Cardiac Surgery In Elderly Patients Research Articles

Low Pre-Existing Gray Matter Volume in the Medial Temporal Lobe and White Matter Lesions Are Associated with Postoperative Cognitive Dysfunction after Cardiac Surgery

ObjectivesPostoperative cognitive dysfunction (POCD) is recognized as a complication in the elderly after cardiac surgery. Imaging of the brain provides evidence of neurodegeneration in elderly patients; however, abnormalities in brain structure and their relation to POCD are uncertain. This pilot study investigated whether loss of gray matter in the bilateral medial temporal lobe (MTL), seen in preoperative MRI, was associated with POCD.MethodsData were collected prospectively on 28 elderly patients scheduled for elective cardiac surgery. MRI of the brains of all patients were assessed for prior cerebral infarctions, and carotid and intracranial arterial stenosis. Patients also completed six neuropsychological tests of memory, attention and executive function before and after surgery. POCD was defined as an individual decrease in more than two tests of at least 1 standard deviation from the group baseline mean for that test. The degree of gray matter loss in the MTL of each patient was calculated using voxel-based morphometry with three-dimensional, T1-weighted MRI. This represented the degree of gray matter change as a Z score.ResultsPostoperative cognitive dysfunction was identified in 8 of the 28 patients (29%). Patients with POCD had significantly more white matter lesions on MRI, and greater loss of gray matter in the bilateral MTL (average Z score 2.0±0.9) than patients without POCD. An analysis by stepwise logistic regression identified gray matter loss in the MTL and cerebral infarctions on MRI as independent predictors of POCD.ConclusionsThese preliminary findings suggested that reduced gray matter in the bilateral MTL and white matter lesions existed in brains of elderly cardiac surgery patients who experienced POCD. Additional studies with larger sample sizes are needed to confirm these findings.

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes.

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

EComment. Postoperative delirium in elderly cardiac surgery patients

I read with great interest the paper by Smulter et al. [1]. The authors aimed at determining the incidence of and risk factors for postoperative delirium (POD), in older patients undergoing cardiac surgery. They reported an incidence of POD of 54.9% and confirmed many of the previously suggested risk factors. In their study, POD was strongly associated with an increased volume load during surgery. I would like to add some comment on this important topic. POD is a common and serious complication in elderly cardiac surgery patients. It is defined as an acute and fluctuating disturbance in consciousness, characterized by disorientation, a disturbed sleep-wake cycle, memory impairment, perceptual disturbances, and altered psychomotor activity [2,3]. POD is an important cause of prolonged hospital stay (economic burden), nursing home placement, and increased morbidity and mortality after cardiovascular surgery. In addition, it is associated with late death, hospital readmission, and reduced cognitive and functional recovery. The reported incidence of POD ranges from 30 to 73% depending on the diagnostic method used to define POD, study design, and type of cardiovascular procedure [2-a5]. The exact pathophysiology of POD is unknown. There are several potential mechanisms including perioperative cerebral hypoperfusion, alterations in the levels of neurotransmitters, systemic inflammation and physiologic stresses. This pathophysiologic complexity contributes to high incidence of POD [3,4]. Elderly cardiac surgery patients are at a particularly high risk for POD owing to the use of cardiopulmonary bypass, the presence of macro- or microemboli resulting from aortic and cardiac manipulation, the complexity and duration of surgical procedure, cerebral reperfusion injury, and large volume and pressure shifts [3]. The likelihood of developing POD increases proportionally with the number of existing risk factors [4]. Identification of risk factors for developing POD allows surgeons to implement interventions aimed at reducing the incidence of POD in these high risk patients. There are many patient (predisposing) and surgery (precipitating) risk factors related to POD. These risk factors include advanced age, pre-existing dementia, depression, functional impairment, cognitive impairment, hearing and visual impairment, alcohol abuse, smoking, decreased left ventricular ejection fraction, pre-existing pulmonary disease, hypertension, atrial fibrillation, laboratory abnormalities, cerebrovascular disease, decreased albumin level, lower hematocrit, postoperative hypotension and increased blood transfusion [2-5]. The most critical steps in management of POD are prevention and early recognition. Both prevention and treatment should focus on the minimization and/or elimination of predisposing and precipitating factors. There is currently no accepted preventive treatment for POD. Due to the multifactorial nature of POD, approaches which include strategies from multiple disciplines are the most effective in its prevention [5]. To prevent POD in high-risk patients, it should be focused on environmental modifications, psychoactive medication reduction, early mobilization, and prevention of complications [3]. Ten targeted domains to reduce delirium include (1) oxygen delivery to the brain, (2) fluid and electrolyte balance, (3) appropriate pain management, (4) decreased use of psychoactive medications, (5) optimization of bowel and bladder function, (6) nutritional support, (7) early mobilization, (8) prevention of postoperative complications, (9) appropriate environmental stimuli, and (10) treatment of delirium symptoms [5]. I think that recognition of early clinical signs and risk factors could be helpful for prevention and treatment, resulting in better outcomes. Conflict of interest: none declared

