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Communications to the Editor |

Elderly Patients as Candidates for Bypass? FREE TO VIEW

Itzhak Shapira, MD, FCCP; Aharon Isakov, MD; Israel Heller, MD; Marcel Topilsky, MD, FCCP
Author and Funding Information

Tel-Aviv Sourasky Medical Center Tel-Aviv, Israel

Correspondence to: Itzhak Shapira, MD, FCCP, Deputy Director General, Tel Aviv Sourasky Medical Center, 6 Weizman St, Tel Aviv 64239, Israel; e-mail: shapiraiz@tasmc.health.gov.il



Chest. 2001;119(1):318-319. doi:10.1378/chest.119.1.318
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Published online

To the Editor:

We wish to compliment Hirose and colleagues (May 2000)1 on their excellent retrospective analysis of patients ≥ 75 years of age who underwent coronary artery bypass grafting (CABG). Our group has also been taking a second look at the policy of excluding the elderly population as unfit for the procedure, and our results support theirs with regard to risk factors and long-term survival.

In addition to the usual parameters for comparing surgical and survival outcome between younger and elderly patients, we correlated the results of equilibrium radionuclide angiography (ERN), using a technique described elsewhere,2 performed soon (4 to 8 months) after CABG over 6 years of follow-up in 87 consecutive patients ≥ 65 years old. Thirteen study patients (15%) died during follow-up, 8 from cardiac death (29 to 54 months postoperatively). Resting and exercise left ventricular ejection fractions (LVEFs) were similar for those who suffered cardiac death and for the survivors, but the mean rest-to-peak exercise differences in LVEF were highly significant (− 4.4 ± 4% in the former vs 1.2 ± 4% in the latter; p = 0.001). Seven of the eight patients who suffered cardiac death had a ΔLVEF < 0; however, the predictive value for death in those with a ΔLVEF < 0 was 7 of 35 patients (20%). In contrast, the predictive value for survival in patients with a ΔLVEF < 0 was 46 of 47 patients (98%). TheΔ LVEF had a significant independent prognostic value (p = 0.03); the larger the rest-to-peak exercise difference, the better the prognosis. The survivors had 15 myocardial infarctions and 5 revascularization interventions. There was an independent positive correlation of LVEF at rest and future nonsurgical cardiac events (p = 0.05); a similar association was found for ΔLVEF and surgical events (p = 0.01). As for all events, ΔLVEF and rest LVEF were both independent prognostic variables (p = 0.009 and p = 0.02, respectively). The multivariate analysis showed that the above difference in LVEF predicted future interventions with a power of p < 0.002.

Forty-four patients (51%) survived without a cardiac event and without cardiac surgery during follow-up. The most significant predictors for event-free survival in this subgroup were exercise heart rate, resting LVEF, and change and fractional change in LVEF during exercise.

In an editorial based on this and other studies, Yim and colleagues (May 2000)3 recommended that patients should not be turned down for surgical revascularization because of advanced age alone. We applaud this approach, which comes in the wake of valuable, novel contributions from a variety of disciplines, one of which is ERN. We demonstrated that ERN performed at an early postoperative interval in elderly CABG patients is prognostically useful and that it provides additional information to help guide the physician in consulting with and treating elderly patients after CABG.

References

Hirose, H, Amano, A, Yoshida, S, et al (2000) Coronary artery bypass in the elderly.Chest117,1262-1270. [CrossRef] [PubMed]
 
Shapira, I, Isakov, A, Yakirevich, V, et al Long-term results of coronary artery bypass surgery in patients with severely depressed left ventricular function.Chest1995;108,1546-1550. [CrossRef] [PubMed]
 
Yim, AP, Arifi, AA, Wan, S Coronary bypass grafting in the elderly: the challenge and the opportunity [editorial].Chest2000;117,1220-1221. [CrossRef] [PubMed]
 

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References

Hirose, H, Amano, A, Yoshida, S, et al (2000) Coronary artery bypass in the elderly.Chest117,1262-1270. [CrossRef] [PubMed]
 
Shapira, I, Isakov, A, Yakirevich, V, et al Long-term results of coronary artery bypass surgery in patients with severely depressed left ventricular function.Chest1995;108,1546-1550. [CrossRef] [PubMed]
 
Yim, AP, Arifi, AA, Wan, S Coronary bypass grafting in the elderly: the challenge and the opportunity [editorial].Chest2000;117,1220-1221. [CrossRef] [PubMed]
 
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