Kardiyak yetmezliği olan ileri yaş hastalarda en iyi tedavi yaklaşımı nedir? 6 yıllık deneyim

Amaç: Genel algı 80 yaş ve üzeri hastalarda, koroner bypass cerrahi (KBC) riskinin daha yüksek olduğu yönündedir. Bununla birlikte, KBC, perkütan koroner arter girişim ve tıbbi tedavinin ileri yaş hasta grubunda yaşam kalitesi üzerine etkileri kapsamlı bir şekilde değerlendirilmemiştir. Gereç ve Yöntemler: Çalışmamızda koroner anjiyografi yapılan 80 yaş ve üzeri 375 hastanın sağ-kalım süresi retrospektif olarak değerlendirildi. Sınırlı sağ-kalım üzerine bir tahmin modeli oluşturuldu. Bulgular: KAG verilerine göre, hastalar yedi grupta değerlendirildi: Grup 1, sonuçları normal olan hastalar; grup 2, lezyonlar için medikal tedavi alan hastalar; grup 3, PCI yapılan hastalar; grup 4, yalnızca sol ön inen arteri (LAD) veya koroner arterleriyle kombine olan hastalar; grup 5, herhangi bir müdahale için uygun bulunmayan kritik durumdaki hastalar; grup 6, KBC geçiren hastalar; grup 7, önerilen girişimleri reddeden hastalardır. İlk yıl sağ-kalım oranının en düşük Grup 5 ‘de ( % 76.1) olduğu tespit edilmiştir. 6 yıl sonra sağ-kalım oranının en yüksek grup 6 da olduğu görülmüştür (% 90.2). Yıllara göre yaşayan hasta oranlarına bakıldığında Grup 6 ile grup 2 ve grup 3 arasında (p=0.001, p = 0.004). Grup 3 ile grup 4 ve grup 7 arasında (p = 0.000) ve grup 7 ile grup 2 (p = 0.007) arasında ile anlamlı bir korelasyon bulundu. Sonuç : Bu çalışmada özellikle beklenen yaşam süresi kısa olan ileri yaş hastalarda, görsel anastomotik replasman ve tam vaskülarizasyonun cerrahi avantajı, PCI'den daha başarılı olmuştur.

Anahtar Kelimeler:

kardiyak cerrahi, koroner bypass, ileri yaş hastalar

What is the best medical approach in octogenarian patients with coronary artery disease? A 6-year experience

Aims: Best popular perception that coronary artery bypass grefting in octogenarians carries high risk related primarily to advanced age. Nevertheless, the effects of CABG, percutaneous coronary intervention , and medical treatment were not assessed on life adequately. Material and Methods: In the present study, survival duration of 375 octogenarian patients who underwent coronary angiography (CAG) in our clinic was evaluated retrospectively. Results: Patients were assigned and compare to seven groups as follows: group 1, patients with normal CAG results; group 2, patients with diffuse coronary narrowness who received medical treatment, group 3, patients who underwent PCI, group 4 was the subgroup of patients from group 3 who underwent PCI in the left anterior descending artery only or in combination with their coronary arteries; group 5, patients in critical condition who were unavailable for any intervention because of cardiac function, group 6, patients who underwent CABG; and group 7, patients who declined the recommended CABG and PCI. For each group, the first-year survival rates were respectively: 100%, 95%, 91.2%, 91.8%, 76.1%, 93.0%, 90.82%. After 6 years, the survival rates were respectively: 76.1%, 80.0%, 72.5%, 71.42%, 52.3%, 90.2%, 76.14%. Rates of patients living by years a significant correlation was revealed between group 6 and group 2 and group 3 (p=0.001, p = 0.004). Group 3 was found to have a significant correlation with Group 4 and Group 7 (p=.000). Group 7 was significantly correlated with groups 3 (p = 0.000), 4 (p = 0.000), and 2 (p = 0.007). Conclusion: Especially in octogenarians who had shortness of the expected survival, the surgical advantage of visual anastomotic replacement, and complete vascularization were successed more than PCI.

