The Tribune, Chandigarh, India

Old hearts do well in surgery
Dr Harinder Singh Bedi

As a result of increasing longevity and a trend towards reducing the birth-rate in the middle class and higher segments, the elderly population is expected to account for an increasing fraction of the population during the next two decades in most industrialised countries. Since we do not have very exact demographic figures, we may learn from the figures of America. Life expectancy in the USA is 75.5 years. Octogenarians constitute about 3% of the American population. The average 80-year-old is expected to survive at least eight years. As many as 40% of all octogenarians have symptomatic cardiovascular disease and a significant number of these may benefit from surgery. Age being an independent risk factor for the development of coronary artery disease, the incidence of symptomatic coronary artery disease (CAD) requiring coronary artery bypass grafting (CABG) in the elderly is bound to increase. The broad demographic trend mentioned above towards a more aged population and the use of percutaneous transliminal angioplasty (PTCA) in younger patients have led to an increasingly greater number of high-risk elderly patients affected, with symptomatic and surgically correctable CAD becoming candidates for CABG.

Unfortunately, there is widespread reluctance to considering surgical therapy in octogenarians until medical therapy has been exhausted at which point the patient is often a relatively poor surgical candidate. Octogenarians with severe pre-op haemodynamic compromise are ill-equipped to rebound from the insult caused by severe ischaemia followed by a cardiac operation and cardio-pulmonary bypass (CPB). Older patients possess diminished physiological reserve and CABG for octogenarians in extremis is ill advised. However, mortality rates for elective procedures compare favourably with those in younger patients.

For octogenarians faced with recurring bouts of angina, surgical intervention can become a necessity. In this impending climate of managed care questions arise regarding both clinical and financial outcomes of such procedures. The elderly are a challenging group as their functional physiological reserve capacity is diminished and they have more associated co-morbid conditions.

Recent studies have shown that elderly patients can undergo CABG with morbidity and mortality rates slightly higher than their younger counterparts. However, slower convalescence during early follow-up may be anticipated and will indicate very careful screening. The increase in post-operative complications — and the length of stay — reflects the increased fragility of the organ systems in the elderly and emphasises the need for the anticipation of these events so that they can be identified and managed early. An increased incidence of stroke (4.1%)has been noted in the elderly. It could be because of:

a calcified aorta
the associated cerebro- vascular disease
prolonged cardio-pulmonary bypass
peri-operative hypotension.

Early referral for surgery, especially in those already hospitalised, should be encouraged both for patient benefits and for reducing costs. A more aggressive approach to correct the disease process earlier during a period of stability might result in a higher overall rate of success in octogenarians. Continuous refinements and advances in cardio-pulmonary bypass techniques, myocardial protection, improved anaesthesia, improved peri-operative and post-operative care, a better understanding of the patho-physiology of disease and, probably most importantly, the use of off-pump (beating heart) techniques have led to a markedly improved safety of surgery in elderly patients.

A successful operation produces much relief from disabling symptoms, leads to an early discharge and fewer readmissions and important social and economic benefits. In the care of octogenarian cardiac patients, meticulous pre and post operative care and aggressive early mobilisation are mandatory to minimise complications and shorten the length of hospital stay.

When appropriately applied in selected octogenarians, cardiac operations can be performed with acceptable mortality and excellent 5-year results. Most octogenarians are very symptomatic. The severity of symptoms and the extent of anatomic disease in the elderly may be related in part to the effect of age and to the progression of coronary atherosclerosis. A decision to treat patients medically at an earlier age because they are "too old" for surgery may in fact result in their admission to the CCU at a later date when the need to intervene becomes more urgent but the patient also becomes more moribund pre-operatively.

However, not all octogenarians are candidates for cardiac surgery. A careful assessment of the associated medical conditions, especially cerebrovascular, pulmonary and renal conditions, should help in making a decision. The risk-benefit ratio must always tilt in favour of the patient before embarking on any intervention. Before any intervention, we must know if added years amount to onus or bonus. According to some authorities, older people may be seen as less deserving of expensive resources.

However, my view is that the wealth of a country is not derived only from those currently active; it is built on the heritage of skills, knowledge and processes developed by countless past generations, and the young and the old are equal heir to this inheritance.

Evidence analysed

Personal series: 254 octogenarians were operated upon. These represented about 5% of the total number of the patients who underwent cardiac surgery. It was noted that older patients were more often female, had more cerebrovascular and peripheral vascular disease, prior M1, LV dysfunction, unstable angina, more diseased vessels and more occluded vessels.

The Euroscore in the group was 8.3 and the Parsonnet score was 21.6: this is much above the risk score of the whole group as such.

There was a significantly increased mortality and morbidity (AF, stroke, infection, reoperation, dialysis and prolonged ventilation). On a careful analysis of the data, higher mortality was found in those elderly patients who had two or more associated risk factors and co-morbidities. In the rest, the figures were very similar to those in younger patients. Thus, when compared to younger patients matched for the cardiac status, most octogenarians experienced an excellent outcome with only a modest increase in the length of stay and resource utilisation. The emergency operations and complex procedures carried high risks for the octogenarians but the majority could be treated surgically with a short-term morbidity, mortality and resource-use that only modestly exceeded those in younger patients.

