Coronary Artery Bypass Grafting Procedures Research Articles

Association between serum biomarkers and postoperative delirium after cardiac surgery.

In cardiac surgery, patients face an increased risk of developing postoperative delirium (POD) that is associated with poor outcomes. Neuron-specific enolase (NSE) and glial fibrillary acidic protein (GFAP) have shown some promising results as potential tools for POD risk stratification, diagnosis, monitoring, and prognosis. Prospective single-centre study enrolled 44 patients undergoing elective coronary artery bypass grafting (CABG) and/or valve procedures using cardiopulmonary bypass (CPB). The patients were assessed and monitored preoperatively, during surgery, and in the early postoperative period. The blood levels of NSE and GFAP were measured before and after surgery. The early POD was assessed by CAM-ICU criteria and patients were assigned to the POD group (with POD) or to the NPOD group (without POD) retrospectively. The incidence of POD was 18.2%. After surgery, NSE significantly increased in the whole sample (p = 0.002). Comparing between groups, NSE significantly increased in the POD group after surgery (p = 0.042). ΔGFAP (before/after operation) for the whole sample was statistically significant (p = 0.022). There was a significant correlation between ΔGFAP and the lowest MAP during surgery in the POD group (p = 0.033). Our study demonstrated that NSE and GFAP are associated with early POD. An increase in NSE level during the perioperative period may be associated with subclinical neuronal damage. Serum GFAP levels show the damage of glial cells. Further studies are needed to find the factors influencing the individual limits of optimal MAP during surgery.

Mitral valve repair using edge-to-edge technique in various situations: real-world experiences.

Edge-to-edge (E2E) mitral valve repair (MVP) is a versatile technique used in various situations for mitral regurgitation (MR). This technique has been regaining attention, given the increasing use of the MitraClip procedure. This real-world study evaluates the durability of the E2E technique in different settings. From January 2002 to May 2015, a total of 303 patients with at least moderate MR who underwent E2E MVP were identified. Patients undergoing isolated MVP (n = 133) and concomitant coronary artery bypass grafting or other valvular procedures (N = 170) were included. Cox proportional hazards modelling was used to evaluate the risk factors for cumulative survival, or MV event (i.e. MV reintervention or MR recurrence) while event-free survival-defined as time to composite outcome of either death or MV event-was determined using competing risk Kaplan-Meier analysis. Median follow-up duration was 6.9 (interquartile range 5.8) years. The most common MR aetiology was myxomatous (34%), followed by Barlow's disease (27.7%), and ischaemic (21.5%). E2E MVP was performed for the following indications: persistent MR (51.5%), systolic anterior motion prophylaxis (22.1%), transaortic approach (17.5%) and systolic anterior motion treatment post-MVP (8.9%). Concomitant ring annuloplasty was performed in 224 patients (73.9%). Operative mortality was 3.6% and MV event rate was 18.5%. Significant predictors of decreased survival included age, renal insufficiency, peripheral vascular disease and ischaemic MR aetiology (all P < 0.050). No ring annuloplasty (HR 2.79; P < 0.001) was the only significant predictor of MV events. Estimated event-free survival for the overall cohort was 8.5 years, and shortest for functional (non-ischaemic; 6.6 years) and ischaemic aetiology (5.5 years). E2E repair is a versatile MVP technique, which can be used in prevention and treatment of systolic anterior motion, transaortic approach or with concomitant techniques, with reasonable outcomes. Ischaemic aetiology and absence of ring annuloplasty were associated with worse cumulative survival and MV event rates, respectively, which raises some concern in light of the expanding indication for MitraClip system.

Measuring quality outcomes across hospital systems: Using a claims data model for risk adjustment of mortality rates.

