Postoperative complications of coronary artery bypass graft in elderly patients: reply of the letter to the editor

LETTER TO THE EDITOR

Postoperative complications of coronary artery bypass graft in elderly patients. Reply of the letter to the editor

Ronaldo Vegni^I; Gustavo Ferreira de Almeida^I; Fabricio Braga^I; Marcia Freitas^I; Luis Eduardo Drumond^I; Guilherme Penna^I; José Kezen^I; Gustavo Freitas Nobre^I; Marcelo Kalichsztein^I; André Miguel Japiassú^II

^IPhysicians from the Intensive Care Unit of Casa de Saúde São José, Rio de Janeiro (RJ), Brazil

^IIPhysician from the Intensive Care Unit of Casa de Saúde São José, Rio de Janeiro (RJ), Brazil and Institute for Clinical Research Evandro Chagas - FIOCRUZ, Rio de Janeiro (RJ), Brazil

Author for correspondence

We wish to thank Dr. Hélcio Griffhorn for his interest in our work.

We have shown that octogenarians present a longer stay, higher incidence of complications and higher mortality, with worse peri-operative severity of illness. However, nonelderly and sexagenarian patients had similar performance, disclosing increased life expectancy and quality in Brazilian population.⁽¹⁾ Septuagenarian were characterized by hybrid results, showing increased severity of disease, higher incidence of postoperative atrial fibrillation and reoperation, however ICU length of stay and mortality were similar to those of younger groups. Worse performance of elderly can result from need for urgent surgery, efforts to prolong treatment with drugs and coronary angioplasty procedures. Blood transfusion was more often used at preoperative of septuagenarians and octogenarians (critical levels of anemia with advanced age or greater use of blood products may significantly influence outcomes).^(2,3)

The study included only patients submitted to coronary artery bypass graft (CABG) as the main surgery although a significant number also had an indication for valve replacement, secondarily. As commented, mortality of CABG patients who needed valve replacement is higher (15.5%). There were 61 orovalvular surgeries during the study's period, with 6 deaths, but they were excluded because we wanted to specifically analyze a homogeneous group of CABG. Presence of aortic valve disease may increase surgical and extracorporeal circulation (ECC) duration, however there was no impact on the incidence of complications, perhaps due to exclusion of most orovalvular surgeries. Of the 343 cardiac surgeries in this time period, 11(3%) were performed without ECC. Duration of surgery and morbidity may be less frequent with this approach,⁽⁴⁾ but could increase heterogeneity of the study group. Decision of the operation technique always rested upon the surgical team before admission.

If the complications most often found in elderly (atrial fibrillation, left ventricle failure, significant thoracic bleeding, acute renal dysfunction and nosocomial sepsis) were added to high frequency of urgent surgeries and longer time of ECC, there are reasons for higher morbidity and mortality of elderly patients.

Finally, postoperative transient inflammatory reaction that comes together with ECC was analyzed in some studies. Cytokines, as macrophage migration inhibitor factor, interleukin 6 and monocyte chemoattractant protein, undergo a significant early increase after induction of anesthesia and return to baseline levels after 24 hours, and⁽⁵⁾ correlate with levels of organ dysfunctions. Researchers are looking for predictive biomarkers of postoperative morbidity, mainly in the elderly.

REFERENCES

• 1. Brasil. Instituto Brasileiro de Geografia e Estatística. Perfil dos idosos responsáveis pelos domicílios no Brasil 2000. Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/perfilidoso/perfidosos2000.pdf . Acesso em 25 de junho de 2008.
• 2. Wu WC, Schifftner TL, Henderson WG, Eaton CB, Poses RM, Uttley G, et al. Preoperative hematocrit levels and postoperative outcomes in older patients undergoing noncardiac surgery. JAMA. 2007;297(22):2481-8. Comment in: JAMA. 2007;297(22):2525-6. JAMA. 2007;298(13):1512-3; author reply 1513-4. JAMA. 2007;298(13):1512; author reply 1513-4. Nat Clin Pract Cardiovasc Med. 20085(1):20-1.
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• 4. Lima R, Diniz R, Césio A, Vasconcelos F, Gesteira M, Menezes A, et al. Revascularização miocárdica em pacientes octogenários: estudo retrospectivo e comparativo entre pacientes operados com e sem circulação extracorpórea. Rev Bras Cir Cardiovasc. 2005;20(1):8-13.
• 5. de Mendonça-Filho HT, Pereira KC, Fontes M, Vieira DA, de Mendonça ML, Campos LA, Castro-Faria-Neto HC. Circulating inflammatory mediators and organ dysfunction after cardiovascular surgery with cardiopulmonary bypass: a prospective observational study. Crit Care. 2006;10(2):R46. Comment in: Crit Care. 2006;10(2):138.

Publication Dates

• Publication in this collection
  04 May 2009
• Date of issue
  Mar 2009