Cardiac Surgery In Elderly Patients Research Articles

Octogenarians Tolerate Heart Surgery Well

Octogenarians Tolerate Heart Surgery Well

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

Because patients with low albumin levels may benefit from human albumin (HA) administration, we studied correction of hypovolemia with HA in hypoalbuminic elderly cardiac surgery patients. In a prospective, randomized study, 50 patients aged >80 yr undergoing cardiac surgery using cardiopulmonary bypass with a preoperative serum albumin concentration of <3.5 mg/dL, received either 5% HA (n = 25) or hydroxyethyl starch (6% HES 130/0.4) (n = 25). Volume was added to the priming (500 mL) and given until the morning of the second postoperative day to keep pulmonary capillary wedge pressure or central venous pressure between 12 and 14 mm Hg. Inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1), and kidney function (including glutathione transferase-alpha and neutrophil gelatinase-associated lipocalin) were measured after induction of anesthesia, 5 h after surgery, and the first and second postoperative day. A follow-up, approximately 60 days after discharge from the hospital, was done. Two thousand nine hundred eighty +/- 430 mL of HA and 3060 +/- 680 mL of HES 130/0.4 were given. Serum albumin concentration was significantly increased by HA (to 4.5 +/- 0.3 mg/dL). Serum creatinine, glomerular filtration rate, and urinary levels of alpha-glutathione transferase and neutrophil gelatinase-associated lipocalin were not different in the HA-compared to the HES-treated patients. The inflammatory response was similar in both groups, whereas endothelial activation was less in the HES group. None of the patients developed renal failure requiring renal replacement therapy. Use of HA in hypoalbuminemic cardiac surgery patients aged >80 yr was without benefit with regard to inflammatory response, endothelial activation, and renal function compared to 6% HES 130/0.4.

RETRACTED ARTICLE: The influence of a balanced volume replacement concept on inflammation, endothelial activation, and kidney integrity in elderly cardiac surgery patients

A balanced fluid replacement strategy appears to be promising for correcting hypovolemia. The benefits of a balanced fluid replacement regimen were studied in elderly cardiac surgery patients. In a randomized clinical trial, 50 patients aged >75 years undergoing cardiac surgery received a balanced 6% HES 130/0.42 plus a balanced crystalloid solution (n = 25) or a non-balanced HES in saline plus saline solution (n = 25) to keep pulmonary capillary wedge pressure/central venous pressure between 12-14 mmHg. Acid-base status, inflammation, endothelial activation (soluble intercellular adhesion molecule-1, kidney integrity (kidney-specific proteins glutathione transferase-alpha; neutrophil gelatinase-associated lipocalin) were studied after induction of anesthesia, 5 h after surgery, 1 and 2 days thereafter. Serum creatinine (sCr) was measured approximately 60 days after discharge. A total of 2,750 +/- 640 mL of balanced and 2,820 +/- 550 mL of unbalanced HES were given until the second POD. Base excess (BE) was significantly reduced in the unbalanced (from +1.21 +/- 0.3 to -4.39 +/- 1.0 mmol L(-1) 5 h after surgery; P < 0.001) and remained unchanged in the balanced group (from 1.04 +/- 0.3 to -0.81 +/- 0.3 mmol L(-1) 5 h after surgery). Evolution of the BE was significantly different. Inflammatory response and endothelial activation were significantly less pronounced in the balanced than the unbalanced group. Concentrations of kidney-specific proteins after surgery indicated less alterations of kidney integrity in the balanced than in the unbalanced group. A total balanced volume replacement strategy including a balanced HES and a balanced crystalloid solution resulted in moderate beneficial effects on acid-base status, inflammation, endothelial activation, and kidney integrity compared to a conventional unbalanced volume replacement regimen.

RETRACTED: Comparison of the effects of gelatin and a modern hydroxyethyl starch solution on renal function and inflammatory response in elderly cardiac surgery patients

Institutional Review Board (IRB) approval of this research could not be verified during an investigation by the Landesärztekammer Rheinland-Pfalz (the State Medical Association of Rheinland-Pfalz in Germany). As a result, this article has been retracted, in accordance with the Journal's regulations, at the request of the Directors and Board of the British Journal of Anaesthesia. Lack of IRB approval means that the research was unethical, and that IRB approval for the research was misrepresented in the published article. It does not mean that the research results per se are fraudulent. For further information please see Retraction.