Effect of early postoperative use of ACEI/ARB or diuretics on the incidence of acute kidney injury after cardiac surgery in elderly patients

To evaluate the efficacy and safety of automatic variable flow rate (AutoFlow) for volume control ventilation through monitoring the number of ventilator alarm. Forty-eight adult patients receiving the Drager Evita 4 ventilator with an expectation of more than 2 days duration were divided into two groups by randomly digital methods, each n=24. The patients in control group were received routinely mode with synchronized intermittent mandatory ventilation (SIMV), and the others in observation group were given SIMV and assist with AutoFlow. The midazolam and fentanyl was given to retain the Ramsay score 2-3 by continuous micro-pump. The ventilator alarm, blood gas analysis and respiratory function were recorded. There were no significant differences in respiratory rate (RR), tidal volume (VT), positive end-expiratory pressure (PEEP), fraction of inspired oxygen (FiO₂), pH, arterial partial pressure of carbon dioxide (PaCO₂), arterial partial pressure of oxygen (PaO₂), oxygenation index (PaO₂/FiO₂), as well as sedative dose and time between two groups within 5 days of mechanical ventilation. Duration of mechanical ventilation in all patients was 164 days (3756 hours), and 78 days (1812 hours) in control group, 86 days (1944 hours) in observation group. The duration of mechanical ventilation in observation group was longer than that in control group [3 (1-15) days vs. 2 (1-28) days, P>0.05]. A total of 23 843 alarms were recorded, approximately 6 times/h, and 17 386 alarms in control group, averagely 9.6 times/h, 6457 alarms in the observation group, averagely 3.3 times/h. The number of ventilator alarm in observation group was less than that in control group (P<0.01). The number of airway pressure alarm in observation group was less than that in the control group [122 (8-1068) vs. 565 (13-1898), P<0.01]. There was no significant difference in sequential organ failure assessment (SOFA) score within 5 days between the two sets of mechanical ventilation. In the observation group ventilator-associated pneumonia (VAP) was occurred in 4 cases, and no pneumothorax happened, while in the control group there were 8 cases and 2 cases respectively. The mortality rate in intensive care unit (ICU) in observation group was lower than that in control group, but there was no statistical difference (25.0% vs. 37.5%, P>0.05). AutoFlow is confirmed be safe for volume control ventilation mode, and could significantly reduce the alarm of ventilator.

Customized Prediction of Short Length of Stay Following Elective Cardiac Surgery in Elderly Patients Using a Genetic Algorithm

ObjectiveTo develop a customized short LOS (<6 days) prediction model for geriatric patients receiving cardiac surgery, using local data and a computational feature selection algorithm.DesignUtilization of a machine learning algorithm in a prospectively collected STS database consisting of patients who received cardiac surgery between January 2002 and June 2011.SettingUrban tertiary-care center.ParticipantsGeriatric patients aged 70 years or older at the time of cardiac surgery.InterventionsNone.Measurements and Main ResultsPredefined morbidity and mortality events were collected from the STS database. 23 clinically relevant predictors were investigated for short LOS prediction with a genetic algorithm (GenAlg) in 1426 patients. Due to the absence of an STS model for their particular surgery type, STS risk scores were unavailable for 771 patients. STS prediction achieved an AUC of 0.629 while the GenAlg achieved AUCs of 0.573 (in those with STS scores) and 0.691 (in those without STS scores). Among the patients with STS scores, the GenAlg features significantly associated with shorter LOS were absence of congestive heart failure (CHF) (OR = 0.59, p = 0.04), aortic valve procedure (OR = 1.54, p = 0.04), and shorter cross clamp time (OR = 0.99, p = 0.004). In those without STS prediction, short LOS was significantly correlated with younger age (OR = 0.93, p < 0.001), absence of CHF (OR = 0.53, p = 0.007), no preoperative use of beta blockers (OR = 0.66, p = 0.03), and shorter cross clamp time (OR = 0.99, p < 0.001).ConclusionWhile the GenAlg-based models did not outperform STS prediction for patients with STS risk scores, our local-data-driven approach reliably predicted short LOS for cardiac surgery types that do not allow STS risk calculation. We advocate that each institution with sufficient observational data should build their own cardiac surgery risk models.

