The probability of continuing your life following bypass surgery is close to being the same as for the population in general — once the patient has completed the procedure itself. But a register study from the Department of Clinical Epidemiology at Aarhus University, Denmark, shows that mortality increases after 8-10 years.
The prognosis following heart bypass surgery is both functional and has improved over the past three decades. The survival rate for bypass patients who make it through the first month after the operation is close to that of the population in general. But 8-10 years after a heart bypass operation, mortality increases by 60-80 per cent. This is new and essential knowledge for the doctors who monitor these patients.
This is the main conclusion of a comprehensive national register-based study that sheds light on the thirty-year prognosis following a heart bypass operation, which has just been published by the Department of Clinical Epidemiology under the Department of Clinical Medicine at Aarhus University. The basis for the study is all of the approx. 51,000 Danish patients who have undergone surgery in the period 1980 — 2009. They have subsequently been correlated with a control group of 500,000 people of the same age and gender drawn at random from the general population.
“The study shows that the rate of survival has improved over the last three decades so that the probability of continuing your life following bypass surgery is close to being the same as in the general population. This holds true providing that the patient has a successful surgery and for the eight-ten years after the surgery. However, after this point, the prognosis changes,” says medical doctor and PhD student Kasper Adelborg from the Department of Clinical Epidemiology.
Kasper Adelborg is the primary author of the publication ‘Thirty-Year Mortality After Coronary Artery Bypass Graft Surgery. A Danish Nationwide Population-Based Cohort Study’, which has recently been published in the American journal Circulation: Cardiovascular Quality and Outcomes.
The study shows that ten-year-survivors have an increased mortality of between 60 and 80 per cent when compared with the general population. This may be due to the fact that the disease is progressive and that atherosclerosis or hardening of the arteries increases, or that the implanted material begins to fail.
“Our register study covers all patients who underwent bypass surgery throughout the last decades throughout Denmark, and there will naturally be differences in the prognosis from patient to patient. So the clinicians who are in contact with the patients should, therefore, assess their prognosis individually — and there are special reasons to do this after the initial eight-ten years, as we now know that ‘something’ happens,” says Kasper Adelborg about the perspectives of the study, which is currently being tweeted all over the world — and which has triggered a personal email to Kasper Adelborg from the journal’s chief editor, who is impressed by the possibilities for studying long-term prognosis following heart bypass surgery using high-quality data.
“Of course, this has to do with the fact that we in Denmark have unique opportunities to link register information from the registries. When we work with a control group of half a million Danes, we have the possibility of directly comparing the prognosis for a 55-year-old man who has undergone bypass surgery with a 55-year-old man who has not had surgery from the control group,” explains Kasper Adelborg.
“It may be that we see this as an obvious correlation to make in Denmark, but the fact is that we in Denmark keep such good track of our citizens that many other countries envy us. In other places such as the US, it is not possible to simply extract information about when people have undergone surgery or died. This is information which is not centrally registered and which can, therefore, be lost if, for example, someone moves to a different region or state,” says Kasper Adelborg.
In addition to the new knowledge about a particular ‘period of attention’ 8-10 years after the bypass surgery, the first month is particularly critical. Within the first 30 days after bypass surgery, patients have an increased risk of dying in connection with the operation, which is not in itself new.
“It is well-known that there are risks associated with a complicated operation in the heart, but fortunately, mortality in connection with the surgery itself is quite low. What is new is that we have precise figures for the prognosis, including the long-term prognosis for patients who have undergone bypass surgery, compared with the rest of the population,” says Kasper Adelborg.
The World Health Organization (WHO) has defined health as being “not only the absence of disease and infirmity but also the presence of physical, mental, and social well-being”. To capture this multifaceted concept, quality of life (QoL) has become increasingly important in medicine, social sciences and health care , because it reflects not only objective clinical or physiologic status, but more specifically, the patients’ subjective perception about the impact of a clinical condition on their lives, such as the ability to perform physical and social activities, feeling happy in their daily life, and maintain fulfilling interpersonal relationships.
One of the main reasons to offer cardiac surgery is to improve both survival and quality of life. In patients whose absolute life expectancy may be limited by age, QoL may, therefore, be particularly important. There is evidence that the gain in QoL may not be substantial for patients with a low symptom burden at baseline. In contrast, significant increases in QoL have been reported in patients aged 80 years and over undergoing cardiac surgery. The assessment of QoL before cardiac surgery has thus garnered increasing interest among clinicians as a factor to be taken into consideration when estimating the potential benefit to be gained by the patient from the intervention. Indeed, complications such as worsening of psychosocial function may be expected, because patients have to face the challenges of a new life phase that can be accompanied by physical and mental deterioration. It is therefore essential for cardiac surgeons to dispose of information about the impact of cardiac surgery on QoL, to be able to inform patients appropriately about the pro and cons of the intervention. The superiority of coronary artery bypass graft surgery (CABG) over a strategy of initial medical therapy in patients with stable coronary artery disease (CAD) or silent ischemia was established in a meta-analysis of seven RCTs over 20 years ago and confirmed in a more recent network meta-analysis . CABG is cost-effective at five years compared to medical therapy and compared to percutaneous coronary intervention in multivessel CAD.
