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Internal thoracic artery grafting in the elderly patient undergoing coronary artery bypass grafting: room for process
T Bruce Ferguson1, Laura P Coombs, Eric D Peterson
1Surgery and Physiology, LSU Health Sciences Center, New Orleans, LA 70112-2822, USA. tfergu@lsuhsc.edu
Insights
Internal thoracic artery grafting in elderly patients (≥75 years) undergoing coronary artery bypass grafting significantly reduces operative mortality. This survival benefit is consistent with findings in younger patients, suggesting underuse in the elderly.
Area of Science:
- Cardiovascular Surgery
- Geriatric Medicine
- Health Services Research
Background:
- Internal thoracic artery (ITA) grafting offers clear benefits in younger patients undergoing coronary artery bypass grafting (CABG).
- The use of ITA grafting in elderly patients (≥75 years) is debated due to higher surgical risks and shorter life expectancy.
- This study investigates ITA graft utilization, complication risks, and operative mortality in elderly CABG patients.
Purpose of the Study:
- To examine the use, complication risks, and 30-day operative mortality associated with ITA grafting in patients aged 75 years and older.
- To determine if the survival benefits of ITA grafting observed in younger populations extend to elderly patients.
- To identify potential areas for quality improvement in the application of ITA grafting for elderly individuals.
Main Methods:
- Analysis of the Society of Thoracic Surgeons National Cardiac Database (1996-1999) including 99,942 patients aged ≥75 years undergoing primary, non-emergency-salvage CABG.
- Utilized risk adjustment for 28 baseline factors and site, alongside treatment propensity score analysis.
- Compared ITA graft use and its impact on operative mortality and major complications in the elderly cohort.
Main Results:
- ITA graft utilization was lower in elderly patients (77.4% for ages 75-84) compared to younger patients (93.5% for ages ≤55).
- ITA use was strongly associated with decreased operative mortality in the elderly (unadjusted 6.20% vs. 4.05%, P <.0001).
- This mortality benefit persisted after adjusting for baseline risk factors and provider effects (adjusted OR, 0.85; 95% CI, 0.79-0.91).
Conclusions:
- Internal thoracic artery grafting provides an acute survival benefit for elderly patients undergoing CABG.
- The observed survival benefit in the elderly is comparable to that in younger patients.
- ITA grafting appears to be underutilized in elderly CABG patients, representing a significant opportunity for quality improvement.
Objective:
The acute and long-term benefits of internal thoracic artery grafting are clear in younger patients undergoing coronary artery bypass grafting. The elderly, however, face higher surgical risks and have shorter life expectancy, and thus the use of internal thoracic artery grafting in this age group has been debated. This study examined the use, complication risks, and operative (30-day) mortality associated with internal thoracic artery grafting in patients 75 years of age and older.
Methods:
Between 1996 and 1999, 522,656 patients in the Society of Thoracic Surgeons National Cardiac Database underwent primary, nonemergency-salvage coronary artery bypass grafting; of these, 99,942 were 75 years of age or older. The influence of internal thoracic artery use on operative mortality and 5 major complications in this elderly group was examined by means of (1) risk adjustment (adjusting for 28 baseline risk factors and site) and (2) a treatment propensity score analysis that compares patients with similar baseline likelihood for receiving an internal thoracic artery graft.
Results:
In the National Cardiac Database 77.4% of patients aged 75 to 84 years received an internal thoracic artery graft compared with 93.5% for those aged 55 years or less. In this elderly group use of the internal thoracic artery was strongly associated with decreased operative mortality (unadjusted mortality, 6.20% vs. 4.05%; P <.0001) that persisted after controlling for baseline risk and provider effects (adjusted odds ratio, 0.85; 95% confidence intervals, 0.79-0.91). This mortality benefit was seen among those with low-to-high baseline propensity for receiving an internal thoracic artery graft.
Conclusions:
Use of the internal thoracic artery in elderly patients undergoing coronary artery bypass grafting provides an acute survival benefit. This benefit is similar to that seen in younger patients and persists after adjusting for both patient and provider selection factors. The internal thoracic artery appears to be underused in elderly patients undergoing bypass grafting and is a potential area for quality improvement.
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