Introduction: Recent times have witnessed almost half, or sometimes more cardiac surgical procedures are performed in patients above 75 years of age. Traditionally, the EuroSCORE II and STS risk scoring systems have been widely used across the globe. Extensive reviews have shown that EuroSCORE II probably overestimates the perioperative risk at lower score levels while the STS score tends to underestimate the risk.  Frailty is a broad term that encircles aspects of nutrition, lack of agility, inactivity, lack of strength and wasting; and is seen in 25-50% of elderly patients. It has been defined as a geriatric syndrome reflecting a state of reduced physiological reserve and increased vulnerability to poor resolution of homeostasis after a stressor event. Conversely, pre-frailty, which is potentially reversible, is associated with higher risk of older adults developing cardiovascular disease.  Frailty assessment includes a variety of physical and cognitive tests, functional assessments and evaluating nutritional status. Literature has highlighted what is referred to as the ‘obesity paradox’, meaning obese patients with heart failure fair better than leaner patients, possibly because they have more metabolic reserve and also because weight loss in itself is a risk factor for frailty.  Patient Selection: To comprehensively assess a patient, factors that describe the biological status of the patient should be incorporated. There are various methods of assessment and modified Fried criteria or comprehensive assessment of frailty are a couple of systems commonly used.  Conclusion: Systematic reviews have shown that frail patients have higher chance of mortality, major adverse cardiac and cerebrovascular events and functional decline after cardiac surgery. A holistic assessment not only categorises patients into the apt risk category and hence match goals and treatments; but also, will pick up patients with pre-frailty who will benefit from multidisciplinary intervention and be better prepared for the intervention. 

1. TREATING THE ELDERLY
& HIGH RISK:
Patient selection &
Functional outcomes
A Hardikar
Head, CTSU, Royal Hobart Hospital

2. DISCLOSURES
 There are no financial / other disclosures

4. Aims for the afternoon
 Case scenario
 What is the proportion of Elderly and / or high risk
patients that are currently treated by us?
 What are the current selection criteria / risk assessment
systems? Are they doing their job?
 What are the current functional outcomes? Room for
improvement? At what cost?
 RHH outcomes
 conclusion

5. Case Scenario
 83 year old lady. 48 kg. 154 cm.
 Previous CABG 11 years ago. Patent LIMA and radial grafts.
Occluded vein to the OM. Not a good target anymore.
 Class III NYHA symptoms.
 Severe aortic stenosis
 eGFR 34. Creatinine: 160.
 Significant calcification in aortic root, 36 mm widest aorta
 History of TIA, no obvious cerebrovascular disease
 Cognitive impairment, mini-mental score 24/30.

6. What proportion of our patients
are elderly / frail / high risk?
 Studies on either side of the continent and also
Australasia have convincingly showed that we are
operating on older and sicker patients.
 Elderly definition: Variable: 70 or 75. Octagenarians
 Frailty definition: Nutrition, Agility, inactivity, weakness,
wasting. 25-50% of elderly patients
 Concept of Pre-frailty: Potentially reversible. > CVD risk
 Obesity paradox: Obese patients with HF fair better

7. Current assessment systems
 Risk assessment:
 Euroscore logistic [2]
 STS-PROM and PROMM
 Parsonnet
 AuScore
 ACEF score
 Frailty assessment:
 Fried score
 Comprehensive assessment of frailty
 5 M gait speed test
 CHA frailty
 MSSA subdimensions
 Disability assessment:
 Nagi items
 ADL
 IADL

9. Circulation Qual Cardiovasc outcomes: 2012 Afilalo et al
 152 patients in a multi centre north American trial
 5 Cardiac surgery risk scores
 3 disability scores
 4 Frailty scores
 Best measure of Frailty: 5 M walk > 6 Sec
 Best measure of disability: Nagi scale > 3
 Risk assessment scores: STS-prom / Parsonnet best.
 However, combination was best predictor of M and M

10. Scoring systems for outcome
prediction post Cardiac Surgery:
ICU perspective
Am J Crit Care 2015 July:24(4)327-34
 150 consecutive patients: Following tested
 Euroscore II
 CASUS: Cardiac Surgery score
 APACHE II [acute physiology & chronic health evaluation]
 SAPS II [simplified acute physiology score]
 SOFA [sequential organ failure assessment]
 30 d mortality was 6%
 CASUS best predicted outcomes
 Euroscore II best predicted 30 day mortality
 SOFA best predicted morbidity, ventilation times, length of
stay in ICU etc

11. What is known
 Conventional scores less
accurate in risk assessment in
the elderly
 Elderly often have heavy
burden of co-morbidity,
disability and perceived frailty
 Multiple scales exist, indicating
none is ideal.
 Optimal combination remains
unknown

14. Comprehensive
assessment
of Frailty
Fried Criteria:
• Unintentional Wt loss
• Weak grip strength
• Self reported
exhaustion
• Gait speed
• Low activity
Laboratory part:
• Albumin
• Creatinine
• BNP
• FEV1
Physical performance:
 Standing balance
 Turn around 360 degree
 Get up and sit down
from a chair
 Pick up a dropped pen
 Put on and remove a
jacket

15. Current Functional outcomes
 Cardio-respiratory: NYHA status
 Neurological-psychological: Scoring systems
 Musculo-skeletal / functional: ADL / IDL
 Renal - Metabolic
 Productivity scale active life years

16. Neurological

17. Partner 1 trial: 5 year outcomes

18. RHH Data Apr2008- Apr2016
2,627 patients
underwent cardiac surgery
279 patients (10.6%)
were ≥ 80 years

19. RHH: Early data
 Extubation:
 129 patients (46%) within 12h
 120 patients (43%) between 12h and 24h
 14 patients (5%) were ventilated >72h
 ICU Discharge:
 139 patients (50%) within 24 hours
 70 patients (25%) between 24h to 48h
 43 patients (15%) required ICU admission >72h
 Isolated CABG & Isolated AVR
 Median length of ventilation: 12h
 Median length of ICU admission: 24h

20. Multivariate Analysis
Respiratory
disease
(OR: 120)*
New
renal
failure
(OR:
33)*
Return to
ICU (OR:
54)*
* P < 0.05
Early mortality

21. Survival Data
Kaplan-Meier analysis estimated the mean survival
of 6.6 years (95%CI: 6.3-7.0 years)
1-year 3-year 5-year 8-year
Survival 93% 84% 72% 59%

22. Conclusions:
 Early mortality: 2.9%
 Stroke: 1.8%
 Discharge from ICU within 48h: 75%
 Direct discharge home: 47%
 Median hospital stay: 8 days
 5-year survival: 72%
 23% Nursing homes
 74% NYHA class I or II

23. Conclusion:
 Multidisciplinary assessment is a must
 Respiratory and Neuro-cognitive assessments are
probably most underrated
 Comprehensive assessment of frailty, disability and co-
morbidity is better than only risk scores
 Individualised patient care to optimize the results

24. THANK YOU