Coronary Artery Bypass Grafting Population Research Articles

Influence of Baseline Characteristics, Operative Conduct, and Postoperative Course on 30-Day Outcomes of Coronary Artery Bypass Grafting Among Patients With Left Ventricular Dysfunction: Results From the Surgical Treatment for Ischemic Heart Failure (STICH) Trial.

Patients with severe left ventricular dysfunction, ischemic heart failure, and coronary artery disease suitable for coronary artery bypass grafting (CABG) are at higher risk for surgical morbidity and mortality. Paradoxically, those patients with the most severe coronary artery disease and ventricular dysfunction who derive the greatest clinical benefit from CABG are also at the greatest operative risk, which makes decision making regarding whether to proceed to surgery difficult in such patients. To better inform such decision making, we analyzed the Surgical Treatment for Ischemic Heart Failure (STICH) CABG population for detailed information on perioperative risk and outcomes. In both STICH trials (hypotheses), 2136 patients with a left ventricular ejection fraction of ≤35% and coronary artery disease were allocated to medical therapy, CABG plus medical therapy, or CABG with surgical ventricular reconstruction. Relationships of baseline characteristics and operative conduct with morbidity and mortality at 30 days were evaluated. There were a total of 1460 patients randomized to and receiving surgery, and 346 (≈25%) of these high-risk patients developed a severe complication within 30 days. Worsening renal insufficiency, cardiac arrest with cardiopulmonary resuscitation, and ventricular arrhythmias were the most frequent complications and those most commonly associated with death. Mortality at 30 days was 5.1% and was generally preceded by a serious complication (65 of 74 deaths). Left ventricular size, renal dysfunction, advanced age, and atrial fibrillation/flutter were significant preoperative predictors of mortality within 30 days. Cardiopulmonary bypass time was the only independent surgical variable predictive of 30-day mortality. CABG can be performed with relatively low 30-day mortality in patients with left ventricular dysfunction. Serious postoperative complications occurred in nearly 1 in 4 patients and were associated with mortality. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

The impact of a second arterial graft on 5-year outcomes after coronary artery bypass grafting in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery Trial and Registry

ObjectiveDespite various evidence supporting the advantages of multiple arterial grafting, inconsistencies in use of the procedure have resulted in high variability in the acceptance and practice of arterial grafting. The purpose of this study was to assess the effects of an arterial versus venous second grafts on outcomes at 5-year follow-up in the coronary artery bypass grafting population from the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial. MethodsPatients (n = 1419) with an arterial graft to the left anterior descending artery and ≥1 other graft were included and divided according to the second graft's type: 2nd-graft-arterial group (n = 456) and 2nd-graft-venous group (n = 963). Five-year outcomes were compared between subgroups. Event rates were estimated with Kaplan-Meier analyses. Propensity-score matching was used, to control for selection bias due to nonrandom group assignment in a 1:1 manner, resulting in 432 pairs with balanced baseline characteristics. ResultsIn unmatched groups, the 2nd-graft-arterial group had significantly lower rates of death (8.9% vs 13.1%; P = .02), and composite safety endpoint of death/stroke/myocardial infarction (13.3% vs 18.7%; P = .02), compared with the 2nd-graft-venous group. The rate of major adverse cardiac or cerebrovascular events was similar between groups (22.9% vs 25.5%; P = .30), because it includes the rate of repeat revascularization (12.6% in the 2nd-graft-arterial group vs 9.6% in the 2nd-graft-venous group; P = .10). After propensity-score matching, no statistically significant differences were found between groups. ConclusionsThis study reveals comparable 5-year outcomes with arterial and venous conduits as second grafts after an arterial graft anastomosed to the left anterior descending artery. This study demonstrates the multi-institutional variation in patient selection and operator technique with regard to arterial revascularization, although extended follow-up beyond 5 years is required to estimate its impact on long-term outcomes. Clinical Trial NumberNCT00114972

Increasing severity of aortic atherosclerosis in coronary artery bypass grafting patients evaluated by transesophageal echocardiography.

BackgroundAtherosclerotic disease in coronary artery bypass grafting (CABG) patients is a potential contributor to complications in the perioperative periods. This study was undertaken to better define how the frequency of aortic atheromatous disease among patients coming for CABG has evolved over the last decade.MethodsData from elective patients coming for CABG who underwent transesophageal echocardiography (TEE) examinations following induction of anesthesia were obtained for the years 2002 and 2009. Aortas were graded according to the method of Kronzon, with the following interpretations: normal = grade I, intimal thickening = 2, atheroma of less than 5 mm = 3, atheroma of > 5 mm = 4, and any mobile atheroma = 5. The data of 124 patients who underwent comprehensive exam of the aorta by one cardiac anesthesiologist were gathered and assigned into two groups based on the year TEE was done. Student’s t-test was used for statistical analysis. A P value < 0.05 was considered significant. The data were presented as mean ± SD.ResultsThere was significant difference between group 2002 (2.05 ± 1.28) and group 2009 (2.59 ± 1.11) in atheroma grade (P = 0.013).ConclusionsPatients coming for CABG in group 2009 exhibited significantly higher grades of aortic atheroma on TEE, compared to group 2002. Understanding the risk of atheroma in the elderly CABG population may help in altering surgical approaches to lessen the risk of catastrophic stroke. Potential options needing further study include the off-pump approach and modification of cross-clamp site and technique as well as other modalities.