Healthcare delivery systems around the world are designing care through value-based models where value is defined as a function of quality of care outcomes and cost. Mortality is a sentinel outcome measure of quality of care, of fundamental importance to patients and providers. Discovery Health (DH), an administrative funder of healthcare in South Africa (SA), uses service claims data of client medical schemes to examine standardised mortality rates (SMRs) at condition level across hospital systems for the purpose of healthcare system improvement. To accurately examine and contrast variation in condition-level SMRs across acute hospital systems, this outcome metric needs to be risk-adjusted for patient characteristics that make mortality more, or less, likely to occur. This article describes and evaluates the validity of risk-adjustment methods applied to service claims data to accurately determine SMRs across hospital systems. While service claims data may have limitations regarding case risk adjustment, it is important that we do not lose the important opportunity to use claims data as a reliable proxy to comment on the quality of care within healthcare systems. This methodology is robust in its demonstration of variation of performance on mortality outcomes across hospital systems. For the measurement period January 2014 - December 2016, the average risk-adjusted SMRs across hospital systems where DH members were hospitalised for acute myocardial infarction, stroke, pneumonia and coronary artery bypass graft procedures were 9.7%, 8.0%, 5.3% and 3.2%, respectively. This exercise of transparently examining variation in SMRs at hospital system level is the first of its kind in SA's private sector. Our methodological exercise is used to establish a local pattern of variation of SMRs in the private sector as the base off which to scrutinise reasons for variation and off which to build quality of care improvement strategies. High-performing healthcare systems must seek out opportunities for learning and continuous improvement such as those offered by examining important quality of care outcome measures across hospitals.

Minimally invasive versus conventional extracorporeal circulation circuits in patients undergoing coronary artery bypass surgery: a propensity-matched analysis.

Minimally invasive extracorporeal circulation circuits provide several advantages compared to conventional extracorporeal circulation circuits. We compared the results of a minimally invasive extracorporeal circulation system with those of conventional extracorporeal circulation system, in patients undergoing isolated coronary artery bypass grafting. We identified 753 consecutive patients who underwent coronary artery bypass grafting at our centre between October 2014 and September 2016. These patients were divided into two groups: a minimally invasive extracorporeal circulation group (M, n = 229) and a conventional extracorporeal circulation group (C, n = 524). Baseline parameters, details of cardiac surgery as well as postoperative complications and outcomes were compared by means of a propensity-matched analysis of 180 matched pairs. The median EuroSCORE II was 1.3%. Transfusion requirement of packed red blood cells (p = 0.002) was lower in Group M compared to conventional extracorporeal circulation systems. There were no differences in hospital mortality or in rates of adverse events between the matched groups. Total in-hospital mortality of the cohort was 1.7%. The use of minimally invasive extracorporeal circulation is associated with a significantly lower use of blood products after isolated coronary revascularisation. There were no differences concerning duration of surgery, complication rates and mortality between the groups. Therefore, the application of minimally invasive extracorporeal circulation systems should be considered as preferred technique in isolated coronary artery bypass grafting procedures.

Safety and efficacy of a simple cardiotomy suction system as a blood salvage procedure during off-pump coronary artery bypass surgery.

The ideal blood-salvaging strategies for off-pump coronary artery bypass graft procedures have not been determined. We developed a new blood-salvaging system that uses a cardiotomy suction. The purpose of this study was to examine the efficacy of this novel method. This was a retrospective study involving 50 consecutive patients undergoing off-pump coronary artery bypass grafting. In 25 patients, a simple cardiotomy suction system was used (cardiotomy suction group). These individuals were compared with 25 historical cohorts who were treating with the conventional cell saver system (cell saver group). There was no in-hospital mortality in either group. In the cell saver group, there was one major complication (stroke) and two minor complications (saphenous vein graft occlusion, superficial wound infection). In the cardiotomy suction group, there was one minor complication (subclinical pulmonary emboli). The cardiotomy suction group received significantly fewer transfused RBC (cardiotomy: 0.56 ± 1.4 units vs. cell saver: 2.46 ± 3.3 units, p = 0.005). The serum total protein and albumin levels were significantly higher in the cardiotomy group. Our newly developed simple cardiotomy suction system, when compared with the conventional cell saver system, produced similar clinical results and attenuated postoperative hemodilution. Our system may emerge as a preferable alternative for blood salvage during off-pump coronary artery bypass grafting.

