, and the black line indicates patients >= 75 years old. The survival rate of aged patients was significantly inferior to that of younger patients (p < 0.01).

 
The remote cardiac events are listed in Table 4 . The long-term cardiac event-free curve is shown in Figure 2 . The actuarial 1-, 3-, and 5-year event-free rates were 96.7, 93.0, and 79.7% in group E, and 95.3, 87.4, and 79.9% in group Y, respectively, showing no significant difference. The analysis of cardiac events revealed more frequent incidence of congestive heart failure in group E than in group Y (p < 0.05).



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  		Figure 2. Long-term cardiac event-free curve, constructed with Kaplan-Meier method. The gray line indicates patients < 75 years old, and the black line indicates patients >=75 years old. There were no significant differences between the two groups.

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Patient Profile
Atherosclerosis in the elderly is common. Coronary artery disease, hypertension, cerebral vascular accident, calcified aorta, and peripheral vascular disease are all related to atherosclerotic vascular changes, and all of these were more prevalent in the elderly in our study. Percutaneous transluminal coronary angioplasty (PTCA) to the advanced coronary artery disease, such as three-vessel disease, left main disease, or calcified coronary artery are difficult and are associated with higher rates of failure. Kaul et al4 reported that PTCA in the elderly had a greater failure rate and that the incidence of hospital mortality after PTCA in the elderly was similar to that after CABG. Limited application of catheter intervention against patients with severe coronary artery disease could be related to the increased number of emergency surgery in the elderly. Since global cardiac function is decreased in the elderly, the history of congestive heart failure was more frequently observed in the elderly group. The increased frequency of female patients among the elderly receiving CABG has been noted in previous reports.1 2 Not only the longer life expectancy of women, but also acceleration of atherosclerosis after menopause may cause the increased percentage of women who undergo CABG in this higher age group. Additionally, coronary artery disease in women is known to have a poorer prognosis than that in men.5 6

Surgical Technique and Its Considerations
Our primary goal of CABG is complete revascularization. The long-term results are known to be generally better in patients who have undergone revascularization with the left IMA than in those who only received saphenous vein grafts.7 8 In selected elderly patients, the outcome of IMA grafting was reported to be better than that of saphenous vein grafting.9 10 The risk of mediastinal infection is known to be associated with uncontrolled diabetes, and the in-hospital morbidity in patients who had bilateral IMA bypassed was reported to be the same as that in patients who had only single IMA bypassed.11 In our practice, we made all effort to revascularize the left anterior descending artery (LAD), which supplies the largest cardiac mass, with either one of the IMAs. The long-term benefit of using the bilateral IMAs will become apparent in 10 to 15 years.12 Other reports demonstrated that bilateral IMA improved the postoperative cardiac event-free rate but failed to improve the late survival.13 14 Based on these findings, in our institute, the use of the bilateral IMAs was not primarily employed in the elderly patients whose life expectancy was considered limited. Bilateral IMAs were only harvested if the patients had no other available grafts for complete revascularization, or if the patients had severe aortic calcification and aortocoronary bypass was not favorable.

Another characteristic of CABG in the elderly was the frequent use of the saphenous vein graft, although the total venous bypass comprised only 5.3% of all cases. Unlike elastic arteries such as the IMA, muscular arteries, such as the radial artery, gastroepiploic artery, and inferior epigastric artery are more prone to atherosclerotic changes.15 16 Early graft failures may occur if atherosclerotic arteries are used as conduits. Thus, in our practice, the arterial grafts were the first choice of conduits; however, the saphenous vein was also harvested if the quality of the arterial conduits appeared poor at the surgery. Vein graft disease becomes apparent > 5 years after surgery12 17 and contributes to the increase frequency of cardiac events. However, early vein graft failure, < 5 years of surgery, can be safely treated by catheter intervention and rarely requires reoperation.18 Since in most cases in our practice, the LAD was protected by the IMA, PTCA against other native coronary arteries or other grafts can be performed with minimal risks. Elderly patients with limited life expectancy may benefit from saphenous vein grafting complimented by the IMA-LAD grafting.