At the time of surgery, several factors have been shown to predict post-operative impairment of QoL, such as age, female sex, history of hypertension, chronic obstructive pulmonary disease, education level, marital status, and also psychological factors such as the presence of mood disorders . It has been shown that pre-operative depression is predictive of decreased cardiac symptom relief, quicker recurrence of symptoms, more frequent re-admission, and increased mortality in the immediate post-operative period. At the same time, post-operative depression is also associated with poor outcomes such as decreased physical function, increased likelihood of wound infection, increased risk of cardiovascular events and even increased mortality. Therefore, for many patients, maintaining a good QoL is as essential as survival . However, there is a lack of data in the literature regarding long-term trends in QoL after CABG surgery, with evaluations often limited to 1 to 2 years after surgery, or rarely, up to a maximum of 5 years . We hypothesised that, even if a substantial gain in absolute life expectancy is unlikely for many patients after cardiac surgery, there may be a significant benefit in terms of quality of life over the long-term, which could be an important factor in decision-making. Against this background, our study prospectively analysed the long-term course of QoL in patients undergoing CABG, through the administration of the Short Form (SF)-36 questionnaire, at baseline (prior to surgery) and then every year up to 10 years after surgery.
Several hundred thousand patients undergo a bypass operation every year in the US. Although the numbers are not as high as a decade ago (mainly due to the number of stent procedures performed by cardiologists) bypass surgery remains the best and safest option for many patients with severe heart artery blockages.
What should I expect during open-heart surgery?
Open heart surgery is a major operation that requires a hospital stay of a week or more. An individual will often spend time in the intensive care unit immediately after surgery.
In adults, a surgeon will operate on the heart to treat problems with the valves, arteries supplying the heart, and aneurysms in the main vessel leaving the centre.
While it is an intensive surgery, the risk of mortality is shallow. One 2013 study showed an in-hospital mortality rate of 2.94 percent. This article will focus on the preparation, procedure, and recovery for open-heart surgery in adults.
Open heart surgery is a major operation that requires close monitoring and immediate post-operative support. It is usual for a person to remain in the intensive care unit (ICU) for a couple of days after the procedure to receive further care.
How Long Is A Person Expected To Live After A Bypass Operation?
The life expectancy after coronary bypass surgery depends again on the individual’s risk factors. And most importantly, on the ventricular function, how well the muscle of the heart works. If the tissue in the centre works well, the life expectancy can be approximately what the healthy population is who’ve never had a heart attack. On the other hand, people with advanced left ventricular dysfunction — that means, who’ve had significant damage to the main pumping chamber of the heart — their life expectancy is more limited.
Let’s summarise the article so far. If a patient has a LIMA bypass, it is almost 90% likely to remain open, even ten years after the operation, and that is just great. For the other blockages where an SVG graft is used, the bypasses are about 50% likely to remain open at ten years. If grafts go down its not necessarily a disaster, there are often good treatment options.
Remember that the bypass was done to treat coronary artery disease, but that’s only half the battle. The same disease process still goes on despite the bypass, and so the emphasis in these patients should be on treatments that can act to stabilise the heart disease. These treatments include medications, blood pressure control, cholesterol management, avoiding smoke, exercise, diet, and the adoption of a healthy lifestyle. Now, these are the truly life-saving measures.
We analysed the 30-year outcome of the first 1041 consecutive patients in our institution (age at operation 53 years, 88% male) who underwent venous CABG between 1971 and 1980. During follow-up, every 5–7 years follow-up status was obtained by reviewing the hospital records and from general practitioners and civil registries. Data were collected on death and repeat coronary revascularization procedures. Follow-up was complete in 98%. Median follow-up was 29 years (26–36 years). The cumulative 10-, 20-, and 30-year survival rates were 77%, 40%, and 15%, respectively. Overall, 623 coronary re-interventions were performed in 373 patients (36%). The cumulative 10-, 20-, and 30-year freedom from death and coronary re-intervention rates were 60%, 20%, and 6%, respectively. Age [hazard ratio (HR) 1.04/year], the extent of vessel disease (VD) (two-VD HR 1.4; three-VD HR 1.9), left central condition (HR 1.6) and impaired left ventricular ejection fraction (LVEF) (HR 1.8) were independent predictors of mortality. We were able to assess the exact LE by calculating the area under the Kaplan–Meier curves. Overall LE after first CABG was 17.6 years. LE in patients with one-, two-, and three-VD was 21.4, 18.8, and 15.4 years, respectively (P < 0.0001). Patients with impaired LVEF had a significant shorter LE than patients with normal LVEF (13.9% vs. 19.3%; P < 0.0001).
This 30-year follow-up study comprises the almost complete life cycle after CABG surgery. Overall median LE was 17.6 years. As the majority of the patients (94%) needed a repeat intervention, we conclude that the classic venous bypass technique is a useful but palliative treatment of a progressive disease.
Thirty-three years after bypass surgery: a heart patient’s perspective
I am a believer in the efficacy of healthy lifestyle choices for the primary and secondary prevention of coronary heart disease (CHD). As a result, I make a serious effort to eat healthily, exercise effectively, manage stress, avoid cigarette smoke, and keep a positive attitude. Looking back on my life, I would love to tell you that my commitment to healthy living was the result of native intelligence, but it was not. Instead, it was born out of need. For the first 33 years of my life, healthy living took a back seat to other, seemingly more important things that made my time and interest: my family, work, and community. Besides, I had always been healthy. Serious diseases such as heart disease and cancer happened to other people.
Sure, some things could have been improved. My cholesterol was too high, I could stand to lose a few pounds, and my exercise regimen was sporadic. There would be time, I thought, to improve my numbers and my health in the future. But I was wrong.
In 1977, I underwent coronary bypass surgery. I was 32 years old. My wife and I had not yet celebrated our 10th wedding anniversary. My daughter was six years old; my son was just 4.
That experience became the motivating force for me to understand the impact of lifestyle habits on health and to take action to improve them.
In retrospect, it was a hard way to learn valuable lessons. What I had to be taught for rehabilitation, I could have discovered for prevention.