Pregabalin Has an Opioid-Sparing Effect in Elderly Patients After Cardiac Surgery

Background In this prospective, randomized, double-blind, placebo-controlled study, we investigated the effect of pregabalin on oxycodone consumption, postoperative confusion, and pain in elderly cardiac surgery patients. Methods Seventy patients, aged ≥75 yr, were randomized to receive either 150 mg of pregabalin before operation and 75 mg of pregabalin twice daily for 5 postoperative days or placebo. Pain intensity was measured with the Verbal Rating Scale (VRS). When pain intensity was ≥2 on the VRS, patients received oxycodone either i.v. (0.05 mg kg-1) or orally (0.10–0.15 mg kg-1). Postoperative confusion was measured with the Confusion Assessment Method for the intensive care unit (CAM-ICU). Postoperative pain was assessed by a telephone interview 1 and 3 months after operation. Results Cumulative consumption of parenteral oxycodone during 16 h after extubation was reduced by 44% and total oxycodone consumption from extubation to the end of the fifth postoperative day was reduced by 48% in the pregabalin group. Time to extubation was 138 min shorter and CAM-ICU scores were significantly lower on the first postoperative day in the placebo group, although there was no significant difference with respect to the Mini-Mental State Examination or the Richmond Agitation Sedation Score. The incidence of pain during movement was significantly lower in the pregabalin group at 3 months postoperative. Conclusions The administration of pregabalin reduced postoperative opioid consumption after cardiac surgery reduced the incidence of confusion on the first postoperative day and increased time to extubation when compared with placebo. Three months after operation, patients in the pregabalin group experienced less pain during movement.

High Thoracic Epidural Analgesia in Cardiac Surgery: Part 1—High Thoracic Epidural Analgesia Improves Cardiac Performance in Cardiac Surgery Patients

The purpose of this study was to evaluate the perioperative cardioprotective effect of high thoracic epidural analgesia (HTEA), primarily expressed as an effect on cardiac performance and hemodynamics in patients undergoing cardiac surgery. A randomized, prospective study. Sixty low-to-moderate risk patients between the ages of 65 and 80 years scheduled for elective coronary artery bypass graft surgery with or without aortic valve replacement. A university hospital. Patients randomized to receive HTEA as a supplement to general anesthesia. Perioperative hemodynamic measurements, perioperative fluid balance, and postoperative release of cardiac enzymes were collected. The end-diastolic volume index (EDVI), the stroke volume index (overall 38 v 32 mL), the cardiac index (overall 2.35 v. 2.18 L/minute/m(2)), the central venous pressure, and central venous oxygenation were higher in the HTEA group. The mean arterial blood pressure was marginally lower in the HTEA group, whereas no difference was noted in the heart rate or peripheral saturation between the groups. No differences were found in the postoperative levels of troponin T and CK-MB between groups. NT-proBNP changed over time (p < 0.001) and was lower in the HTEA group (p = 0.013), with maximal values of 291 ± 265 versus 326 ± 274. The findings of a higher stroke volume index and central venous oxygenation without an increase in heart rate or mean arterial pressure suggest that HTEA improves cardiac performance in elderly cardiac surgery patients.

Direct Transatrial Transcatheter SAPIEN Valve Implantation Through Right Minithoracotomy in a Degenerated Mitral Bioprosthetic Valve

Transcatheter valve implantation into failing surgical mitral bioprosthetic valves have been reported. This strategy avoids performing high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. All these patients have been treated by a transapical approach. We report a case of failing bioprosthetic mitral valve in an 82-year-old woman successfully treated with a 29-mm Edwards SAPIEN balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA) with direct left atrial approach through a right anterior thoracotomy. Our experience demonstrates the technical feasibility and safety of this approach. Therefore, mitral valve-in-surgical valve implantation may be a viable treatment alternative in carefully selected patients.

Cost and cost-effectiveness of cardiac surgery in elderly patients

Cost and cost-effectiveness of cardiac surgery in elderly patients

Retraction Note: The influence of a balanced volume replacement concept on inflammation, endothelial activation, and kidney integrity in elderly cardiac surgery patients

Retraction Note: The influence of a balanced volume replacement concept on inflammation, endothelial activation, and kidney integrity in elderly cardiac surgery patients

Retraction Note: Prophylactic use of the phospodiesterase III inhibitor enoximone in elderly cardiac surgery patients: effect on hemodynamics, inflammation, and markers of organ function

Objective. Elderly patients appear prone to develop overwhelming post-bypass inflammation and organ dysfunction. We assessed the effect of prophylactic administration of the phosphodiesterase III inhibitor enoximone on inflammation and organ function.