Contemporary Outcomes Following Coronary Artery Bypass Graft Surgery for Left Main Disease

BackgroundAlthough results of percutaneous coronary intervention (PCI) have been steadily improving, whether surgical outcomes have improved over time is not fully elucidated. ObjectivesThis study sought to compare the current outcomes of patients undergoing coronary artery bypass grafting (CABG) with prior surgical results, in the context of randomized trials including the left main (LM) coronary artery stem. MethodsThe authors performed a propensity-matched analysis of patients randomized to CABG in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) (enrollment period 2005 to 2007) and EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) (enrollment period 2010 to 2014) trials. All patients had left main (LM) disease with or without multivessel disease. Adjustment was based on 15 clinical and angiographic variables, including anatomic SYNTAX score, with a 2:1 ratio for the EXCEL and SYNTAX trials, collectively analyzing 909 subjects (n = 580 and n = 329, respectively). The primary endpoint was the composite of all-cause death, myocardial infarction (MI), stroke, or ischemia-driven revascularization at 3 years. ResultsBaseline characteristics, anatomic SYNTAX score, number and types of grafts, and duration of hospitalization for the procedures were similar in both groups. CABG procedures in the EXCEL compared with the SYNTAX trial were more often off-pump (29.6% vs. 15.4%; p < 0.001), and guideline-directed medical therapies were used more frequently in the EXCEL surgical cohort. The primary endpoint occurred in 14.0% and 20.9% (p = 0.008) of patients in the EXCEL and SYNTAX trials, respectively. With the exception of MI (4.1% vs. 3.7%), all nonhierarchical events tended to contribute to the improved outcomes in the more recent trial: all-cause death (5.5% vs. 8.5%), stroke (3.1% vs. 5.1%), and ischemia-driven revascularization (7.1% vs. 9.4%) in the EXCEL and SYNTAX trials, respectively. ConclusionsOver a 5- to 7-year period, significant improvement in event-free survival after surgical revascularization for LM disease at 3 years was noted between the SYNTAX and EXCEL trials, consistent with improving results with cardiac surgery over time. (Synergy Between PCI With Taxus and Cardiac Surgery [SYNTAX]; NCT00114972; Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization [EXCEL]; NCT01205776)

Abstract 171: User Beware: Understanding the Adjusted Estimates of Propensity Score Methods

Background: Propensity score methods are used in observational studies to compensate for the lack of random allocation by balancing measured baseline characteristics between treated and untreated patients. Yet default implementations of propensity score methods may lead to contradictory findings. Our goal was to illustrate differences in treatment effect estimates produced using propensity score methods such as matching and inverse probability weighting (IPW). Methods: We used data from a retrospective analysis of the Northern New England Cardiovascular Disease Study Group registry that studied reintervention after single internal mammary artery (SIMA) versus bilateral internal mammary artery (BIMA) conduit use in 41,481 coronary artery bypass grafting (CABG) procedures from 1992-2014. Results: The mean duration of follow-up was 13.2 (IQR: 7.4-17.7) years. In our standard multivariable Cox regression analysis, the adjusted HR for reintervention was 0.83 (95% confidence interval (CI): 0.75-0.92) in patients receiving BIMA compared to SIMA (Table). The 1:1 propensity matched analysis (HR=0.79, 95% CI: 0.69-0.91) and IPW estimate among the treated (HR=0.83, 95% CI: 0.75-0.92) show a similar protective treatment effect of BIMA use on reintervention. However, the IPW approach for the overall population effect unusually showed no difference between BIMA and SIMA on reintervention-free survival (HR=1.08, 95% CI: 0.94-1.24). Conclusions and Relevance: The adjusted HR for reintervention after BIMA versus SIMA use in CABG was remarkably different for the two IPW estimates. This difference is attributed to the population represented by the two IPW approaches- the IPW among the treated estimate represents the effect in the average study population, whereas the IPW in the treated represents the effect in the treated population alone. Determining how the study population is balanced (weighted to look like the overall study population versus treated group) is a large driver of treatment effect, and a key element of propensity score methods. Ultimately, the treatment effect estimate desired should drive the choice of propensity score adjustment method.

Impacts of incomplete revascularization following off-pump coronary artery bypass grafting on clinical outcomes of patients with triple-vessel lesions: insights from a single-center study of propensity-matched data.

