Consecutive Coronary Artery Bypass Grafting Research Articles

Consecutive coronary artery bypass grafting and orthotopic living donor liver transplantation

Consecutive coronary artery bypass grafting and orthotopic living donor liver transplantation

Mortality in isolated coronary artery bypass surgery in elderly patients. A retrospective analysis over 14 years

Abstract Introduction We aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. Material and method From January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. Results We identified 99 patients older than 80 years (80-group; mean age 82 ± 3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2 ± 9.7 years). Additive EuroSCORE was 8.4 ± 4.8 and 4.6 ± 4.6 (p 0 .001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (p 0 .001) in the 80-group vs. the control group, respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (p 0 .001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; p = 0 .001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; p = 0 .001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6–19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1–12.2). The mean follow-up was 6.3 ± 4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. Conclusion Coronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Early Aspirin administration post Coronary Artery Bypass Graft Surgery – Changing hospital culture through a two-cycled audit

“Early Aspirin” or a medium dose of aspirin 6 hours after Coronary Artery Bypass Graft (CABG) Surgery is strongly recommend by international guidelines (EACTS 2007/AHA 2011 guidelines, Level1a evidence) to...

Mortalidad de la cirugía coronaria aislada en octogenarios. Análisis restrospectivo de 14 años

IntroductionWe aim to describe our experience in coronary artery bypass graft in elderly patients older than 80 years and assess the associated risk and predictors of mortality in this subgroup. Material and methodFrom January 1999 to June 2013, 3097 patients underwent consecutive coronary artery bypass graft surgery. Patients aged over 80 years were identified. Multivariate survival analysis using Cox's regression model was performed. ResultsWe identified 99 patients older than 80 years (80-group; mean age 82±3.5 years) and 2957 younger than 80 years (control group) (mean age 64.2±9.7 years). Additive EuroSCORE was 8.4±4.8 and 4.6±4.6 (P<.001) in the 80-group vs. control group, respectively. Off-pump coronary artery bypass graft was performed in 79.6 vs. 41.6% (P<.001) in the 80-group vs. the control group. respectively. There was significantly higher 30 day-mortality in the 80-group, 11.2 vs. 3.3%, respectively (P<.001). Patients in the 80-group underwent reintervention for bleeding more frequently (9.2 vs. 2.9%; P=.001) and had a higher incidence of major cardiovascular complications than the control group (6.1 vs. 2.1%; P=.001). Independent predictors of mortality for the 80-group were: reoperation for bleeding (HR 5.7; 95% CI 1.6-19.5) and cardiovascular complications (HR 3.7; 95% CI 1.1-12.2). The mean follow-up was 6.3±4.2 years for the octogenarian group. The cumulative survival of these patients was 65.7% during the study period. ConclusionCoronary artery bypass graft is performed preferably in patients over 80 years old under the off-pump procedure. Mortality is higher in this group of patients probably related to a higher incidence of cardiovascular complications and reintervention for bleeding in the immediate postoperative period.

Circulating non-hematological cells during cardiopulmonary bypass: new findings in cardiac surgery procedures.

Several factors have been historically advocated to explain the coagulative and inflammatory disorders following cardiopulmonary bypass (CPB). In this paper, we describe the presence of circulating non-hematological cells, introduced within the bloodstream during CPB. We defined the origin of the cells and tested their impact on coagulation. We collected peripheral arterial blood samples in twenty consecutive coronary artery bypass graft cases at four different surgical moments and assessed the presence and nature of circulating cells with the use of the CELLSEARCH® Test, immunocytochemistry and immunofluorescence, evaluating the expression of cytokeratin and calretinin. The effect of the circulating non-hematological cells on coagulation was tested in vitro, using the ROTEM assay. A mean of 263.85 ± 57.5 (median 258.5) cells were present in the samples following the suction of blood from the surgical field while all the other samples were negative (zero cells) (p<0.00001). Immunologic tests confirmed the mesothelial origin of the cells. The ROTEM® assay of the blood samples contaminated by the mesothelial cells presented longer clotting times (53.4 ± 8.2 secs 48.3 ± 8.9 sec, p=0.05), longer clot formation times (137.1 ± 31.5 sec vs 111.9 ± 25.2 sec, p=0.009), smaller alfa angle amplitudes (66.7 ± 9.1° vs 71.1 ± 5.1°, p=0.04) and maximum clot firmness times (59.0 ± 5.4 sec vs 61.9 ±4.6 sec, p=0.004) than the controls. The presence of circulating non-hematological cells during CPB with a mesothelial immunophenotype alters in vitro coagulation assays. This finding can help to further understand the pathophysiology of CPB.

