G. Rainey Williams Symposium September 30, 2005

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G. Rainey Williams SymposiumSeptember 30, 2005

• CABG in the Elderly Patient
• On or Off pump?
• A Single Center Experience
• R. Nathan Grantham, M.D.

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WILL DRUG-ELUTING STENTS REPLACE CORONARY ARTERY
BYPASS SURGERY?

• Ross M. Reul, M.D. (Tex Heart Inst J
  200532323-30)

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Cardiac Surgery in Nonagenarians and Centenarians

• Bridges et al, J Am Coll Surg 197, September
  2003
  
• 347-357

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Cardiac Surgery in Elderly Patients What do we
know?

• 25-40 of elderly patients have symptomatic CAD
• Currently (2002) a million octogenarians.
  Estimated 2050 38 million octogenarians
  
• CABG can safely be performed with acceptable
  mortality/morbidity.
  
• Mortality/Morbidity is higher in elderly than
  younger patients.
  
• Preoperative co-morbid conditions predispose the
  elderly to post-surgical mortality/morbidity but
  benefits may be greatest in this high risk group.

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Cardiovascular Surgery Imperatives

• Continue present trend for improved results in
  higher acuity patients.
  
• Pursue less invasive procedures with lower
  morbidity.
  
• Evaluate results in our own practice against
  benchmark data (STS).
  
• Evidence based practice.
• Cost effective, efficient practice with careful
  quality monitoring.

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GOLD STANDARDfor Direct Myocardial
Revascularization

• Cardiopulmonary bypass
• Cardioplegic arrest

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Morbidity fromCardiopulmonary Bypass

• Neurocognitive dysfunction/CVA
• Renal impairment
• Pulmonary complications
• Coagulopathy
• SIRS (Systemic Inflammatory Response Syndrome)

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Possible Benefits of Off-Pump Coronary Bypass

• Less cognitive dysfunction/CVA
• Less renal impairment
• Less systemic effects
• Less pulmonary dysfunction

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Possible Benefits of Off-Pump Coronary Bypass

• Better myocardial protection
• Improved mortality in severely impaired LV
  function
  
• Less blood loss/transfusion
• Economic advantage

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Concerns with OPCAB

• Increased incidence of ascending aortic
  dissection/injury
  
• Early and late graft patency
• Hypercoagulopathy/procoagulant effect

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OPCAB vs. CCAB in the Elderly6/1/99 -
1/31/05Comanche County Memorial Hospital

• CABG
• OPCAB
• CCAB

• 1076
• 594 (55.2)
• 482 (44.8)

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OPCAB vs. CCAB in the Elderly

• CABG 75 yr. or older OPCAB
• CCAB

• 205
• 132 (64.3)
• 73 (35.7)

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OPCAB vs. CCAB in the ElderlyPreoperative
Characteristics

• OPCAB n132 CCAB n73 p
  value
  
• Age 80
  78 NS
  
• EF 47
  47 NS
  
• Diabetes 38 41
  NS
  
• Hypertension 82 86
  NS
  
• Hyperlipidemia 57 56
  NS
  
• Smoker 51 48
  NS

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OPCAB vs. CCAB in the Elderly Preoperative
Characteristics

• OPCAB n132 CCAB n73 p
  value
  
• ARF/CRF 22 (17) 9
  (12) NS
  
• CVA 15 (11) 4
  (6) NS
  
• A-fib 16 (12)
  11 (15) NS
  
• Unstable
• Angina 63 (48) 33
  (45) NS
  
• Recent MI 47 (37) 21
  (29) NS
  
• Redo 9 (7)
  16 (22) 0.001
  
• Preo IABP 18 (14) 9
  (12) NS

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OPCAB vs. CCAB in the ElderlyIntraoperative
Characteristics