Although complete revascularization (CR) has been a goal of surgical revascularization, comorbidities and anatomical variables often conspire against a successful surgical CR. Currently, incomplete revascularization (IR) has been also considered as an acceptable strategy of surgical revascularization in some categories of patients. In the past decade, off-pump coronary artery bypass grafting (CABG) became one of the mainstream procedures of CABG due to its low incidence of perioperative complications. However, the magnitude of the impacts of off-pump IR on clinical outcomes of patients with triple-vessel disease remained unclear. Eligible patients who received isolated off-pump CABG with left internal mammary artery (LIMA) grafting to the left anterior descending coronary artery (LAD) in our institute from January 2011 to December 2013 were entered into an IR group or a CR group. The incidence of off-pump IR was investigated. In-hospital and follow-up outcomes were also evaluated by adjusting baseline characteristics using propensity score matching (1:1). A total of 1,349 patients (268 in the IR group and 1,081 in the CR group) were analyzed. The off-pump IR rate was 19.9%. Using matching propensity scores, 234 pairs were successfully established in a 1:1 manner. The two matched groups had similar surgical mortality and major postoperative morbidity. Multivariate Cox regression analysis showed that IR was not an independent predictor of cardiac death at follow-up (HR =1.215; 95% CI, 0.883-2.164; P=0.371). The two matched groups received a similar cumulative survival freedom from repeat revascularization in Kaplan-Meier curves (χ2=2.120, log-rank P=0.145). CR can be achieved in the majority of off-pump CABG cases. Compared with off-pump CR, off-pump IR with the LIMA grafting to the LAD was associated with acceptable clinical outcomes.

Improving coronary artery bypass grafting: a systematic review and meta-analysis on the impact of adopting transit-time flow measurement.

Summary Despite there being numerous studies of intraoperative graft flow assessment by transit-time flow measurement (TTFM) on outcomes after coronary artery bypass grafting (CABG), the adoption of contemporary TTFM is low. Therefore, on 31 January 2018, a systematic literature search was performed to identify articles that reported (i) the amount of grafts classified as abnormal or which were revised or (ii) an association between TTFM and outcomes during follow-up. Random-effects models were used to create pooled estimates with 95% confidence intervals (CI) of (i) the rate of graft revision per patient, (ii) the rate of graft revision per graft and (iii) the rate of graft revision among grafts deemed abnormal based on TTFM parameters. The search yielded 242 articles, and 66 original articles were included in the systematic review. Of those articles, 35 studies reported on abnormal grafts or graft revisions (8943 patients, 15 673 grafts) and were included in the meta-analysis. In 4.3% of patients (95% CI 3.3–5.7%, I2 = 73.9) a revision was required and 2.0% of grafts (95% CI 1.5–2.5%; I2 = 66.0) were revised. The pooled rate of graft revisions among abnormal grafts was 25.1% (95% CI 15.5–37.9%; I2 = 80.2). Studies reported sensitivity ranging from 0.250 to 0.457 and the specificity from 0.939 to 0.984. Reported negative predictive values ranged from 0.719 to 0.980 and reported positive predictive values ranged from 0.100 to 0.840. This systematic review and meta-analysis showed that TTFM could improve CABG procedures. However, due to heterogeneous data, drawing uniform conclusions appeared challenging. Future studies should focus on determining the optimal use of TTFM and assessing its diagnostic accuracy.

Trends of coronary revascularization procedures in Gaza

Background: we investigated the results of diagnostic coronary angiography and trends in rates of myocardial revascularization procedure included Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG) procedures in Gaza between 2015 and 2018. Methods: A descriptive retrospective study based on the analysis of all diagnostic Coronary Angiographies (CAG) based on the Ministry of Health hospitals in Gaza City Report and the Center of Bureau of Statistics, to evaluate the annual rate of PCI and CABG volume have been done since January 2015until January 2019. Results: A total of 4887 diagnostic coronary angiography procedures were performed. The mean age of patients was 58.0±10.2 years. A 3245 of cases were male (66.4%). A total of 5225 revascularization procedures (PCI: 4286,CABG: 939) were performed during the study period. From 2014 to 2018 the PCI volume increased by 94 % (80/100 000 to 155/100 000)(P &lt; 0.0001), CABG volume decreased by 47 % (30/100 000 to 17 /100 000) (P &lt;0.0001), PCI/CABG ratio increased from 2.7 to 9.1(P&lt;0.0001).The indications for diagnostic coronary angiography were stable angina (57% of cases), non-ST-elevation acute coronary syndrome (NSE-ACS) in 24.0%, ST-elevation myocardial infarction (STEMI) in 19.0%, the diagnostic coronary angiography results showed significant lesions in 64.5% of patients. About 19.2% of total cases have three vessel disease, 21% have two vessel disease and 24.4% of them have one vessel disease. The segments most involved were Left Anterior Descending Artery (LAD) which was involved in 47.2% of cases. Discussion: We observed dramatic increases in the total coronary revascularization procedures with a marked decrease in CABG and increase in PCI procedures in Gaza.