Effect of Posterior Pericardiotomy on the Incidence of Postoperative Atrial Fibrillation in 1000 Consecutive Isolated CABG

Purpose: Postoperative atrial fibrillation (POAF) is the most common arrhythmia and morbidity after cardiac surgery and is associated with prolonged hospital stay, stroke and increased costs. At the Royal Hobart Hospital, one of the two surgeons routinely performed posterior pericardiotomy for patients undergoing coronary artery bypass grafting (CABG). We took this opportunity to review risk factors associated with postoperative atrial fibrillation and in particular if posterior pericardiotomy reduces the incidence of postoperative atrial fibrillation.

Comparison of logistic EuroSCORE and EuroSCORE II in predicting operative mortality of 1125 total arterial operations.

The purpose of this study was to compare effectiveness of the 1999 logistic EuroSCORE (LES) and of the 2012 EuroSCORE II (ESII) in a real-world patient population of 1125 patients undergoing total arterial grafting (TAG) coronary artery bypass graft (CABG) surgery. The performance of the two risk scores was compared using (i) discrimination (accuracy of discriminating non-survivors from survivors), (ii) calibration (assessment of agreement between the predicted/observed outcomes) and (iii) agreement between the two scores. By averaging medians of LES and ESII and then sub-division into 10 equal groups, actual operative mortality rate was compared with the median LES and ESII within each risk group, the difference plotted against the average risk score (as in a Bland and Altman plot), and using the traditional risk groupings for EuroSCORE of low (0-2.99), medium (3-5.99) and high risk (6.0 and above), the reclassification rate of ESII was compared with that of LES. In 1125 consecutive total arterial CABG patients, demographics included: mean age 64.6 years, 79% males, 35% diabetic patients, 57% urgent/emergent patients, 37% off-pump and 77% bilateral mammary grafting. Overall operative mortality was 3.2% (36 patients). Comparison of the LES and ESII showed (i) good discrimination for both LES and ESII (area under the curve for LES was 0.85 and for ESII was 0.87); (ii) neither score was well calibrated: LES tended to overestimate and ESII underestimated risk. In general, the ESII provided a better estimate of risk in lower risk patients and LES was better for the highest risk group. (iii) In terms of agreement, in the lower four risk groups the risk was overestimated by both scores, in five of the higher six risk groups ESII underestimated risk and LES overestimated risk, and in the highest risk group LES was very close (17.2 cf. 17.7) compared with ESII (5.6 cf. 17.7). In addition, ESII downgraded risk in 96.8% of survivors and in 97.2% of non-survivors. In 1125 consecutive TAG CABG patients, neither LES nor ESII performed well enough to be used as a consistent risk stratification tool; LES overestimated risk but was highly accurate for the highest of 10 risk groups and ESII consistently underestimated risk in all patients.

Is off-pump technique a safer procedure for coronary revascularization? A propensity score analysis of 20 years of experience.