Integrating Telehealth as a Strategy for Patient Management After Discharge for Cardiac Surgery

Advances in telecommunication technologies have improved access and availability of telehealth for use in healthcare. In cardiac care, telehealth has predominantly been used to manage patients with heart failure. The use of telehealth as a strategy for patient management after discharge for cardiac surgery can be beneficial in monitoring postoperative status and in the early detection of complications. This article provides an overview of the use of telehealth and telemanagement in cardiac patients and discusses the results of a pilot study as an example of an application of the use of telehealth for elderly cardiac surgery patients at high risk of postoperative complications.

Cardiac Surgery in Elderly Patients

Cardiac Surgery in Elderly Patients

A Closed Perfusion System With Heparin Coating and Centrifugal Pump Improves Cardiopulmonary Bypass Biocompatibility in Elderly Patients

Cardiopulmonary bypass induces a systemic inflammatory and hemostatic activation, which may contribute to postoperative complications. Our aim was to compare the inflammatory response, coagulation, and fibrinolytic activation between two different perfusion systems: one theoretically more biocompatible with a closed-circuit, complete heparin coating, and a centrifugal pump, and one conventional system with uncoated circuit, roller pump, and a hard-shell venous reservoir. Forty-one elderly patients (mean age, 73 +/- 1 years, 66% men) undergoing coronary artery bypass grafting or aortic valve replacement were included in a prospective, randomized study. Plasma concentrations of complement factors (C3a, C4d, Bb, and sC5b-9), proinflammatory cytokines (tumor necrosis factor-alpha, interleukin-6, and interleukin-8), granulocyte degradation products (polymorphonuclear elastase), and markers of coagulation (thrombin-antithrombin) and fibrinolysis (D-dimer, tissue plasminogen activator antigen and tissue plasminogen activator-plasminogen activator inhibitor-1 complex) were measured preoperatively, at bypass during rewarming (35 degrees C), 60 minutes after bypass, and on day 1 after surgery. The mean concentrations of C3a (-39%; p = 0.008), Bb (-38%; p < 0.001), sC5b-9 (-70%; p < 0.001), interleukin-8 (-60%; p = 0.009), polymorphonuclear-elastase (-55%; p < 0.003), and tissue plasminogen activator antigen (-51%; p = 0.012) were all significantly lower in the biocompatible group during rewarming. Sixty minutes after bypass, the mean concentrations of sC5b-9 (-39%; p = 0.006) and polymorphonuclear-elastase (-55%; p < 0.001) were lower in the biocompatible group. The results suggest that a closed perfusion system with a heparin-coated circuit and a centrifugal pump may improve cardiopulmonary bypass biocompatibility in elderly cardiac surgery patients in comparison with a conventional system.

Renal Dysfunction After Hydroxyethyl Starch: In Response

We thank Dr Celik for his simulating remarks and would like to answer to his criticisms in detail: 1. In a study of our group using different HES preparations in elderly patients (>60 yr) undergoing major abdominal surgery (2) we found indeed a small increase in some markers of altered kidney function (e.g., α-1-microglobulin). However, also patients in whom gelatin was given showed similar changes. As gelatin is unlikely to alter kidney function, these changes are most likely due to an extended surgical trauma rather than due to IV administration of HES. 2. The same results were seen in elderly cardiac surgery patients (3) also indicating considerable negative effects of the cardiopulmonary bypass rather than negative effects of modern HES preparations. 3. In the study from Dehne et al. (4), 1000 mL of HES was continuously given over 24 h in critically ill intensive care patients (n = 10)—a rather unusual technique to correct hypovolemia in these patients. A group of patients without volume served as a control (n = 15)—also rather unusual that critically ill patient do not need volume. Significantly more of the HES-treated patients needed hemofiltration due to development of acute renal failure (ARF). Whether these patients were removed from the further study or not remains unclear. Moreover, this was a very small study without power analysis! 4. In the study from Schortgen (5), a HES preparation with high molar substitution (MS) (HES 200/0.62) was used in intensive care patients and compared with a group in whom gelatin was given. Unfortunately, the HES-patients showed higher creatinine levels than gelatin patients already prior to the study. HES patients showed higher creatinine levels during the study period, however, there were no differences between the two groups with regard to the need of hemofiltration/dialysis and outcome. The authors concluded that by using more rapidly degradable HES preparations (with a lower MS) these negative results on kidney function may not have been noticed. 5. This statement remains unclear: “Renal impairment is also seen with high-molecular weight HES preparations used in the United States.” The study (6) Dr. Celik cited has the title: “Hydroxyethyl starches does no impair immediate renal function in kidney transplant recipients...”. 6. In the retrospective study in cardiac surgery by Winkelmeyer et al. (7), an HES preparation with a very large MW (670 kd) and a very high MS (0.75) was shown to alter kidney function; this is an argument pro the fact that the different HES preparations have to be distinguished—especially slowly degradable HES preparations that show considerable risk to produce kidney dysfunction. 7. It remains unclear what the reported differences in histamine release have to do with possible alterations in kidney function (8). 8. In the study using albumin in patients with spontaneous bacterial peritonitis, one group received albumin, and a control group received no additional volume (9). As expected, the untreated (hypovolemic) control patients developed kidney dysfunction more often; this has nothing to do with beneficial effects of albumin on kidney function! This comparison is not fair. 9. Finally, Dr. Celik has (unfortunately) forgotten to mention a recently published study using a new, third-generation HES preparation (HES 130/0.4) in patients with mild-to-severe renal dysfunction before IV HES administration (1). No negative effects on cre-atinine clearance were seen with the HES preparation. Summarizing all studies, it seems to be well established that some older HES preparations (especially with a higher MW and a higher MS) may be associated with alterations in kidney function. Joachim Boldt, MD Hans-Joachim Priebe, FRCA