A Retrospective Cohort Study on Coronary Endarterectomy Outcomes in Coronary Artery Bypass Graft Patients.

Introduction: The aim of this study is to determine the outcomes following coronary endarterectomy (CE) in patients who underwent coronary artery bypass grafting (CABG) for revascularization in our hospital.Methods: We retrospectively reviewed patients who underwent CABG over a six-month period, from November 1, 2016 to May 31, 2017 and examined their outcomes in regards to CE.Results: A total of (n=361) CABG procedures were performed in our study period, though complete records were available for only (n=254) patients. Amongst these, (n=37) patients (14.5%) required CE. Ages ranged from 43 to 75 years for these patients, (n=7) were females and (n=30) males. Comorbidities included hypertension in (n=19) patients, diabetes in (n=12) patients and hepatitis B in (n=11) patients. The right coronary artery (RCA) was the most common artery endarterectomized (n= 15), followed by the left anterior descending (LAD) (n= 10), obtuse marginal (n= 6 patients), diagonals (n=5) and ramus (n=2). Two vessels were endarterectomized in (n=4) patients. A total of (n=9) patients had two-vessel CABG, (n=16) had three-vessel CABG and (n=8) had four-vessel CABG. The left internal mammary artery (LIMA) was used in (n=25) patients. Two patients required intra-aortic balloon pump post-operatively. All the patients had received inotropic support postoperatively in the intensive care unit (ICU). There were no reports of postoperative mortality. One patient remained in the ICU for four days postoperatively, the rest of the patients were stepped down to the ward in less than four days.Conclusions: CE is a safe and viable option as an adjunct to CABG in long segment totally occluded vessels needing revascularization and reconstruction.

Phase of Care Mortality Analysis According to Individual Patient Risk Profile

Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk (<4%), intermediate (4% to 8%), and high risk (>8%). A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

WOMEN'S OUTCOMES ARE IMPROVING AFTER CONTEMPORARY CORONARY ARTERY BYPASS GRAFT PROCEDURES

Higher mortality in women than in men after isolated coronary artery bypass graft (CABG) procedures has been historically accepted. We have reviewed our continuous series of isolated CABG performed in a single institution providing all coronary interventions in a geographically isolated region,

Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass.

