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Editor,—We read with interest the manuscript by Zaidi and coworkers who reported their experience on 575 patients aged 70 years and older, in whom various cardiac surgical procedures were performed.1 Their study, along with many others published in the literature in recent years,2-4 shows that the role of cardiac surgery in the elderly, and particularly coronary artery revascularisation, is still evolving. Despite refinements in the perioperative management of cardiac surgical patients, valve surgery as well as coronary artery revascularisation in the elderly continue to be associated with operative risks considerably greater than those observed in the younger population.2-4 In addition, older patients are at higher risk for developing devastating complications such as stroke, which often lead to long term disability. In this regard, Hogue et al in a recent review of 2972 patients aged 65 years and older subjected to a variety of cardiac operations, reported that although age was not an independent risk factor for perioperative stroke, other significant independent factors (such as previous neurological events, carotid artery stenosis, aortic atherosclerosis, and diabetes) were more frequently encountered in older patients.5 Based on these consideration, arguments have been made as to whether these therapeutic modalities should be offered to elderly high risk patients who, as a result of their advanced age and comorbid conditions, invariably face reduced life expectancies.
Of the 575 elderly patients included in Zaidi et al's series, 334 underwent isolated coronary artery bypass grafting (CABG). Importantly, the perioperative outcomes noted in these patients compare favourably with, and are actually lower than, those reported in the literature. In fact, they reported a 30 day mortality rate of 3.9% in patients who received isolated CABG. Accordingly, the incidence of postoperative neurological events in CABG patients was remarkably low (1.8%), as was the incidence of other complications, such as renal failure, reoperation, myocardial infarction, and low output syndrome requiring an intra-aortic balloon pump. The proportion of redo operations reported was 7.3% in the two groups combined (valve patients and CABG patients).
We have recently reviewed our experience of coronary revascularisation in more than 450 patients aged 70 years and older, in whom the operation was conducted without using cardiopulmonary bypass (“off pump”). In recent years, advances in techniques of cardiac elevation in combination with adequate exposure of all target vessels and mechanical stabilisation, have made coronary revascularisation on the beating heart safe and effective. Importantly, more than 22% of the patients were octogenarians. Our analysis revealed a 30 day mortality rate of 4.8% (risk adjusted < 2%), along with an overall rate of postoperative complications of 12%, including a stroke rate of 2.1%. None of the patients in the octogenarian subgroup suffered postoperative neurological events. In our study, however, these figures were obtained in the face of a substantial proportion of redo operations (28% of cases), in combination with a 47% rate of urgent and emergent procedures, and a 31% incidence of preoperative cerebrovascular disease. Based on these results, in agreement with Zaidi and colleagues, we believe that elderly patients with surgically correctable, symptomatic coronary occlusive disease should not be denied surgical intervention based solely on their age. Our preliminary data suggest that myocardial revascularisation without using cardiopulmonary bypass may offer these patients an advantage in terms of perioperative outcomes, especially in the presence of meaningful perioperative risk factors, such as those associated with redo operations. Finally, avoiding extracorporeal circulation seems to provide additional benefit in lowering the rate of postoperative stroke, which remains one of the most debilitating sequelae following coronary revascularisation in the elderly.