We aim to describe our experience in coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass by comparing intraoperative and postoperative outcomes. From January 1993 to June 2013, 3097 patients underwent consecutive emergency and scheduled CABG surgery. A total of 1770 patients underwent on-pump CABG (ONCABG) and 1327 off-pump CABG (OPCABG). A propensity score matching was performed to identify appropriate matched-pair patients; univariable and multivariable logistic regression analyses were performed to assess significant predictors of hospital and 30-day morbidity and mortality composite end-points. Morbidity composite end-point was defined as any renal, pulmonary, cardiovascular and neurological complication that occurred during hospital stay. We collected all-cause mortality data during the study period. We identified 1004 patients in each group. There were no significant differences in thirty day mortality, 2.8 vs 3.8%, in OPCABG and ONCABG, respectively (P = 0.21). Cardiovascular, neurological, respiratory and renal complications were more frequent in the ONCABG group: 13.9 vs 8.7% (P < 0.001), 3.9 vs 2.2% (P = 0.03), 13.5 vs 7.5% (P < 0.001), 7.1 vs 5.3% (P = 0.095), respectively. The long-term all-cause mortality rate was 12.3 vs 12.9% in the OPCABG versus ONCABG group (P = 0.42), respectively. In both uni- and multivariable analysis preoperative renal failure, chronic obstructive pulmonary disease and ONCABG were independent predictors of mortality and morbidity composite end-points. OPCABG is associated with less postoperative morbimortality and shorter hospital and intensive care unit length of stay. ONCABG resulted as an independent predictor of morbidity and mortality composite end-point. No statistically significant differences were observed in long-term all-cause mortality between groups.

Completeness of Revascularisation Increases Survival and Weaning Success in Patients with Myocardial Infarction-Induced Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support

Objectives: Aim of this study was to investigate the prognostic outcome of patients with AMI and profound CS in patients receiving emergency veno-arterial extracorporeal membrane oxygenation (va-ECMO). Methods: A consecutive series of 81 patients with AMI and severe CS receiving emergency va-ECMO from 1997 to 2015 in was investigated. Outcome evaluation regarding in-hospital mortality, “bridge to recovery” and long-term outcome in patients with successful weaning from va-ECMO was performed. Kaplan Meier survival analysis was performed to identify relevant prognostic parameters predicting weaning from va-ECMO and patient survival. Permission to perform this study was obtained from the local IRB. Results: Mean patient age was 58.8 ± 10.0 years and 77.8% were male gender. Out-of-hospital mechanical cardiopulmonary resuscitation (CPR) was performed in 7 patients (8.9%), within the cath-laboratory in 18 patients (24.1%) and during surgical insertion of va-ECMO in 20 patients (25.3%). Initial installation of intra-aortic-balloon counter-pulsation (IABP) was sustained in 33 patients (41.8%). De novo MI was responsible for 43 (53.1%) of cases, acute stent thrombosis in 13 (16.0%), and complications resulting from PCI were responsible for MI in 30.9%. Mean duration of va-ECMO support was 5.9 ± 5.4 days. Mean time from onset of MCI to reperfusion was 5.4 ± 3.9 hours. Mean “door-to-reperfusion-time” was 1.35 ± 1.2 hours. Actuarial 30-day survival was 52.6%, 43.8% at 1 year and 36.4% at 5 years. Restoration of spontaneous circulation enabling bridge to recovery and weaning from va-ECMO was possible in 33 patients (46.8%) and was significantly higher in patients with complete revascularisation (p = 0.026). Bridge to recovery was significantly higher in patients with va-ECMO and consecutive coronary artery bypass grafting (CABG) versus patients with culprit lesion PCI (p = 0.011). In patients successfully weaned from ECMO, CABG patients demonstrated significantly higher long term survival than PCI patients (log-rank: p = 0.04). Conclusion: AMI complicated by cardiogenic shock is associated with a high in-hospital mortality even in patients undergoing emergency va-ECMO. Complete revascularisation significantly improves weaning success from va-ECMO and long term survival. Complete revascularisation seems to be better provided by CABG rather than PCI only - therefore weaning and long term prognosis is significantly improved by consecutive CABG rather than PCI or consecutive conservative management.

Oxidant Status following Cardiac Surgery with Phosphorylcholine-Coated Extracorporeal Circulation Systems.