Keywords:

cardiac disease, coronary artery bypass grefting, octagenarian,

PDF

___

1. Shinmura K. Cardiac Senescence, Heart Failure, and Frailty: A Triangle in Elderly People. Keio J Med 2016; 65: 25–32
2. National Center for Health Statistics. Vital statistics of the United States, 1989: Vital Health Statistics, vol 2, Washington, DC: US Government Printing Office, 1992, 11.
3. National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1989; Vital Health Statistics, series 10. Washington, DC: US Government Printing Office, 1990, No176.
4. Johnson WM, Smith JM, Woods SE, Hendy MP, Hiratzka LF. Cardiac surgery in octogenarians: does age alone influence outcomes? Arch Surg 2005; 140:1089-93. doi:10.1001/archsurg.140.11.1089.
5. Peterson ED, Alexander KP, Malenka DJ et al; American Heart Association Chronic CAD Working Group. Multicenter experience in revascularization of very elderly patients. Am Heart J 2004; 148: 486-92.
6. Dakik HA, Hannoush H, Obeid MY. Coronary artery bypass surgery in octogenarians: outcomes in a tertiary referral university hospital in a developing country. Int J Cardiol 2003; 92: 253-6.
7. Amano A, Yoshida S, Takahashi A, Nagano N, Kohmoto T. Coronary artery bypass grafting in the elderly. Chest 2000; 117: 1262-70.
8. Huber CH, Goeber V, Berdat P, Carrel T, Eckstein F. Benefits of cardiac surgery in octogenarians- postoperative quality of life assessment. Eur J Cardiothorac Surg 2007; 31: 1099-105.
9. Zingone B, Gatti G, Rauber E, Tiziani P, Dreas L, Pappalardo A, Benussi B, Spina A. Early and Late Outcomes of Cardiac Surgery in Octogenarians. Ann Thorac Surg 2009; 87:71-8.
10. Alexander KP, Anstrom KJ, Muhlbaier LH et al. Outcomes of cardiac surgery patients>or=80 years: results from the National Cardiovascular Network. J Am Coll Cardiol 2000; 35: 731-8.
11. Dacey LJ, Likosky DS, Ryan TJ et al. for the Northern New England Cardiovascular Disease Study Group, Long term survival after surgery versus percutaneous intervention in Octogenarians with multi vessel disease. Ann Thorac Surg 2007; 84: 1904-11.
12. Craver JM, Puskas JD, Weintraub WW. 601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups. Ann Thorac Surg 1999; 67: 1104-10.
13. De Gregorio J, Kobaayashi Y, Albiero R. Coronary stenting in the elderly: short term outcome anf long term angiographic and clinical follow-up. J Am Coll Cardiol 1998; 32: 577-83.
14. Vander Salm TJ, Kip KE, Jones RH. What constitutes optimal surgical revascularization? Answers from the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol 2002; 39: 565- 72.
15. Dalrymple-Hay MJ, Alzetni A, Aboel Nazar. Cardiac surgery in the elderly. Eur J Cardiothorac Surg 1999; 15: 61-6.
16. Loop FD, Golding LR, Macmillan JP. Coronary artery surgery in women compared with men: analyses of risks and long term results. J Am Coll Cardiol 1983; 1: 383-90.
17. Eritsland J, Arnesen H, Fjeld NB. Risk factors for graft occlusion after coronary artery bypass grafting. Scand J Thorac Cardiovasc Surg 1995; 29: 63-9.
18. Morris RJ, Strong MD, Grunewald KE. Internal thoracic artery for coronary bypass grafting in octogenarians. Ann Thorac Surg 1996; 62: 16-22.
19. Barner HB. Arterial grafting: techniques and conduits. Ann Thorac Surg 1998; 66: 2-5.
20. Reardon MJ, Conklin LD, Reardon PR. Coronary artery bypass conduits:review of current status. J Cardiovasc Surg 1997; 38: 201-19.
21. Subramanian VA. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997; 63: 68-71.
22. Cooper GJ, Underwood MJ, Deverall PB. Arterial and venous conduits for coronary artery bypass: a current review. Eur J Cardiothorac Surg 1996; 10: 129-40.
23. Mack MJ, Osborne JA, Shennib H. Arterial graft patency in coronary bypass grafting: what do we really know? Ann Thorac Surg 1998; 66: 1055-9.
24. Williams DB, Carillo RG, Traad EA. Determinants of operative mortality in octogenarians undergoing coronary bypass. Ann Thorac Surg 1995; 60: 1038-43.
25. Brener SJ, Lytle BW, Casserly IP, Schneider JP, Topol EJ, Lauer MS. Propensity analyses of long term survival after surgical or percutaneous revascularization in patients with multi vessel coronary artery disease and high risk features. Circulation 2004; 109: 2209-5.