1. G. Rainey Williams Symposium September 30, 2005 CABG in the Elderly Patient: On or Off pump? A Single Center Experience R. Nathan Grantham, M.D.

2. WILL DRUG-ELUTING STENTS REPLACE CORONARY ARTERY BYPASS SURGERY? Ross M. Reul, M.D. (Tex Heart Inst J 2005;32:323-30)

3. Cardiac Surgery in Nonagenarians and Centenarians Bridges et al, J Am Coll Surg 197, September 2003 347-357

4. Cardiac Surgery in Elderly Patients What do we know? 1.25-40% of elderly patients have symptomatic CAD 2.Currently (2002) a million octogenarians. Estimated 2050 – 38 million octogenarians 3.CABG can safely be performed with acceptable mortality/morbidity. 4.Mortality/Morbidity is higher in elderly than younger patients. 5.Preoperative co-morbid conditions predispose the elderly to post-surgical mortality/morbidity but benefits may be greatest in this high risk group.

6. Cardiovascular Surgery Imperatives 1.Continue present trend for improved results in higher acuity patients. 2.Pursue less invasive procedures with lower morbidity. 3.Evaluate results in our own practice against benchmark data (STS). 4.Evidence based practice. 5.Cost effective, efficient practice with careful quality monitoring.

7. GOLD STANDARD for Direct Myocardial Revascularization Cardiopulmonary bypass Cardioplegic arrest

8. Morbidity from Cardiopulmonary Bypass Neurocognitive dysfunction/CVA Renal impairment Pulmonary complications Coagulopathy SIRS (Systemic Inflammatory Response Syndrome)

9. Possible Benefits of Off-Pump Coronary Bypass Less cognitive dysfunction/CVA Less renal impairment Less systemic effects Less pulmonary dysfunction

10. Possible Benefits of Off-Pump Coronary Bypass Better myocardial protection Improved mortality in severely impaired LV function Less blood loss/transfusion Economic advantage

11. Concerns with OPCAB Increased incidence of ascending aortic dissection/injury Early and late graft patency Hypercoagulopathy/procoagulant effect

12. OPCAB vs. CCAB in the Elderly 6/1/99 - 1/31/05 Comanche County Memorial Hospital CABG OPCAB CCAB 1076 594 (55.2%) 482 (44.8%)

13. OPCAB vs. CCAB in the Elderly CABG 75 yr. or older OPCAB CCAB 205 132 (64.3%) 73 (35.7%)

14. OPCAB vs. CCAB in the Elderly Preoperative Characteristics OPCAB n=132 CCAB n=73 p value Age 80 78 NS EF 47% 47% NS Diabetes 38% 41% NS Hypertension 82% 86% NS Hyperlipidemia 57% 56% NS Smoker 51% 48 % NS

15. OPCAB n=132 CCAB n=73 p value ARF/CRF 22 (17%) 9 (12%) NS CVA 15 (11%) 4 (6%) NS A-fib 16 (12%) 11 (15%) NS Unstable Angina 63 (48%) 33 (45%) NS Recent MI 47 (37%) 21 (29%) NS Redo 9 (7%) 16 (22%) 0.001* Preo IABP 18 (14%) 9 (12%) NS OPCAB vs. CCAB in the Elderly Preoperative Characteristics

16. OPCAB vs. CCAB in the Elderly Intraoperative Characteristics OPCAB n=132 CCAB n=73 p value Mean # Distals 3 4 NS LIMA 83 (62.9%) 45 (61.6%) NS RIMA 0 4 (5.5%) 0.006* Radial 4 (3%) 8 (10.9%) 0.02* Vein Grafts 122 (92.1%) 69 (94.5%) NS GEPA 1 (0.8%) 0 NS Less than or equal 2 grafts 31 (23.5%) 4 (5.4%) 0.0001*

17. OPCAB vs. CCAB in the Elderly Operative Mortality OPCAB n=132 CCAB n=73 p value Mortality (30 day) 8 (6%) 6 (8%) NS Predicted 10% 8% Cardiac 1 (0.8%) 4 (6%) 0.03* Sepsis, Multiple Organ Failure 2 (1.5%) 1 (1.4%) NS Respiratory Failure 4 (3%) 1 (1.4%) NS Unknown 1 (0.8%) 0 NS

18. OPCAB vs. CCAB in the Elderly Post-op Morbidity OPCAB n=132 CCAB n=73 p value Major Complications Prolonged Intubation >24 9 (6.8%) 11 (15%) NS Bleeding/ Tamponade 7 (5%) 6 (8%) NS Infection 2 (1.5%) 4 (5.5%) NS New CVA 0 3 (4.1%) 0.01*

19. OPCAB vs. CCAB in the Elderly Post-op Morbidity OPCAB n=132 CCAB n=73 p value Other Complications New onset A-fib 16 (12.1%) 18 (24.7%) 0.02* Renal Failure 4 (3%) 9 (12.3%) 0.008*

20. OPCAB vs. CCAB in the Elderly Post-op Morbidity OPCAB n=132 CCAB n=73 p value Hemodynamic Support Vasopressors >24 12 (9.1%) 16 (21.9%) 0.0104* IABP > 24 11 (8.3%) 10 (13.7%) NS

21. OPCAB vs. CCAB in the Elderly OPCAB n=132 CCAB n=73 p value Transfusions % Patients PRBC 125 (95%) 72 (99%) 0.1638 Total mean units 4 7 0.0008* % Patients FFP 29 (22%) 40 (54.8%) 0.000002* % Patients CYRO 13 (9.8%) 15 (20.5%) 0.0327* % Patients Platelets 20 (15%) 30 (41%) 0.00003*

22. OPCAB vs. CCAB in the Elderly Post-op Morbidity OPCAB n=132 CCAB n=73 p value Ventilator Extubated in OR 4 (3%) 0 NS 0.5 to 2 hours vent time 10 (7.6%) 2 (2.7%) NS > 24 hours 9 (6.8%) 11 (15.1%) NS

23. OPCAB vs. CCAB in the Elderly OPCAB n=132 CCAB n=73 p value Mean LOS Hospital 7 9 0.04* Mean LOS ICU 3 5 0.04*

24. OPCAB vs. CCAB in the Elderly OPCAB CCAB Follow-up 82% 84% Months (mean) 33 29 Late death 16 (13%) 6 (9.5%) Improved quality of life 89% 91% Residence-home or relative 95% 95% Freedom from stroke, MI reintervention or death 25 (24.5%) 10(18.9%)

25. Conclusions 1.Both OPCAB and CCAB are safe for elderly patients with lower than predicted mortality. 2.Cardiac mortality was lower in OPCAB compared with CCAB.

26. Conclusions 3.Morbidity was lower for OPCAB 1.New CVA 2.New onset A-fib 3.Renal failure 4.Vasopressors > 24 hr. 5.Total blood product usage 6.LOS ICU 7.LOS hospital

27. Conclusions 4. Our practice is to perform OPCAB on the majority of our elderly patients.