Introduction. Extracorporeal circulation (ECC) related systemic oxidative stress is a well-known entity but the underlying mechanisms are not clearly described. Our aim was to investigate the relation between the oxidative stress indices, inflammatory markers, and phosphorylcholine-coated (PCC) ECC systems. Patients and Methods. Thirty-two consecutive coronary artery bypass grafting (CABG) cases were randomly assigned to Group I (PCC, n = 18) and Group II (noncoated, n = 14) ECC circuits. Total Antioxidant Status (TAS), Total Oxidant Status (TOS), Tumor Necrosis Factor-α (TNF-α), Interleukin-1β (IL-β), Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interleukin-10 (IL-10), and Procalcitonin (PCT) levels were measured at 5 different time points. The association between the oxidative indices levels and PCC system used was analyzed. Results. In Group I TOS and TAS statuses were increased at T1, T2, T3, and T4, while IL-10 and TNF-α levels accompanied those raises only at T2 (Group I-Group II, 4.73 ± 2.04 versus 2.79 ± 0.63, p = 0.002, and 30.56 ± 8.11 versus 23.97 ± 7.8, p = 0.031, resp.). In contrast, mean TAS and TOS levels were similar to baseline at all time points in Group II but IL-6 and IL-8 levels were increased at T2 (Group I-Group II, 16.84 ± 5.63 versus 44.81 ± 17.0, p = 0.001, and 38.88 ± 9.8 versus 46.14 ± 9.25, p = 0.038, resp.). Conclusion. Even coated ECC systems are still incapable of attenuating the inflammatory response to cardiopulmonary bypass (CPB).

Morbidity of Open Saphenous Vein Harvesting after Preoperative Ultrasonic Mapping

Preoperative echography of a saphenous vein graft (SVG) was studied. In 58 cases of consecutive coronary artery bypass grafting, 31 patients underwent SVG echography. Preoperative assessment revealed vein caliber, branching, or varicose saphenous veins. The location of the saphenous vein was marked. Saphenous veins were harvested by the open harvest technique, and the caliber of the veins and the availability of the anastomosis device were recorded. Postoperative morbidity was recorded. Preoperative findings revealed that four (6.5%) of 62 femoral saphenous veins were estimated as “not graftable” because of being a varicose vein or having a small caliber. Seven of 32 lower saphenous veins were estimated as “not graftable”. The mean discrepancy of the caliber was 0.6 mm undersized with preoperative estimation. During harvesting, one of 31 patients had a wrong marking. We were able to use all harvested veins. The morbidity of saphenous harvesting was observed in two (6.5%) of 31 patients. One patient whose marking was wrong had minor skin necrosis. Another patient experienced a hematoma because of the excess effect of warfarin. Preoperative ultrasonic mapping of the saphenous vein reduced useless harvesting, provided information concerning anastomosis device availability, and seemed to reduce morbidity because dissection can be minimal.

Morphological and functional consequences of transradial coronary angiography on the radial artery: implications for its use as a bypass conduit.

To assess the degree of damage to the radial artery (RA) in coronary artery bypass grafting (CABG) patients who underwent preoperative transradial coronary angiography (RA-CA). From May 2012 to October 2013, 50 consecutive CABG patients who underwent RA-CA were prospectively enrolled in the study. All patients underwent echo-Doppler evaluation of the RA of the catheterized arm; the contralateral RA was used as control. The distal segment of the RA was submitted to immunohistochemical assessment of endothelial integrity. Patients were divided in three groups according to the time interval from angiography to evaluation: ≤24 h, >24 h to <7 days and ≥7 days. Baseline RA median diameters were 0.25 ± 0.04 cm in the cannulated arm and 0.22 ± 0.04 cm in the non-cannulated arm (P = 0.01). The flow-mediated dilatation (FMD) in the RA in the catheterized arm and in the control arm were 11.6 ± 7.9 and 14.2 ± 8.9 (P = 0.01), respectively. A statistically significant correlation was found between FMD of the catheterized RA and the time from RA-CA (Pearson's r = 0.348). Linear regression analysis confirmed that the FMD of the catheterized RA was dependent on days elapsed from the procedure (P = 0.032; OR 1.11, CI 0.009-0.203). Immunohistochemical evaluation showed extensive endothelial lesion in all examined RAs, with a trend towards reduction of the damage with time. Endothelial function and integrity of the cannulated arm did not reach those of the control arm in any of the study patients. RA-CA produces extensive damage to the RA. The lesions tend to heal with time but incomplete recovery of endothelial integrity and function is still present more than 30 days after the procedure. After RA-CA, the cannulated RA should not be used for CABG.

Staged hybrid procedure for the management of emergency leaking type a aortic dissection

Staged hybrid procedure for the management of emergency leaking type a aortic dissection

Angiography for management of perioperative myocardial ischemia: does it have any role?