General anaesthesia combined with epidural analgesia may have a beneficial effect on clinical outcomes. However, use of epidural analgesia for cardiac surgery is controversial due to a theoretical increased risk of epidural haematoma associated with systemic heparinization. This review was published in 2013, and it was updated in 2019. To determine the impact of perioperative epidural analgesia in adults undergoing cardiac surgery, with or without cardiopulmonary bypass, on perioperative mortality and cardiac, pulmonary, or neurological morbidity. We searched CENTRAL, MEDLINE, and Embase in November 2018, and two trial registers up to February 2019, together with references and relevant conference abstracts. We included all randomized controlled trials (RCTs) including adults undergoing any type of cardiac surgery under general anaesthesia and comparing epidural analgesia versus another modality of postoperative pain treatment. The primary outcome was mortality. We used standard methodological procedures as expected by Cochrane. We included 69 trials with 4860 participants: 2404 given epidural analgesia and 2456 receiving comparators (systemic analgesia, peripheral nerve block, intrapleural analgesia, or wound infiltration). The mean (or median) age of participants varied between 43.5 years and 74.6 years. Surgeries performed were coronary artery bypass grafting or valvular procedures and surgeries for congenital heart disease. We judged that no trials were at low risk of bias for all domains, and that all trials were at unclear/high risk of bias for blinding of participants and personnel taking care of study participants.Epidural analgesia versus systemic analgesiaTrials show there may be no difference in mortality at 0 to 30 days (risk difference (RD) 0.00, 95% confidence interval (CI) -0.01 to 0.01; 38 trials with 3418 participants; low-quality evidence), and there may be a reduction in myocardial infarction at 0 to 30 days (RD -0.01, 95% CI -0.02 to 0.00; 26 trials with 2713 participants; low-quality evidence). Epidural analgesia may reduce the risk of 0 to 30 days respiratory depression (RD -0.03, 95% CI -0.05 to -0.01; 21 trials with 1736 participants; low-quality evidence). There is probably little or no difference in risk of pneumonia at 0 to 30 days (RD -0.03, 95% CI -0.07 to 0.01; 10 trials with 1107 participants; moderate-quality evidence), and epidural analgesia probably reduces the risk of atrial fibrillation or atrial flutter at 0 to 2 weeks (RD -0.06, 95% CI -0.10 to -0.01; 18 trials with 2431 participants; moderate-quality evidence). There may be no difference in cerebrovascular accidents at 0 to 30 days (RD -0.00, 95% CI -0.01 to 0.01; 18 trials with 2232 participants; very low-quality evidence), and none of the included trials reported any epidural haematoma events at 0 to 30 days (53 trials with 3982 participants; low-quality evidence). Epidural analgesia probably reduces the duration of tracheal intubation by the equivalent of 2.4 hours (standardized mean difference (SMD) -0.78, 95% CI -1.01 to -0.55; 40 trials with 3353 participants; moderate-quality evidence). Epidural analgesia reduces pain at rest and on movement up to 72 hours after surgery. At six to eight hours, researchers noted a reduction in pain, equivalent to a reduction of 1 point on a 0 to 10 pain scale (SMD -1.35, 95% CI -1.98 to -0.72; 10 trials with 502 participants; moderate-quality evidence). Epidural analgesia may increase risk of hypotension (RD 0.21, 95% CI 0.09 to 0.33; 17 trials with 870 participants; low-quality evidence) but may make little or no difference in the need for infusion of inotropics or vasopressors (RD 0.00, 95% CI -0.06 to 0.07; 23 trials with 1821 participants; low-quality evidence).Epidural analgesia versus other comparatorsFewer studies compared epidural analgesia versus peripheral nerve blocks (four studies), intrapleural analgesia (one study), and wound infiltration (one study). Investigators provided no data for pulmonary complications, atrial fibrillation or flutter, or for any of the comparisons. When reported, other outcomes for these comparisons (mortality, myocardial infarction, neurological complications, duration of tracheal intubation, pain, and haemodynamic support) were uncertain due to the small numbers of trials and participants. Compared with systemic analgesia, epidural analgesia may reduce the risk of myocardial infarction, respiratory depression, and atrial fibrillation/atrial flutter, as well as the duration of tracheal intubation and pain, in adults undergoing cardiac surgery. There may be little or no difference in mortality, pneumonia, and epidural haematoma, and effects on cerebrovascular accident are uncertain. Evidence is insufficient to show the effects of epidural analgesia compared with peripheral nerve blocks, intrapleural analgesia, or wound infiltration.

Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study.

IntroductionApproximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not.Methods and analysesIn this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score.Ethics and disseminationThis protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals.Trial registration number NCT01842568.

Chronic opioid use after coronary bypass surgery.