• OPCAB n132 CCAB n73
  p value
  
• Mean Distals 3
  4 NS
  
• LIMA 83 (62.9)
  45 (61.6) NS
  
• RIMA 0
  4 (5.5) 0.006
  
• Radial 4 (3)
  8 (10.9) 0.02
  
• Vein Grafts 122 (92.1) 69
  (94.5) NS
  
• GEPA 1 (0.8)
  0 NS
  
• Less than or equal
• 2 grafts 31 (23.5) 4
  (5.4) 0.0001

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OPCAB vs. CCAB in the ElderlyOperative Mortality

• OPCAB n132
  CCAB n73 p value
  
• Mortality (30 day) 8 (6)
  6 (8) NS
  
• Predicted 10
  8
  
• Cardiac 1 (0.8)
  4 (6) 0.03
  
• Sepsis, Multiple
• Organ Failure 2 (1.5)
  1 (1.4) NS
  
• Respiratory
• Failure 4 (3)
  1 (1.4) NS
  
• Unknown 1 (0.8)
  0 NS
  

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OPCAB vs. CCAB in the ElderlyPost-op Morbidity

• OPCAB n132 CCAB n73 p
  value
  
• Major Complications
• Prolonged
• Intubation 24 9 (6.8) 11
  (15) NS
  
• Bleeding/
• Tamponade 7 (5)
  6 (8) NS
  
• Infection 2 (1.5)
  4 (5.5) NS
  
• New CVA 0
  3 (4.1) 0.01
  

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OPCAB vs. CCAB in the ElderlyPost-op Morbidity

• OPCAB n132 CCAB n73
  p value
  
• Other
• Complications
• New onset A-fib 16 (12.1) 18
  (24.7) 0.02
  
• Renal Failure 4 (3)
  9 (12.3) 0.008

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OPCAB vs. CCAB in the ElderlyPost-op Morbidity

• OPCAB n132 CCAB n73 p
  value
  
• Hemodynamic
• Support
• Vasopressors 24 12 (9.1) 16
  (21.9) 0.0104
  
• IABP 24 11 (8.3) 10
  (13.7) NS

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OPCAB vs. CCAB in the Elderly

• OPCAB n132 CCAB n73
  p value
  
• Transfusions
• Patients PRBC 125 (95) 72 (99)
  0.1638
  
• Total mean units 4
  7 0.0008
  
• Patients FFP 29 (22) 40
  (54.8) 0.000002
  
• Patients CYRO 13 (9.8) 15
  (20.5) 0.0327
  
• Patients Platelets 20 (15) 30
  (41) 0.00003

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OPCAB vs. CCAB in the ElderlyPost-op Morbidity

• OPCAB n132 CCAB n73
  p value
  
• Ventilator
• Extubated in OR 4 (3) 0
  NS
  
• 0.5 to 2 hours
• vent time 10 (7.6)
  2 (2.7) NS
  
• 24 hours 9 (6.8)
  11 (15.1) NS

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OPCAB vs. CCAB in the Elderly

• OPCAB n132 CCAB n73
  p value
  
• Mean LOS Hospital 7
  9 0.04
  
• Mean LOS ICU 3
  5 0.04

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OPCAB vs. CCAB in the Elderly

• 
  OPCAB CCAB
  
• Follow-up
  82 84
  
• Months (mean)
  33 29
  
• Late death
  16 (13) 6 (9.5)
  
• Improved quality of life 89
  91
  
• Residence-home or relative 95
  95
  
• Freedom from stroke, MI
• reintervention or death 25
  (24.5) 10(18.9)

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Conclusions

• Both OPCAB and CCAB are safe for elderly patients
  with lower than predicted mortality.
  
• Cardiac mortality was lower in OPCAB compared
  with CCAB.

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Conclusions

• Morbidity was lower for OPCAB
• New CVA
• New onset A-fib
• Renal failure
• Vasopressors 24 hr.
• Total blood product usage
• LOS ICU
• LOS hospital

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Conclusions

• 4. Our practice is to perform OPCAB on the
  majority of our elderly patients.