The Prophylactic Use of the Beta-Blocker Esmolol in Combination with Phosphodiesterase III Inhibitor Enoximone in Elderly Cardiac Surgery Patients

The Prophylactic Use of the Beta-Blocker Esmolol in Combination with Phosphodiesterase III Inhibitor Enoximone in Elderly Cardiac Surgery Patients

Is Albumin Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of Benefit with Regard to Inflammation, Endothelial Activation, and Long-Term Kidney Function?

Is Albumin Administration in Hypoalbuminemic Elderly Cardiac Surgery Patients of Benefit with Regard to Inflammation, Endothelial Activation, and Long-Term Kidney Function?

Cost and cost-effectiveness of cardiac surgery in elderly patients

Cost-effectiveness of heart surgery for elderly patients is still poorly defined. We evaluated outcome, quality of life (QoL), cost, and cost-effectiveness of octogenarians undergoing cardiac surgery. One thousand six hundred forty octogenarians undergoing various cardiac surgical procedures were prospectively studied between January 1998 and January 2009 and compared with similar patients aged 70 to 79 years. Several questionnaires were used to assess QoL. Six hundred age- and sex- matched healthy octogenarians and three hundred forty patients older than 80 years with medically treated valvular or coronary artery disease were healthy and unoperated control groups, respectively. In-hospital costs were obtained from the hospital's financial accounting department and cost-effectiveness was estimated and expressed as cost/QoL-adjusted life year (QALY) and cost-effectiveness ratio. Significant improvements occurred in elderly patients in Role Physical (P < .001), Bodily Pain (P < .001), General Health (P = .004), Social Functioning (P < .001), and Role Emotional (P < .001), whereas Physical Functioning, Vitality, and Mental Health did not change (difference not signficant). Total direct costs were $5293 higher in the octogenarian group. Cost-effectiveness was $1391/QALY for elderly surgical patients, $516/QALY for younger cardiac surgical patients (P < .001 vs elderly), $897/QALY for untreated control group, and $641/QALY for healthy control group (P < .001 vs elderly surgical patients). The cost-effectiveness ratio for octogenarians was $94,426. Our findings confirm that cardiac surgery in elderly patients remains controversial from a cost-effectiveness standpoint, making econometric analysis an important component for any future evaluation of novel cardiovascular therapies. Our findings need to be confirmed by additional multicenter studies.

Minocycline may be useful to prevent/treat postoperative cognitive decline in elderly patients

Postoperative cognitive dysfunction (POCD) is reported to occur frequently after all types especially cardiac surgery in elderly patients. It can be short-term or long-term and some cases even develop into Alzheimer’s disease (AD). Although multi-risk factors associated with POCD have been identified, the etiology and pathophysiological mechanisms of this surgical complication remain elusive. Therefore, developing strategies for preventing or treating POCD is still challenging. However, increasing evidence suggests that central and systemic inflammation triggered by surgery likely plays a fundamental role in POCD developing and progression. Minocycline, a tetracycline derivative with anti-inflammatory properties, has been shown to be effective in treating neuroinflammatory related conditions or neurodegenerative diseases such as AD, Parkinson’s disease, Huntington’s disease. Considering that inflammation may be a potential factor of POCD and minocycline is effective in improving cognitive dysfunction induced by inflammation, we hypothesize that minocycline may be useful to treat/prevent the POCD development after surgery in elderly patients.

Long term results of cardiac surgery in octo- and nanogenarians

Introduction: Outcomes after cardiac surgery in elderly patients become better and better. Yet some practitioners are reticent to refer elderly patients for surgery. This study analyzes long term survival in patients' aged 80 years and older undergoing cardiac surgery.

Preoperative and operative predictors of delirium after cardiac surgery in elderly patients

Delirium is a common complication in elderly patients after cardiac surgery and is associated with adverse outcomes including prolonged hospital stay and increased mortality. Therefore, prevention or early detection of delirium is indicated. Our objective was to identify preoperative and operative characteristics that could predict delirium after cardiac surgery in elderly patients. We conducted a prospective cohort study in which we analysed 201 patients of 70 years and older who underwent cardiac surgery, for developing a delirium. Patients were assessed daily using the Confusion Assessment Method-Intensive Care Unit. Sixty-three patients (31%) developed a delirium after cardiac surgery. The Mini-Mental State Examination (MMSE) score prior to surgery was lower in the delirious patients when compared with the non-delirious patients (27 vs. 28, P = 0.026), creatinine level was higher (98 vs. 88 μmol/l, P = 0.003) and extracorporeal circulation (ECC) time was longer (145 vs. 113 min, P < 0.001). Mortality during the first 30 days after surgery in patients with delirium was significantly higher than that in the non-delirious patients (14 vs. 0%, P < 0.001). Low MMSE score and high creatinine level prior to surgery as well as increased ECC time are important independent predictors of delirium. In addition, delirium is an important predictor of 30-day mortality. Patients with a substantial risk for delirium should be candidates for interventions to reduce postoperative delirium and to potentially improve overall surgical outcomes.