Opioid dependence has become a major health care issue. Pain management of invasive surgical procedures with opioids may potentially contribute to this epidemic. We sought to determine the association of opioid-prescribing patterns with chronic opioid use. We retrospectively reviewed all patients undergoing isolated coronary artery bypass graft (CABG) procedures during 2016 at a single institution. Prescribing patterns and medication usage were compared between opioid-naïve and opioid-exposed patients (patients with reported opioid use within 30 days prior to surgery). Chronic opioid dependence was defined as opioid usage beyond 90 days after discharge. We included 284 opioid-naïve and 46 opioid-exposed patients. Although overall prescribing patterns were similar between groups, a higher proportion of opioid-exposed patients were prescribed a total dose >150 mg of oxycodone per discharge prescription (15.2% vs 4.9%; P = 0.024), and had a higher proportion of refills within 30 days (28.3% vs 10.9%; relative risk [RR] 3.2 [95% confidence interval (CI): 1.5-6.8]; all P < 0.05). The incidence of chronic opioid dependence was higher among opioid-exposed patients compared to opioid-naïve patients (21.7% vs 3.2%; RR 8.5 [95%CI: 3.2-22.3]; P = 0.001). Ongoing opioid use 3 months after CABG is present in 21.7% of opioid-exposed patients and 3.2% of opioid-naïve patients. These preliminary findings highlight the burden of prescribing patterns on the overall opioid epidemic and the need to develop alternative pain management strategies.

Additional filtering of blood from a cell salvage device is not likely to show important additional benefits in outcome in cardiac surgery.

Several authors and manufacturers of cell salvage devices recommend additional filtering of processed blood before transfusion. There is no evidence to support this practice. Therefore, we compared the clinical outcome and biochemical effects of cell salvage with or without additional filtering. The patients, scheduled for coronary artery bypass grafting, valve replacement, or combined procedures were part of our randomized multicenter factorial study of cell salvage and filter use on transfusion requirements (ISRCTN 58333401). They were randomized to intraoperative cell salvage or cell salvage plus additional WBC depletion filter. We compared the occurrence of major adverse events (combined death/stroke/myocardial infarction) as primary outcome and minor adverse events (renal function disturbances, infections, delirium), ventilation time, and length of stay in the intensive care unit and hospital. We also measured biochemical markers of organ injury and inflammation. One hundred eighty-nine patients had cell salvage, and 175 patients had cell salvage plus filter and completed the study. Demographic data, surgical procedures, and amount of salvaged blood were not different between the groups. There was no difference in the primary outcome with a risk of 6.3% (95% confidence interval [CI], 3.34-11.25) in the cell salvage plus filter group versus 5.8% (95% CI, 3.09-10.45) in the cell salvage group, a relative risk of 1.08 (95% CI, 0.48- 2.43]. There were no differences in minor adverse events and biochemical markers between the groups. The routine use of an additional filter for transfusion of salvaged blood is unlikely to show important additional benefits.

Atrial electrical remodeling induced by chronic ischemia and inflammation in patients with stable coronary artery disease.

The pathophysiology of coronary artery disease (CAD) includes low-grade chronic inflammation. At its turn, inflammation is known to promote myocardial structural remodeling and to increase vulnerability to atrial arrhythmias. Meanwhile, the impact of chronic inflammation on the electrophysiological properties of the atria remains unknown. We aimed to evaluate the impact of low-grade chronic inflammation on atrial electrophysiology in patients with stable CAD undergoing elective coronary artery bypass grafting (CABG). Circulating levels of several inflammatory, angiogenesis, and endothelial dysfunction markers were determined 1 day before CABG in 30 consecutive CAD patients. Right atrial appendage samples were collected during the CABG procedure; action potential recordings were performed in six study patients using the microelectrode technique. Interleukin (IL)-1b (r = 1.00, P = 0.01), IL-6 (r = 0.98, P < 0.01), vascular endothelial growth factor (VEGF) (r = 0.98, P < 0.01), and hemoglobin (r = 0.98, P < 0.01) levels significantly positively correlated with the duration of atrial depolarization. Consequently, IL-6, VEGF, and hemoglobin (r = -0.86, P = 0.03 for all) levels significantly negatively correlated with the velocity of atrial depolarization. There was no significant correlation between any of the studied markers levels and any of the other parameters of the action potential (all P > 0.05). The present study is the first to demonstrate that in patients with stable CAD, chronic inflammation and ischemia are associated with pro-arrhythmic atrial electrical remodeling. These changes may contribute to the increased propensity to postoperative atrial arrhythmias seen in some of the patients undergoing CABG.

Is Hypoalbuminemia a Predictor for Acute Kidney Injury after Coronary Bypass Grafting in Diabetes Mellitus Patients?