The degree of post-operative functional recovery was stratified by age to determine the quality of life post-operatively. At a mean of three years of follow-up, 90% said that they were improved by surgery with no limitation of activity, 5% felt no improvement and 5% were worse. On a late follow-up, no significant difference from younger patients was noted.

So, the decision to operate should be taken on an individual basis with a careful risk-benefit estimate. Planned surgical interventions can be offered to appropriate candidates early in their disease process to optimise the surgical outcome. In addition, targeted strategies such as minimally invasive procedures in high-risk patients may result in a better outcome.

The strategy

A meticulous pre-operative workup is essential to avoid surprises in the operative and peri-op period. All patients should undergo a routine carotid screening by a doppler and if a significant critical stenosis is found, it should also be tackled. A very detailed pre-anesthesia checkup (PAC), with pre-emptive measures taken well before surgery (e.g cessation of smoking, addition of bronchodilators, teaching of breathing exercises etc), is a must. The surgical procedures should be absolutely well-planned so that not even a minute of OR time is wasted and a complete and thorough but expeditious correction of all defects should be the aim. It has to be a "commando precision operation" quick in, do a complete job and quick out. Especially for the elderly patient, I employ the KISS approach — Keep It Safe and Simple — and this has paid rich dividends (better results) to my patients. The approach was taught to me by my teacher, Prof Mark X. Shanahan, Chairman of Cardiac Surgery at the St. Vincents Hospital in Sydney, Australia.

Considerations: On CPB: the use of a hollow fibre membrance oxygenator in all, maintaining the flow at 2.51/min/sq m, using blood cardioplegia in 4:1 ratio, keeping hematocrit above 20% with packed cells if required, keeping perfusion pressure above 50 mm Hg mean, continuous invasive pressure and cardiac output monitoring in the immediate post-op period and keeping the cardiac index > 2.51/min/sq m and the mean arterial pressure > 60 mm Hg after CPB with the volume or vasoactive drugs as required.

Off CPB: Now we are performing more and more cases off-pump. The avoidance of CPB leads to a significant reduction in complications in high-risk patients undergoing CABG partly due to a reduction in the systemic inflammatory response Syndrome (SIRS), renal failure and respiratory failure all partly induced by the foreign surfaces of the cpb system. The recovery period is shorter with much less usage of blood products and a shorter hospital stay.

Peri-operative arrhythmias are treated prophylactically in all octogenarians with digoxin and beta-blockers (unless contra-indicated). Nephrotoxic drugs and antibiotics are to be avoided. Central lines are removed as soon as possible and early mobilisation and early enteral feeding is started.

The incidence of stroke in our series has been reduced by:

the routine use of epicardial and trans-oesophageal echocardiography in all cases to detect atheroma in the ascending aorta

avoiding cannulation at the site of a calcific plaque
careful and minimal clamping of the aorta (eg for proximal anastomosis)
the use of the single cross clamp technique
the use of an in situ IMA (as then no clamping is required for the proximal)
keeping perfusion pressure > 60 mm HG mean.
tackling known significant carotid disease by a combined carotid endarterectomy
using an off-pump beating heart technique which does away with the problems of cardio-pulmonary bypass.

Conclusions: The completeness of recovery and the good functional result in the elderly patients suggest that they should be offered CABG without regard to age alone and with good expectations of excellent post-op recovery and improved longevity.

As improvements in surgical care continue, the ongoing analysis of the outcome for octogenarians with surgically treatable heart disease will be needed to help us guide patients to in the matter of appropriate therapy.

We advocate an aggressive proactive approach in managing cardiac disease in this age group, thus avoiding emergency interventions in poor surgical candidates.

Dr Bedi is Senior Consultant Cardio-Vascular Surgeon at the Fortis Heart Institute, Mohali, Punjab.

Allergy: the facts
Dr Shakuntala Lavasa

Allergies are among the common and significant causes of morbidity, lost productivity and demanding health-care. It is not uncommon to see children on antibiotics, antihistamines, cough syrups, tonics and off-and-on bronchodilators for years together without any referral to a specialist. This irrational treatment not only results in disease burden and economic burden on the family but also in lost opportunities of growth and development for the child.

There is a big psychological and academic burden on the child because of missing school and due to not being allowed to eat so many so called "cough-producing cold foods". Why should we not treat patients scientifically when the science of allergy has advanced and tests are not difficult?

A few doctors have been misguiding patients, saying that allergy is "Allah ki marzi", others ask: what is the use of tests? Twenty things will be found for which you can do nothing.

Doctors without adequate training are conducting tests and putting this science into disrepute. Allergy tests do not consist merely of skin pricks (as is being done by people with vested interests), misdiagnosing allergies and putting patients to inconvenience. These tests are not laboratory tests. They have to be conducted by an allergy specialist who knows how to go into the depth of a patient’s history. He or she must have the knowledge of allergens based upon season, symptom, geographical region, occupation, hobby, food habit, personal habit and indoor and work place environment.