Perioperative myocardial ischemia (PMI) is a relatively rare but potentially fatal complication after coronary artery bypass grafting and is due to graft-related problems in a significant proportion of cases. The usual indicators of MI in the postoperative setting are unreliable and therefore have uncertain diagnostic value. Angiography, the criterion standard for preoperative angina, remains underused for evaluation of PMI. The aim of this study was to evaluate the role of angiography in the management of PMI. Between January 2011 and September 2012, a total of 2312 isolated primary consecutive coronary artery bypass graft surgeries were performed, of which 2057 (89%) were carried out on the beating heart. Twenty-six (1.12%) of these patients needed perioperative angiography. The patients needing angiography were selected on the basis of a number of clinical, biochemical, and other diagnostic parameters Twenty-six patients with PMI required angiography, of which 18 (69 %) were found to have graft-related issues. The mean (SD) time between operation and angiography was 24.58 (6.71) hours. Of the 18 patients, 17 (94.44%) required surgical intervention and 1 patient was treated with angioplasty. There were 2 deaths (11.1%) in the group undergoing intervention. Angiographic findings included occluded vein graft (n = 7), narrowing of the left internal mammary artery (n = 3), and kinking or stretching of grafts (n = 8). Angiography is useful in diagnosing graft-related problems in the perioperative period. In presence of signs of graft compromise, we suggest that having a low threshold for angiographic graft evaluation may be beneficial in a carefully selected subset of patients after coronary artery bypass.

Prognostic Value of Coronary CTA in Coronary Bypass Patients: A Long-Term Follow-Up Study

The goal of this study was to determine the long-term prognostic value of coronary computed tomography angiography (CTA) in a large coronary artery bypass graft (CABG) population. Coronary CTA has shown prognostic utility in patients without previous revascularization. However, prognostication with coronary CTA in CABG patients has not been fully assessed. Between March 2005 and April 2009, 887 consecutive CABG patients (mean age 66.8 ± 8.4 years) were considered for the inclusion in the study. Patients were classified by the number of unprotected coronary territories (UCTs) and a summary of native vessel disease and graft patency: the coronary artery protection score (CAPS). A primary endpoint (cardiovascular [CV] death, nonfatal myocardial infarction [MI]) and a secondary combined adverse events endpoint (CV death, MI, unstable angina, and late revascularizations) were recorded. Among the 887 evaluated, 166 did not meet the inclusion criteria. The final study population consisted of 721 subjects. Ten patients were excluded for unevaluable coronary CTA images. Of the remaining 711 patients, follow-up (mean 73.5 ± 14 months) was obtained in 698. Three hundred forty-seven events were recorded. By univariable analysis, the strongest coronary CTA predictors of events were UCT 2 and 3 (hazard ratio [HR] for CV death/MI: 7.5 and 10.19, p < 0.0001 and p < 0.0003, respectively) and CAPS 4 (HR for CV death/MI: 24.1, p < 0.0001). A high number of UCTs was also a strong multivariable independent predictor of CV death/MI (HR: 7.78 and 10.18 for UCT 2 and 3, p < 0.0001 and p < 0.0007, respectively). Cumulative survival rates for CV death/MI and composite adverse CV events were 86% and 73% with UCT 0, 84% and 49% with UCT 1, 53% and 3% with UCT 2, and 29% and 0% with UCT 3, respectively. Coronary CTA appears to be a promising tool for long-term risk stratification of CABG patients. The UCT score has significant prognostic value to predict CV deaths/MI.