ObjectiveAcute kidney injury (AKI) is one of the most important complications after coronary artery bypass grafting (CABG) procedure. Serum albumin, which is an acute phase reactant, is suggested to be associated with AKI development subsequent to various surgical procedures. In this study, we research the relation between preoperative serum albumin levels and postoperative AKI development in diabetes mellitus (DM) patients undergoing isolated CABG.MethodsWe included a total of 634 diabetic patients undergoing CABG (60.5±9.1 years, 65.1% male) into this study, which was performed between September 2009 and January 2014 in a single center. The relation between preoperative serum albumin levels and postoperative AKI development was observed. AKI was evaluated and diagnosed using the Kidney Disease: Improving Global Outcomes (KDIGO) classification.ResultsAKI was diagnosed in 230 (36.3%) patients. Multiple logistic regression analysis was performed to determine the independent predictors of AKI development. Proteinuria (odds ratio [OR] and 95% confidence interval [CI], 1.066 [1.002-1.135]; P=0.043) and low preoperative serum albumin levels (OR and 95% CI, 0.453 [0.216-0.947]; P=0.035) were found to be independent predictors of AKI. According to the receiver operating characteristic curve analysis, albumin level <3mg/dL (area under the curve: 0.621 [0.572-0.669], P<0.001) had 83% sensitivity and 10% specificity on predicting the development of AKI.ConclusionWe observed that a preoperative low serum albumin level was associated with postoperative AKI development in patients with DM who underwent isolated CABG procedure. We emphasize that this adjustable albumin level should be considered before the operation since it is an easy and clinically implementable management for the prevention of AKI development.

On-pump and off-pump coronary artery bypass grafting for patients needing at least two grafts: comparative outcomes at 20 years.

Despite evidence from several randomized controlled trials and observational studies validating short-term safety and efficacy of off-pump coronary artery bypass grafting (CABG), concerns persist regarding the impact of off-pump CABG on long-term survival and freedom from reintervention. This persistent scepticism regarding off-pump CABG prompted us to review our practice of CABG over the last 20 years with a view to comparing the impact of off-pump and on-pump CABG on short-term and long-term outcomes in a high-volume off-pump coronary surgery centre. We retrospectively analysed prospectively collected data from the Patients Analysis and Tracking System database (Dendrite Clinical Systems, Oxford, UK) for all isolated first-time CABG procedures with at least 2 grafts performed at our institution from January 1996 to September 2017. Over the study period, 5995 off-pump CABG and 4875 on-pump CABG were performed by surgeons with exclusive off-pump and on-pump practices, respectively. Multivariable logistic regression and the Cox model were used to investigate the effect of off-pump versus on-pump procedures on short-term outcomes and long-term survival. Propensity score matching was used to compare the 2 matched groups. Off-pump CABG was associated with a lower risk for 30-day mortality [odds ratio (OR) 0.42, 95% confidence interval (CI) 0.32-0.55; P < 0.001], reintubation/tracheostomy (OR 0.58, 95% CI 0.47-0.72; P < 0.001) and re-exploration for bleeding (OR 0.48, 95% CI 0.37-0.62; P < 0.001). The benefit in terms of operative deaths from off-pump was significant in those with Society of Cardio-Thoracic Surgery logistic EuroSCORE >2 (interaction P = 0.04). When compared with on-pump CABG, off-pump CABG did not significantly reduce the risk of stroke (OR 0.96, 95% CI 0.88-1.12; P = 0.20) and postoperative haemofiltration (OR 0.98, 95% CI 0.86-1.20; P = 0.35). At the median follow-up of 12 years (interquartile range 6-17, max 21), off-pump CABG did not affect late survival [log rank P = 0.24; hazard ratio (HR) 0.95, 95% CI 0.89-1.02] or the need for reintervention (log rank P = 0.12; HR 1.19, 95% CI 0.95-1.48). This large volume, single-centre study with the longest reported follow-up confirms that off-pump CABG performed by experienced surgeons, who perform only off-pump procedures in a high-volume off-pump coronary surgery centre, is associated with lower risk of operative deaths, fewer postoperative complications and similar 20-year survival and freedom from reintervention rates compared with on-pump CABG.