Allergen selection is important and equally important is the test material, the preparation of the test material if it is not available commercially, the test technique and the confirmation of tests by challenges and specific IgE (allergy detection by blood or nasal secretions) and correlation by aerobiological surveys. When so much is done for the patient, only a single major allergen will be identified which can be put to use for the treatment. The aim of the test is not to supply the patient with just a list of 20 allergens. It is to identify a major allergen and offer a treatment plan to the patient. Allergy tests are relevant only if the patient is seen as an individual. performing a battery of tests is not the purpose. The food allergens need avoidance. Food allergy is an important cause even of asthma and rhinitis. In a study of asthma 27% persons had food induced asthma. There is some concern about the "fact" that symptomatic treatment for inhalant allergies is prescribed for many patients who in fact suffer from food allergy. Experts warn that patients should not keep focusing on possible suspects by the hit-and-trial method. Misguided steps could be disastrous for growing children.

Dietary management of children must always be approached with keen awareness of the nutritional needs of growth and development. When allergen-avoidance is not practical, specific immunotherapy is the answer. Immunotherapy is the only known mode that can increase immunity in the body and has the potential to modify the course of allergic diseases and possibly even to prevent them.

It is of confirmed use in asthma and rhinitis and in rhinoconjunctivitis and other nasobronchial allergies. The evidence for efficacy of inhalant allergen immunotherapy is overwhelming. This treatment decreases medication like steroid, etc and improves the quality of life. It is useful if it is started early in asthma and other allergies. Success depends upon the reliability of allergy tests and the compliance of patients.

Dr Lavasa, the well-known paediatrician and allergy specialist, can be contacted at 226, Sector 9, Panchkula, and SCO 80, 15D, Chandigarh. (Ph: 892226, 562239, 782766.)

AYURVEDA & TOTAL HEALTH
Bhringaraja: hair herb
Dr R. Vatsyayan, Ayurvedacharya

Called by many names as bhangara, kesharaja and Eclipta alba (botanically), bhringaraja is prominent among the herbs chosen by Ayurveda for hair-care. Depending upon the colour of its flowers, ancient texts describe bhringaraja to be of three types — white, yellow and blue. Practically, only the first two varieties are found as the blue form seems to be the transformation of the white one at the ripe stage. The whole plant (panchang) is medicinal.

Bhringaraja is pungent and bitter in taste and light, dry and hot in effect. Experts in modern medicine have drawn an alkaloid known as ecliptine from it. Bhringaraja pacifies vata and kapha but aggravates pitta. Ayurveda texts have described bhringaraja as keshya, which means something beneficial for one's hair. The less known but equally important virtue of bhringaraja is its salutary effect on the liver. It is also carminative, digestive, diuretic and laxative. It helps in blood formation and is a rejuvenator and tonic of immense value.

Both Charaka and Sushruta have mentioned several uses of bhringaraja, whereas another leading light of Ayurveda, Rishi Vagbhatta, has written about bhringaraja kalpa, which is a specific regime for the purpose of rejuvenation only. In case of liver disorders like jaundice, bhringaraja is a promising herb. It is also used in a number of other problems like skin and ophthalmic disease, anaemia, hyperacidity, migraine and non-specific glandular swellings. Some of the common uses of bhringaraja are as under:

Hair and scalp tonic: Since time immemorial bhringaraja is used to prevent hair loss, dandruff and premature greying. Oils prepared with bhringaraja are, therefore, found occupying an important place in the hair-care kit in every Indian home. Though there are many formulations of the famous Bhringaraja Taila, it can be made at home by simply processing one kilogram of its juice in 4 kg of sesame oil.

Liver and spleen disorders: Taking 10 ml of the fresh juice of bhringaraja daily is a good adjunct in the treatment of jaundice and also in the enlargement of the liver and the spleen. It improves appetite and digestion too.

Hyperacidity: Chronic cases of acidity respond well if given 2 gm of the powder of dry bhringaraja, hararh and amla, all crushed in equal parts. Sootshekhara Rasa, the well-known classic ayurvedic, medicine for acidity and ulcer, is actually prepared by stirring the core medicine in the juice of bhringaraja.

A tonic: To gain the tonic effect, ayurvedic texts mention a number of formulations containing bhringaraja. Whereas 10 to 20 ml of its simple juice is prescribed to be taken every morning for at least 40 days, another way of taking 2 gm of triphala churna with 10 ml juice of bhringaraja dissolved in a cup of water daily is described as an anti-aging prescription.

Other uses: Bhringaraja is also used for treating many diseases like leucoderma, migraine and skin disorders. Though it is better to use bhringaraja in its fresh form, in winter, when it is out of season, its powder or decoction can be adopted by procuring it from the pansari shop in the dry form. (Next week: Apamarg: benefits and uses).

Dr R. Vatsyayan is an ayurvedic consultant based at the Sanjivani Ayurvedic Centre, Ludhiana. (Phones - 423500 and 431500; e-mail - sanjivni@satyam.net.in)