Cardiovascular risk profile before coronary artery bypass graft surgery in relation to depression and anxiety disorders: An age and sex propensity matched study

ObjectiveThe cardiovascular risk profile and postoperative morbidity outcomes of anxiety disorder patients undergoing coronary artery bypass surgery is not known. MethodsIn a cross-sectional design, 114 consecutive coronary artery bypass graft surgery patients were evaluated to create four matched groups (30 with anxiety disorder, 27 with depression disorder and 57 age-sex matched coronary artery bypass surgery control patients with no depression or anxiety disorder). ResultsBy comparison to non-depression disorder age-sex matched controls, depressed patients presented for coronary artery bypass surgery with significantly greater myocardial inflammatory markers (Troponin T>02, 33.3% vs. 11.1%, p=.03), metabolic risk (body surface area>35 (22.2% vs. 0%, p=.03), comorbid cardiovascular risk (peripheral vascular disease 18.5% vs. 0%, p=.05). Depressed patients also recorded longer intraoperative time at higher temperatures >37°C on cardiopulmonary bypass (11.1±9.0 vs. 6.0±4.9, p<005) and had higher maximum postoperative Troponin T (.44±.2 vs. .28±.1, p=.03). Patients with anxiety disorder on the other hand presented with significantly higher Creatinine Kinase-Muscle Brain (5 IQR 4–5ng/ml vs. 4 IQR 3–4ng/ml, p=.04), higher intraoperative glucose levels (7.8±2.5mmol/l vs. 7.0±1.2mmol/l, p=.05), and received fewer grafts (2.1±.9 vs. 2.5±.9 p=.04). ConclusionsA differential cardiovascular risk profile and postoperative outcome was observed dependent on anxiety and depression disorder status. There were few modifiable cardiovascular risk factors at the time of surgery other than psychiatric status, perioperative management of depression and anxiety may have promise to reduce further cardiac morbidity after coronary artery bypass surgery.

Mitral valve repair versus replacement in patients with ischaemic mitral regurgitation and depressed ejection fraction: risk factors for early and mid-term mortality

Mitral valve (MV) surgery for ischaemic mitral regurgitation (IMR) in patients with depressed left ventricular ejection fraction (LVEF) is associated with poor outcomes. The optimal surgical strategy for IMR in these patients remains controversial. The objective of this study was to compare the early mortality and mid-term survival of MV repair versus MV replacement in patients with IMR and depressed LVEF undergoing coronary artery bypass grafting (CABG). A retrospective, observational, cohort study was undertaken of prospectively collected data on 126 consecutive CABG patients with IMR and LVEF <40% undergoing either MV repair (n = 98, 78%) or MV replacement (n = 28, 22%) between July 2002 and February 2011. The overall mortality rate was 7.9% (n = 10). MV replacement was associated with a 4-fold increase in the risk of death compared with MV repair [17.9%, n = 5 vs 5.1%, n = 5; odds ratio (OR) 4.04, 95% confidence interval (CI) 1.08-15.1, P = 0.04]. However, after adjusting for preoperative risk factors, the type of surgical procedure was not an independent risk factor for early mortality (OR 0.1, 95% CI 0.01-31, P = 0.7). Multivariable analysis showed that preoperative LVEF (OR 0.8, 95% CI 0.6-0.9, P = 0.018), preoperative B-type natriuretic peptide (BNP) levels (OR 1.01, 95% CI 1-1.02, P = 0.025), preoperative left ventricle end-systolic diameter (OR 0.8, 95% CI 0.7-1.0, P = 0.05) and preoperative left atrial diameter (OR 1.3, 95% CI 1.0-1.6, P = 0.015) were independent risk factors of early mortality. At the median follow-up of 45 months (interquartile range 20-68 months), the mid-term survival rate was 74% in the MV repair group and 70% in the MV replacement group (P = 0.08). At follow-up, predictors of worse survival were BNP levels [hazard ratio (HR) 1.0, 95% CI 1.0-1.01, P = 0.047], preoperative renal failure (HR 4.6, 95% CI 1.1-20.3, P = 0.039) and preoperative atrial fibrillation (HR 3.3, 95% CI 1.1-10, P = 0.032). MV repair in CABG patients with IMR and depressed LVEF is not superior to MV replacement with regard to operative early mortality and mid-term survival.