ACUTE MYOCARDIAL INFARCTION TREATED WITH PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH PRIOR CORONARY ARTERY BYPASS GRAFTING AT A SINGLE CENTRE IN CANADA

Due to an aging population, there is an increase in the number of patients undergoing coronary artery bypass grafting (CABG) presenting with ST-segment elevation myocardial infarction (STEMI). Despite this, there is a lack of data in this high-risk patient population. The purpose of the study is to characterize the baseline characteristics, culprit lesions and outcomes of patients with previous CABG and STEMI. We retrospectively reviewed a database of all patients undergoing emergency percutaneous coronary intervention (PCI) of which 95.8% of patients had electrocardiographic evidence of STEMI at a single-centre in British Columbia between January 2009 and December 2013. There were 94 (2.9%) patients with a prior history of CABG in a total of 3231 patients. The prior CABG group was significantly older and had a significantly greater incidence of hypertension, dyslipidemia, diabetes, previous MI, previous heart failure, and previous PCI. There was a significantly greater length of stay in the CABG population, but no difference when comparing in hospital mortality. The infarct-related vessel in the CABG group was a bypass graft in 44 patients (48.9%), native coronary artery in 36 patients (40.0%), was not identifiable in 10 patients (11.1%) and 4 patients had missing data. We further stratified previous CABG patients by the time between emergency PCI and index CABG. There were 79 patients (84.0%) who had CABG more than five years from emergency PCI. There were no significant differences in baseline characteristics, culprit lesions and 30-day mortality between CABG more than five years and less than five years from emergency PCI. Emergency PCI for STEMI after previous CABG is associated with more comorbidities when compared with patients that did not undergo previous CABG. However, there were similar outcomes in short-term mortality. Furthermore, there were no significant differences in baseline characteristics and short-term mortality between the timing from initial CABG to emergency PCI. Further data analysis is needed to characterize longer-term outcomes.

Unprotected left main coronary artery disease after revascularization

It is unknown whether the effect of diabetes on patients with unprotected left main coronary artery (LMCA) disease differs according to the different revascularization strategies. This study was conducted to evaluate the impact of diabetes on patients with unprotected LMCA disease treated with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). We prospectively enrolled 823 consecutive patients with unprotected LMCA disease who had drug-eluting stent (DES; n = 331) implantation or underwent CABG (n = 492) in the study. We compared the effects of diabetes on clinical outcomes according to different revascularization strategies. Among 823 eligible patients enrolled, 226 had diabetes. In the DES population, no significant differences were observed in occurrences of death, cardiac death, repeat revascularization, stroke, and major adverse cardiac and cerebrovascular events. However, the risks of the composite of death/myocardial infarction (MI)/stroke (21.5 % DM vs. 7.2 % non-DM; p = 0.001) and MI (15.4 % DM vs. 1.6 % non-DM; p = 0.000) were significantly higher in the diabetic patients than those without diabetes. In the CABG population, similar rates of all clinical endpoints were observed between the diabetic and nondiabetic group. Diabetes was associated with worse outcome in patients undergoing DES implantation for the treatment of unprotected LMCA disease. However, its negative prognostic impact was not found among patients undergoing CABG.

Are intraoperative precursor events associated with postoperative major adverse events?

Precursor events are undesirable events that can lead to a subsequent adverse event and have been associated with postoperative mortality. The purpose of the present study was to determine whether precursor events are associated with a composite endpoint of major adverse cardiac events (MACE) (death, acute renal failure, stroke, infection) in a low- to medium-risk coronary artery bypass grafting, valve, and valve plus coronary artery bypass grafting population. These events might be targets for strategies aimed at quality improvement. The present study was a retrospective cohort design performed at the Queen Elizabeth Health Science Centre. Low- to medium-risk patients who had experienced postoperative MACE were matched 1:1 with patients who had not experienced postoperative MACE. The operative notes, for both groups, were scored by 5 surgeons to determine the frequency of 4 precursor events: bleeding, difficulty weaning from cardiopulmonary bypass, repair or regrafting, and incomplete revascularization or repair. A univariate comparison of ≥1 precursor events in the matched groups was performed. A total of 311 MACE patients (98.4%) were matched. The primary outcome occurred more frequently in the MACE group than in the non-MACE group (33% vs 24%; P=.015). The incidence of the individual events of bleeding and difficulty weaning from cardiopulmonary bypass was significantly higher in the MACE group. Those patients with a precursor event in the absence of MACE also appeared to have a greater prevalence of other important postoperative outcomes. Patients undergoing cardiac surgery who are exposed to intraoperative precursor events were more likely to experience a postoperative MACE. Quality improvement techniques aimed at mitigating the consequences of precursor events might improve the surgical outcomes for cardiac surgical patients.

