[八旬老人的心脏手术：一项为期六年的多维干预随访研究]

Speziale Giuseppe, Bonifazi Raffaele, Cavagnaro Paolo, Di Gregorio Omar, Pasquè Achille, Zanardi Sabrina, Ravera Gianbattista, Marini Maurizio, Coppola Roberto

Dipartimento di Chirurgia Cardiovascolare, Villa Azzurra Hospital, Rapallo, GE.

Ital Heart J Suppl. 2005 Oct;6(10):674-81.

BACKGROUND

Elderly subjects frequently experience a decline in function following hospitalization and surgery. Specific changes in the provision of acute hospital care can improve the ability of acutely ill older patients to perform activities of daily living at the time of discharge and the quality of life. The aim of this study was to investigate outcomes of older (age > or =80 years) cardiac surgery patients managed with multicomponent intervention.

METHODS

Between 1998 and 2004, we studied records of 193 octogenarian patients who underwent cardiac surgery and were treated with a multicomponent intervention that included: specially designed environment, patient-centered care, planning for patient discharge at home, and an interdisciplinary approach that incorporates in- and out-of-hospital health professionals.

RESULTS

Mean follow-up was 26.4 months and 100% complete. Mean age of patients was 82.3 +/- 2 years. Eighty-nine patients had myocardial revascularization (CABG), 40 aortic valve replacement (AVR), 34 AVR + CABG, 8 mitral valve replacement (MVR), 11 MVR + CABG and 11 other interventions. Rates of hospital death, major complications and prolonged stay (> 14 days) were as follows: CABG 4 (4.4%), 3 (3.3%), 6 (6.4%); AVR 1 (2.5%), 3 (7.5%), 2 (5%); AVR + CABG 1 (2.9%), 2 (5.8%), 4 (11.7%); MVR 0 (0%), 0 (0%), 1 (12.5%); MVR + CABG 2 (18.1%), 2 (18.1%), 3 (27.2%). Multivariate predictors of hospital deaths were NYHA class, cardiopulmonary bypass and cross-clamping time, urgent procedure and ischemic mitral valve procedures. The actuarial 6-year survival was as follows: CABG 91%,AVR 92.5%, AVR + CABG 88.2%, MVR + CABG 81.8%. Total survival rate, free from rehospitalization and redo surgery, was 89.7, 69.8 and 99% respectively. Multivariate predictors of late death were urgent procedure and ischemic mitral valve procedures. At follow-up NYHA classification had improved a median of two classes. Global patients' satisfaction was excellent in 76.7% of survivors; 95.7% were autonomous, 40.5% live at home, 64% had a light-moderate physical activity, and 70% of patients had good social relationships and quality of life. Medical therapy was reduced in 29.3% and level of anxiety improved in 76%.

CONCLUSIONS

An interdisciplinary approach and multicomponent intervention with an appropriate postoperative care, provides beneficial effects on outcome in geriatric cardiac surgery patients.

背景

老年患者在住院和手术后功能常出现下降。急性医院护理提供方式的特定改变可提高急性病老年患者出院时进行日常生活活动的能力及生活质量。本研究旨在调查采用多组分干预管理的老年（年龄≥80岁）心脏手术患者的结局。

方法

1998年至2004年期间，我们研究了193例接受心脏手术并接受多组分干预的八旬患者的记录，该干预包括：专门设计的环境、以患者为中心的护理、在家中出院计划以及纳入院内和院外卫生专业人员的跨学科方法。

结果

平均随访时间为26.4个月，随访完整率为100%。患者平均年龄为82.3±2岁。89例患者进行了心肌血运重建（冠状动脉旁路移植术[CABG]），40例进行了主动脉瓣置换术（AVR），34例进行了AVR + CABG，8例进行了二尖瓣置换术（MVR），11例进行了MVR + CABG，11例进行了其他干预。医院死亡率、主要并发症发生率和延长住院时间（>14天）如下：CABG组分别为4例（4.4%）、3例（3.3%）、6例（6.4%）；AVR组分别为1例（2.5%）、3例（7.5%）、2例（5%）；AVR + CABG组分别为1例（2.9%）、2例（5.8%）、4例（11.7%）；MVR组分别为0例（0%）、0例（0%）、1例（12.5%）；MVR + CABG组分别为2例（18.1%）、2例（18.1%）、3例（27.2%）。医院死亡的多因素预测因素为纽约心脏协会（NYHA）分级、体外循环和主动脉阻断时间、急诊手术以及缺血性二尖瓣手术。6年精算生存率如下：CABG组为91%，AVR组为92.5%，AVR + CABG组为88.2%，MVR + CABG组为81.8%。无再次住院和再次手术的总生存率分别为89.7%、69.8%和99%。晚期死亡的多因素预测因素为急诊手术和缺血性二尖瓣手术。随访时NYHA分级中位数改善了两级。76.7%的幸存者对整体患者满意度很高；95.7%的患者能够自理，40.5%的患者居家生活，64%的患者有轻度至中度体力活动，70%的患者有良好的社会关系和生活质量。29.3%的患者药物治疗减少，76%的患者焦虑水平改善。