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J Thorac Cardiovasc Surg 2006;132:1226-1228
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Papworth Hospital, Cambridge, United Kingdom.
Received for publication June 14, 2006; accepted for publication June 28, 2006. * Address for reprints: Samer A. N. Nashef, FRCS, Consultant Cardiothoracic Surgeon, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK. (Email: Sam.Nashef{at}papworth.nhs.uk).
An average early mortality in low, single-percentage figures is now the norm in most cardiac surgical centers. Nevertheless, the spectrum of risk for individual patients is wide, and there are times when surgeons are called on to perform operations in patients in a precarious situation, for example, with associated comorbidity, an inherent risk of complex surgery, or, commonly, both. Risk-assessment models can help identify high-risk patients who require cardiac surgery. Some studies report good results for patients who have a protracted stay in the intensive care unit because of perioperative problems, but the majority of such patients have an acceptable risk to start with. Little is known about the long-term outcomes of drastic-risk cardiac surgery. Are such high-risk, resource-intensive interventions worthwhile?
We sought to determine late survival and quality of life (QOL) in patients undergoing cardiac surgery with a predicted risk of death greater than 50% at the time of operation. Estimated mortality was calculated using the logistic EuroSCORE because of its good track record for accurately identifying high-risk cases.1
Ethical approval for the study was sought and obtained. Of 9971 consecutive patients who underwent cardiac surgery at Papworth Hospital between 1998 and 2004, 142 (1.4%) had a logistic EuroSCORE greater than 50. The control group comprised 142 patients matched by age, gender, and time and type of operation. Late survival was ascertained through the National Health Service tracking service to November 2005, estimated using Kaplan-Meier methods and compared using the log-rank test.
Patients alive at follow-up and their controls were posted a Short-Form 36 Health Survey questionnaire to assess QOL in 8 dimensions (Figure 1). Scores range from 0 (worst) to 100 (best). Mean scores were compared using paired Student t tests.
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In the high-risk patients, hospital mortality was 38% (95% confidence interval 30%-46%; predicted 65%, P < .001). For patients discharged from the hospital, survival to 12 months was 86%, compared with 93% for controls (P = .07).
Sixty-four high-risk patients were alive at a mean follow-up of 4 years (range 1.5-6.8 years), among whom there were 46 paired cases and controls who returned the health questionnaire. Their characteristics are shown in Table 1. High-risk cases stayed longer in the intensive care unit and the hospital. The control group tended toward higher QOL scores in most dimensions, but none of the differences were statistically significant (Figure 1).
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This study examines the long-term outcomes of patients who were more likely to die than survive at the time of proposed cardiac surgery. Our main finding is that the QOL attained by survivors of the highest risk operations is comparable to that of other patients of the same age undergoing similar major heart surgery. Although matched by age, gender, and operation type, the two groups are necessarily different in predicted outcome because of the study design. Among other cardiac risk factors and noncardiac comorbidities, the high-risk group had significantly worse left ventricular function and more nonelective operations (80% vs 28%) than the controls.
The study has two limitations. The first is incomplete follow-up, with 72% returning completed questionnaires. Although this is generally an acceptable rate of return, it is possible that nonresponders are different from responders, and this may have biased the results. Second, surgeons and cardiologists may exercise judicious patient selection over and above the information provided by the risk model, so our conclusion may not necessarily apply to all drastic-risk patients.
Although the EuroSCORE itself has been shown to be the most important single predictor of early outcome and resource use after heart surgery,2 we showed that it is possible to outperform the logistic EuroSCORE by an important margin. We believe that cardiac surgical centers should measure their own performance in the highest risk subsets before performing cardiac surgery in high-risk patients.
Our results suggest that despite substantial predicted and actual early mortality, long-term survival and good QOL make cardiac surgery worthwhile in selected high-risk patients. Predicted mortality greater than 50% alone should not be an absolute contraindication to surgery.
Acknowledgments
We thank Angela O'Farrell for her support with the Short-Form 36 Health Survey.
References
This article has been cited by other articles:
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  D. H. Freed, A. J. Drain, J. Kitcat, M. T. Jones, and S. A.M. Nashef Death in low-risk cardiac surgery: the failure to achieve a satisfactory cardiac outcome (FIASCO) study Interactive CardioVascular and Thoracic Surgery, October 1, 2009; 9(4): 623 - 625. [Abstract] [Full Text] [PDF]
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 D. S. Likosky, L. J. Dacey, Y. R. Baribeau, B. J. Leavitt, R. Clough, R. P. Cochran, R. Quinn, D. A. Sisto, D. C. Charlesworth, D. J. Malenka, et al. Long-Term Survival of the Very Elderly Undergoing Coronary Artery Bypass Grafting Ann. Thorac. Surg., April 1, 2008; 85(4): 1233 - 1237. [Abstract] [Full Text] [PDF]
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S. A.M. Nashef Invited commentary Ann. Thorac. Surg., December 1, 2006; 82(6): 2088 - 2088. [Full Text] [PDF]
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