The Low Triiodothyronine Syndrome: A Strong Predictor of Low Cardiac Output and Death in Patients Undergoing Coronary Artery Bypass Grafting

There is strong clinical and experimental evidence that altered thyroid homeostasis negatively affects survival in cardiac patients, but a negative effect of the low triiodothyronine (T3) syndrome on the outcome of coronary artery bypass grafting (CABG) has not been demonstrated. This study was designed to evaluate the prognostic significance of low T3 syndrome in patients undergoing CABG. The thyroid profile was evaluated at hospital admission in 806 consecutive CABG patients. Known thyroid disease, severe systemic illness, and use of drugs interfering with thyroid metabolism were considered exclusion criteria. The effect of the baseline free T3 (fT3) concentration and of preoperative low T3 syndrome (fT3 <2.23 pmol/L) on the risk of low cardiac output (CO) and death was analyzed in a logistic regression model. There were 19 (2.3%) deaths, and 64 (7.8%) patients experienced major complications. After univariate analysis, fT3, low T3, New York Heart Association class greater than II, low left ventricular ejection fraction (LVEF), and emergency were associated with low COand hospital death. History of atrial fibrillation, cardiopulmonary bypass time, and peripheral vascular disease were associated only with low CO. At multivariate analysis, only fT3, low T3, emergency, and LVEF were associated with low CO, and fT3 (odds ratio, 0.172, 95% confidence interval, 0.078 to 0.379; p < 0.0001) and LVEF (odds ratio, 0.934, 95% confidence interval, 0.894 to 0.987; p= 0.03) were the only independent predictors of death. Our study demonstrates that low T3 isa strong predictor of death and low CO in CABG patients. For this reason, the thyroid profile should beevaluated before CABG, and patients with low T3 should be considered at higher risk and treated accordingly.

Cardiac Surgery Nurse Practitioner Home Visits Prevent Coronary Artery Bypass Graft Readmissions

We designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death. A total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The "Follow Your Heart" program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates. Binary logistic regression analysis identified "Follow Your Heart" as the only independently significant variable in preventing the composite outcome (p=0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group (p=0.023). A home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.

Quicker yet safe: skeletonization of 1640 internal mammary arteries with harmonic technology in 965 patients

Skeletonization of the internal mammary artery (IMA) facilitates arterial grafting and has been shown to reduce deep sternal infection but is more time-consuming and tedious than pedicle harvest. We wished to determine if use of harmonic technology (HT) facilitates skeletonization of the IMA and is as safe as the conventional technique of skeletonization. In a consecutive series of 1057 patients with isolated coronary artery bypass graft (CABG) surgery from 2003 to 2013, adverse events and recorded harvest times were compared between harmonic (965 patients) and non-harmonic patients (86 patients). HT was used to harvest 1640 IMAs in 965 (91%) of 1057 consecutive CABG patients and skeletonization with the traditional technique (use of an electrocautery tip as a dissector) was used to harvest 147 IMAs in 86 patients. Six patients had no IMA harvested with this surgery (4 patients had an IMA used from a previous CABG, 1 had no disease of the left anterior descending coronary artery and 1 patient was in cardiogenic shock precluding IMA use). Excluding patients with single-vessel disease, 730/987 (74%) of patients received bilateral IMAs. Demographics of patients with and without harmonic skeletonization, respectively, were the following: mean age: 64.7 vs 67.7 years; diabetes: 33 vs 34%; women: 21 vs 26% and median European System for Cardiac Operative Risk Evaluation: 2.9 vs 3.2. The mean harvest time for 77 non-harmonic skeletonized mammary arteries (49 surgeries) was 32.2 min (95% confidence interval (CI): 30.1, 34.3), for harmonic skeletonized arteries after 450 surgeries was 28.4 min, (95% CI: 27.8, 29.1) and in the last 100 IMAs harvested for the isolated harmonic device use/mammary was 15.4 min (95% CI: 14.0, 16.7). Major adverse events for patients with and without harmonic skeletonization, respectively, were: reoperation for bleeding: 2.7 vs 3.5% (difference = 0.8%, 95% CI: -3.2, 4.8); damaged mammaries: 0.4 vs 0.7% (difference = 0.3%, 95% CI: -1.0, 1.7); deep sternal infection: 1.6 vs 1.2% (difference = -0.4%, 95% CI: -2.8, 2.0) and perioperative infarction: 1.7 vs 2.3% (difference = 0.7%, 95% CI: -2.6, 4.0). In this largest series to date of harmonic IMA skeletonization, this technique results in rare damage, is quicker and with a comparable adverse event rate compared with the non-harmonic method.