Mid-term survival after cardiac surgery in elderly patients: analysis of predictors for increased mortality

This study examines and quantifies the potential risk factors for increased mid-term mortality in elderly patients (> or = 75 years old) undergoing cardiac surgery. We undertook a retrospective analysis of 840 consecutive elderly patients who underwent cardiac surgery (CABG and/or Valve) between April 1997 and March 2002. Deaths occurring as a function of time were described using the product limit methodology of Kaplan and Meier. Cox proportional hazards analysis was used to identify preoperative risk factors for mortality with hazard ratios (HR). One hundred and sixty-two (19.3%) deaths occurred during the study period, with a total follow-up of 1866 patient years (mean 2.2 years, SD 1.5 years). Observed freedom from death in the elderly patients at 5 years was 71.7%, compared to 70.9% for the age- and sex-matched general population (P=0.252). Multivariate analysis for independent predictors of increased mortality found that renal dysfunction (HR 3.2; P<0.001), valves(s) surgery (HR 1.8; P<0.001), cerebrovascular disease (HR 1.8; P=0.003), and catastrophic state (HR 2.2; P=0.011) were the major risk factors. We have identified and quantified several risk factors, which need to be considered when assessing patients for cardiac surgery.

Risk Factors for Mortality and Nosocomial Infections in Elderly Cardiac Surgery Patients

An abstract is not available for this content so a preview has been provided. As you have access to this content, a full PDF is available via the ‘Save PDF’ action button.

RETRACTED: Prophylactic use of pentoxifylline on inflammation in elderly cardiac surgery patients

Inflammation plays a pivotal role in the pathogenesis of organ injury after cardiopulmonary bypass (CPB). Elderly patients appear to be especially prone to develop general inflammation. Use of pentoxifylline (PTX) before surgery may be a promising approach to minimize the negative effects of CPB in these patients. In a prospective, randomized study, patients more than 80 years old undergoing aortocoronary artery bypass grafting received either PTX (n = 15) after induction of anesthesia (initial bolus of 300 mg followed by a continuous infusion of 1.5 mg.kg(-1).h(-1) during the next 2 days) or saline as placebo (control group; n = 15). Polymorphonuclear neutrophil (PMN) elastase, C-reactive protein (CRP), and interleukins (IL-6, IL-8, IL-10) were measured from arterial blood samples before surgery (T0), at the end of surgery (T1), 5 hours after surgery (T2), and at the morning of the first (T3) and second (T4) postoperative day. Postoperatively, PTX-treated patients less often needed catecholamines and were extubated earlier than the control patients (p < 0.05). On the intensive care unit, cardiac index inceased more in the PTX-treated (from 1.95 +/- 0.3 to 3.26 +/- 0.4 L.min(-1).m(-2)) than in the control patients (from 1.89 +/- 0.2 to 2.78 +/- 0.3 L.min(-1).m(-2)). Increase in CRP and PMN-elastase was significantly higher in the untreated control than in the PTX patients. After CPB, IL-6, IL-8, and IL-10 increased in both groups showing a significantly higher increase in the untreated control patients (IL-8 control: from 11.3 +/- 2.6 to 154.4 +/- 57 pg/mL [T1]); IL-8 PTX: from 10.9 +/- 2.7 to 71.8 +/- 23 pg/mL [T1]). In elderly cardiac surgery patients, use of PTX before surgery and continued after CPB resulted in less inflammatory response than in an untreated control group. The value of attenuating the inflammatory process by PTX on outcome in this patient population needs to be evaluated in further controlled studies.