Valvular surgery associated with CABG was conducted if the valvular lesion was considered to affect to the patient’s hemodynamics, which was usually determined by intraoperative transesophageal echocardiography. Only seven patients > 75 years old underwent concomitant valvular surgery in our study. There was no in-hospital mortality in this small group of patients, which was previously reported to carry a high risk for in-hospital death.2 19 Our study demonstrated that coexisting valvular lesions were predictors of in-hospital death, but valvular surgery itself did not increase the incidence of in-hospital death. This implies that if valvular lesions were not corrected, residual lesions may have negatively affected in-hospital mortality. In the elderly heart, congestive heart failure associated with residual valvular disease is difficult to manage, even if revascularization is completed. Thus, we consider that grade III or higher valvular lesions detected by transesophageal echocardiography should be treated at the same time as CABG.

After late 1996, off-pump CABG was introduced to our institute, and its application has rapidly expanded. Off-pump CABG under beating heart promises minimal invasiveness to the heart, and facilitates early recovery with fewer complications.20 21 22 The major beneficiary of off-pump-CABG would be the patient with calcified aorta, which carries risks for postoperative stroke, and patients with decreased cardiac function, which carries risks of postoperative low-output syndrome. We are currently performing off-pump CABG in selected patients, and these results have been excellent. Among the 20 cases of off-pump CABG performed in patients > 75 years old, there was no postoperative stroke or perioperative myocardial infarction. The postoperative intubation period, ICU stay, and hospital stay were significantly shorter than conventional CABG.

Early Results
Postoperative recovery in elderly patients requires a longer period than that in younger patients. Although the surgical quality (number of grafts, clamp time, cardiopulmonary bypass time, and operative time) was almost same between groups E and Y. The longer postoperative recovery may be the reflection of the increased incidence of major complications in the elderly. However, elderly patients without major complications still showed a significantly longer intubation period (12.3 ± 11.4 h), ICU stay (3.0 ± 1.5 days), and postoperative in-hospital stay (18.0 ± 7.6 days) than the younger patient group (p < 0.001). Thus, delayed recovery in the elderly may simply be due to the aging process affecting all organs.

Postoperative pump failure requiring IABP support, cerebral vascular accident, and respiratory failure were the major forms of morbidity in the elderly. Postoperative stroke is difficult to predict preoperatively. Among the 11 cases of postoperative stroke, only 1 patient had a preoperative history of stroke, and another 1 patient had calcified aorta, while the remaining 9 patients were free of such risk factors. Five of 11 patients with postoperative stoke died after CABG (two in-hospital and three remote deaths). The recent technique of off-pump CABG may contribute to reducing the incidence of postoperative stroke.

Postoperative atrial fibrillation requiring medical control occurred more often in the elderly (53 of 190 patients; 27.9%) than in the younger patients (229 of 1,380 patients; 16.6%), with p < 0.0001. Since atrial fibrillation would not be a life-threatening complication, it had no effect on either in-hospital mortality or long-term death in our study, determined by univariate analysis.

The in-hospital mortality rate of elderly patients in our study was 3.2%, which was within the range of previous reports.1 2 19 23 In our study, age > 75 years was identified as a predictor of in-hospital death by univariate analysis with a relative risk of 3.4 (95% CI, 1.3 to 9.1), but not by multivariate analysis. Multivariate preoperative predictors of in-hospital death in elderly included the following: congestive heart failure, atrial fibrillation at admission, valvular disease, emergent surgery, and shock at the presentation, which were similar to those in previous reports.1 2 4 19

Long-term Results
Our results demonstrated a greater likelihood of late death in the elderly (84.3% survival rate at 5 years after CABG) than in the young (92.5% survival rate at 5 years after CABG). A previous report of the late survival rate of the elderly CABG patients ranged from 73% at 4 years,24 74.6% at 4.5 years,23 79.7% at 5 years,2 to 66% at 5 years,25 although these studies were conducted among patients > 80 years old. In our study, a relatively small percent of patients were > 80 years old. Thus, it would be difficult to compare our findings to these previous reports; however, there were 31 patients >= 80 years old and there were no in-hospital deaths and three remote deaths, giving a survival rate of 90.3% at a mean follow-up period of 2.5 ± 1.6 years.