Transatrial Transcatheter Tricuspid Valve-in-Valve Implantation of Balloon Expandable Bioprosthesis

Transcatheter valve-in-valve implantation into failing mitral and aortic bioprosthetic valves have been reported. This strategy avoids performing high-risk repeat cardiac surgery in elderly patients with multiple comorbidities. Tricuspid valve-in-valve implantation has not been described. We report a case of failing bioprosthetic tricuspid valve in a 48-year-old woman with carcinoid syndrome. We attempted a transatrial transcatheter approach and we successfully deployed a 26-mm Edwards Sapien balloon expandable bioprosthesis (Edwards Lifesciences, Irvine, CA) into a severely stenotic tricuspid bioprosthesis. This case demonstrates the technical feasibility and safety of this approach. Therefore, tricuspid valve-in-valve implantation may be a viable treatment alternative in carefully selected patients.

Serum Cystatin C in Elderly Cardiac Surgery Patients

Elderly cardiac surgery patients are more prone to develop postoperative acute kidney injury (AKI). The common clinical glomerular filtration marker, plasma creatinine, is considered to be inadequate to discover AKI in its early stage. The aim of this study was to determine if serum cystatin C can detect mild renal failure earlier than plasma creatinine. From 110 cardiac surgery patients aged 70 or greater years, serum cystatin C and plasma creatinine samples were collected preoperatively and on postoperative days 1 to 5. Their urine output, creatinine, and estimated glomerular filtration rate were calculated and AKI was determined by the risk-injury-failure-loss-end-stage kidney disease criteria (RIFLE). The correlation of plasma creatinine and serum cystatin C to AKI was calculated. After cardiac surgery, 62 of the 110 patients (56.4%) developed AKI according to the RIFLE classification. In this group, both serum cystatin C and plasma creatinine peaked on postoperative day 3. Cystatin C and creatinine correlated equally with AKI at different time points calculated with receiver operating characteristic curves. On postoperative day 1 the area under the curve (AUC) for creatinine was 0.66 (0.55 to 0.76) and for cystatin C 0.71 (0.61 to 0.81); Delta AUC 0.05 (0.01 to 0.12), p = 0.11. On postoperative day 2 the AUC for creatinine was 0.74 (0.64 to 0.83) and for cystatin was C 0.77 (0.68 to 0.86); Delta AUC -0.03 (-0.09 to 0.03), p = 0.32. Elderly cardiac surgery patients have a high incidence of AKI, as defined by the RIFLE criteria. After cardiac surgery serum cystatin C and plasma creatinine detected AKI similarly.

Preoperative protein and energy intake and postoperative complications in well-nourished, non-hospitalized elderly cardiac surgery patients

Little is known about the impact of preoperative protein or energy intake in relation to the occurrence of postoperative complications in patients who are not undernourished but cannot keep up their daily protein or energy requirements prior to cardiac surgery. Therefore, a prospective study on intake in preoperatively well-nourished, non-hospitalized cardiac surgery patients (>or= 65 y) was carried out. Between December 2004 and November 2005 preoperative protein and energy intake and postoperative outcome data were collected from 100 consecutive patients undergoing cardiac surgery. Comparison of low protein intake (<or= 0.98 g/kg/d) with high protein intake (>0.98 g/kg/d) showed a low protein intake did not result in more complications or prolonged length of stay. In low-risk operation patients in particular, a high-energy intake (>22 kcal/kg/d) resulted in more postoperative complications than a low energy intake (<or= 22 kcal/kg/d) (33.3% and 13.2%, respectively; (OR 5.0 95% CI [1.5-16.9])). A preoperative protein intake <or= 0.80 g/kg/d was seen in 22.6%, and an energy intake <or= 25 kcal/kg/d in 72.2% of the patients. The outcome of this study suggests that detecting and correcting a preoperative low protein or energy intake is of no clinical relevance in the well-nourished, non-hospitalized elderly cardiac surgery patients. Caloric overfeeding may be associated with an increased complication rate.