Changes in Exercise Tolerance Before and After Cardiac Surgery in Elderly Patients

Changes in Exercise Tolerance Before and After Cardiac Surgery in Elderly Patients

Good outcomes from cardiac surgery in the over 70s

OBJECTIVETo determine the early mortality and major morbidity associated with cardiac surgery in the elderly.DESIGNRetrospective case record review study of 575 patients ⩾ 70 years old who underwent cardiac surgery...

Nursing grand rounds

As advances are made in medical-surgical technology and overall life expectancy increases, cardiac surgery previously done only in younger populations is now becoming common in older adult age groups. Most of the nursing literature regarding elderly cardiac surgery patients focuses on the 65- to 75-year-old age group; little has been written about the 80- to 90-year-old age group. Very elderly patients present unique and complex challenges to the interdisciplinary teams involved in their care. Nurses must recognize and anticipate the specialized needs of these frail individuals to optimally manage their care. Aortic valve replacement is the most common cardiac valve surgical procedure performed in very elderly persons. A case study and an integrated care plan for the aortic valve surgery patient are described.

Functional capacity after cardiac surgery in elderly patients

Objectives. This study was performed to determine whether cardiac surgery improves functional capacity in patients >70 years of age and to identify factors associated with good and poor functional results in this age group.Background. Cardiac surgery has been used increasingly among older patients, but the effectiveness of surgery in this age group remains controversial.Methods. Self-reported functional capacity was assessed by the Dyke Activity Status Index preoperatively and again 1 year after coronary artery bypass or valve replacement surgery in a total of 199 patients with a mean age of 76 years (range 70 to 91).Results. Functional capacity improved significantly after surgery (mean Duke Activity Status Index 27.9 at baseline vs. 36.8 at 12 months, p < 0.001), with improvements in most patients (74%). Six preoperative factors were independent predictors of less improvement in functional capacity between baseline and 1 year: smoking, female gender, higher Charlson comorbidity index, syncope, previous cardiac operation and older age. Postoperative complications were also a highly significant predictor of lower functional capacity at 1 year.Conclusions. Most older patients have meaningful improvements in functional capacity after cardiac surgery, and clinical factors appear to modify the degree of improvement attainable.

Social Support and Depression After Cardiac Surgery in Elderly Patients

Two methods of measuring social support components were compared for their ability to predict depression 6 months after cardiac surgery in older patients (N = 155). Multiple regression models were used to compare summary support measures with subtype measures. A personality inventory was also included to rule out the possibility that significant findings about relationships of depression and social support were due primarily to personality dimensions. In the summary model, only the number of network members seen regularly was associated with less depression. In the subtype model, the number of relatives seen regularly and perceived adequacy of support from friends were associated with less depression, whereas receipt of tangible support was associated with more. When examined together with personality dimensions, both the summary components and subtypes of components of social support were better predictors of depressive symptomatology than the personality dimensions. The results helped confirm the importance of social support factors to the occurrence of depression in elderly patients and suggested that measures of social support subtypes were more informative than summary measures of social support.

"Not clinically indicated": patients' interests or resource allocation?

The decision that a particular intervention is not clinically indicated may conceal two quite different ethical assumptions. The first assumption is that the intervention is not of overall benefit to this patient. The second is that limited resources should not be used for this patient. These issues are discussed with reference to cardiac surgery in elderly patients with reference to the main theories of allocation: QALYs, needs theories, the sanctity of life theory, the lottery theory, and market forces.

Increased complications and prolonged hospital stay in elderly cardiac surgical patients with low serum albumin

Cardiac surgery in elderly patients is associated with acceptable operative mortality but an increased complication rate. Malnutrition is common in the elderly and may adversely affect surgical outcome. To determine the effect of hypoalbuminemia on postoperative complications, 92 patients ≥75 years (range 75 to 90) undergoing a variety of major cardiac surgical procedures were evaluated. Thirteen patients (14%) had a serum albumin level <3.5 g/dl preoperatively. Compared to patients with normal albumin, hypoalbuminemic patients had an increased frequency of postoperative confusion, congestive heart failure, low cardiac output, renal dysfunction and gastrointestinal complications (all p < 0.05). Mean postoperative length of stay was markedly prolonged in these patients (27 vs 12 days; p < 0.001), and mortality also tended to be higher (31 vs 13%; p = 0.11). Using multivariate analysis, albumin <3.5 g/dl was the most powerful predictor of postoperative renal dysfunction (p < 0.01), and was also an independent predictor of increased length of stay (p < 0.01) and gastrointestinal disorders (p < 0.05). Thus, hypoalbuminemia is a powerful indicator of ah increased risk of perioperative complications in elderly patients undergoing cardiac surgery. Increased attention to nutritional factors is warranted in these patients.