Advanced aged was a predictor of late death only on univariate analysis, with a relative risk of 2.0 (95% CI, 1.2 to 3.4), but not on multivariate analysis. Multivariate preoperative predictors of remote death include the following: previous myocardial infarction, poor ejection fraction, peripheral vascular disease, renal dysfunction, and coexisting malignant neoplasm. Postoperative complications influencing long-term mortality on univariate analysis included the following: low-output syndrome, cerebral vascular accident, mediastinitis, pneumonia, prolonged mechanical ventilation, reintubation, and postoperative dialysis. Re-exploration for bleeding, postoperative myocardial infarction, and postoperative IABP support had no impact on long-term survival. Multivariate analysis revealed independent postoperative predicators for late death included the following: postoperative stroke, mediastinitis, prolonged ventilator support, and postoperative induction of dialysis.

The frequency of cardiac death in the aged group did not differ from that in younger patients. The elderly patients after CABG were more likely to die of noncardiac causes (p < 0.005). The likelihood of developing life-threatening noncardiac disease may be more prevalent than that among younger patients. Not only the cardiac status but also the general health status of elderly patients after CABG should be carefully monitored.

The long-term cardiac events rate among the elderly in our study was acceptable. Cumulative event-free rate in elderly patients at a mean follow-up of 2.7 years was 87.5%, which was within the range of the previous studies (79.9% at 5 years after CABG in patients > 80 years old,2 and 74% at 3 years after CABG in patients > 80 years old25 ). After successful CABG, freedom from cardiac events in the aged group was almost equal to that in the younger patient group. Graft patency in selected patients did not differ between the groups. Angina recurrence, myocardial infarction, or repeated catheter intervention was adequately avoided after CABG. The similar rates of graft patency and remote cardiac events shown in the two groups reflected the similar quality of CABG (similar number of distal anastomoses and similar utilization of the arterial conduits). However, the older patients more frequently developed postoperative congestive heart failure. Aged patients were more likely to have stiffer heart and reduced cardiac functional reserve,1 which may easily fail into congestive heart failure.

The continued life expectancy at age 75 among the Japanese population is 10.3 years in men and 13.4 years in women.26 The first three major causes of death in Japan at age 75 are malignant neoplasm (21.0%), cerebral vascular accident (19.4%), and cardiac disease (16.8%). A report from the Cleveland Clinic with the longest follow-up of elderly CABG patients > 75 years old demonstrated an 8-year survival rate of 53.3%, which was better than the matched US population. In our study, the mean follow-up period was only 2.7 ± 1.8 years. Thus, we cannot yet demonstrate whether patients after CABG had any survival differences from the normal Japanese population.

Study Limitations
Our study was performed in a single institute with a single surgical group, which may bias the operative data. Postoperative length of the stay was almost three times longer than that reported in the United States.3 This would be a reflection of the Japanese cultural background and health insurance program. The hospital of our study is a tertiary referral cardiac center, where most of the patients were followed by private referral physicians. Outpatient management was mainly performed by these private cardiologists. This may be related to the relatively high incidence of lost follow-up (9.2%).

Summary
In summary, CABG in the elderly patients can be performed with acceptable risks. Successful surgical revascularization in the elderly will provide freedom from cardiac events as expected in younger patients. Recently developed off-pump CABG may contribute to reducing in-hospital mortality and morbidity. Late noncardiac death was frequent among elderly patients and considered related to aging. Advanced age cannot be safely ignored at the time of surgery, since both short- and long-term prognosis in the elderly are influenced not only associated disease but also by the physiologic nature of aging itself.


   Footnotes
 
Abbreviations: CABG = coronary artery bypass grafting; CI = confidence interval; IABP = intra-aortic balloon pumping; IMA = internal mammary artery; LAD = left anterior descending artery; NS = not significant; PTCA = percutaneous transluminal coronary angioplasty; STS = Society of Thoracic Surgeons

Presented at the 61st Annual Meeting of the Japan Surgical Association, November 25, 1999, in Tokyo, Japan.

Received for publication July 7, 1999. Accepted for publication December 8, 1999.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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