The Effect of Race and Chronic Obstructive Pulmonary Disease on Long-Term Survival after Coronary Artery Bypass Grafting

Background: Chronic obstructive pulmonary disease (COPD) is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined.Methods: A retrospective cohort study was conducted of CABG patients between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.Results: A total of 984 (20%) patients had COPD (black n = 182; white n = 802) at the time of CABG (N = 4,801). The median follow-up for study participants was 4.4 years. COPD was observed to be a statistically significant predictor of decreased survival independent of race following CABG (no COPD: HR = 1.0; white COPD: adjusted HR = 1.9, 95% CI = 1.7–2.3; black COPD: adjusted HR = 1.6, 95% CI = 1.1–2.2).Conclusion: Contrary to the expected increased risk of mortality among black COPD patients in the general population, a similar survival disadvantage was not observed in our CABG population.

Impact of Preoperative Left Ventricular Ejection Fraction on Long-Term Survival After Aortic Valve Replacement for Aortic Stenosis

The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature. Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%-49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%; P=0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts. Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.

Invited Commentary

The population prevalence of patients receiving hemodialysis (HD) due to end stage renal disease is progressively increasing, and cardiovascular complications have been identified as the most common cause of death in these patients [1U.S. Renal Data System2011 Atlas of CKD and ESRD.http://www.usrds.org/atlas.aspxGoogle Scholar]. As a consequence, cardiac operations on HD patients are becoming more common. Traditionally, the results of myocardial revascularization in these patients have been poor because of advanced coronary disease and complications from the underlying condition. Indeed, guidelines from the European Society of Cardiology on myocardial revascularization suggest accounting for the general condition of the HD patient and life expectancy when considering a revascularization strategy [2Kolh P. Wijns W. Danchin N. et al.Guidelines on myocardial revascularization.Eur J Cardiothorac Surg. 2010; 38: S1-S52Crossref PubMed Scopus (316) Google Scholar]. The article by Takami and colleagues provides important new data on predictors of early and late outcomes after coronary artery bypass grafting (CABG) in HD patients [3Takami Y. Tajima K. Kato W. et al.Predictors for early and late outcomes after coronary artery bypass grafting in hemodialysis patients.Ann Thorac Surg. 2012; 94: 1940-1946Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. In their retrospective analysis of 152 HD patients, the authors found a significant reduction in hospital mortality with the introduction of an off-pump coronary artery bypass (OPCAB) in 2003. Early mortality decreased from 15.3% in the pre-OPCAB era to 6.3% afterward. Crude mortality in these patients is still significantly higher that in the general CABG population, but the improvement associated with the introduction of OPCAB in their experience was noteworthy. The effect of off-pump CABG on renal function in non-HD patients remains controversial [4Lamy A. Devereaux P.J. Prabhakaran D. et al.Off-pup or on-pump coronary artery bypass grafting at 30 days.N Eng J Med. 2012; 366: 1489-1497Crossref PubMed Scopus (530) Google Scholar, 5Elmistekawy E. Chan V. Bourke M.E. et al.Off-pump coronary artery bypass grafting does not preserve renal function better than on-pump coronary artery bypass grafting: results of a case-matched study.J Thorac Cardiovasc Surg. 2012; 143: 85-92Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar], but OPCAB may confer a clear benefit in the specific subgroup of HD patients. One may speculate as to the possible mechanisms leading to this association, with OPCAB potentially resulting in less manipulations of the aorta, a lower need for transfusion, volume replacement and hemodilution, and therefore fewer strokes, a shorter duration of mechanical ventilation, and a lower incidence of infections. Another important finding of this study was that the long-term survival of HD patients who underwent CABG appeared equivalent to that of HD patients who did not undergo myocardial revascularization. Thus, despite the high early mortality, CABG effectively returns HD patients to their life expectancy curve. Although indication bias in selecting patients was likely in Takami's study, this finding carries important implications for the patient and clinician when considering HD patients for coronary surgery. External validation by further studies will be needed to confirm whether OPCAB is indeed the optimal strategy for myocardial revascularization in HD patients. Moreover, future studies may consider the role of minimally invasive procedures such as minimally invasive cardiac surgery-CABG in further reducing surgical trauma [6McGinn Jr, J.T. Usman S. Lapierre H. Pothula V.R. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients.Circulation. 2009; 120: S78-S84Crossref PubMed Scopus (139) Google Scholar], considering that mediastinitis is the most common fatal complication in HD patients after conventional surgery [7Liu J.Y. Birkmeyer J.O. Sanders J.H. et al.Risk of morbidity and mortality in dyalisis patients undergoing coronary artery bypass surgery.Circulation. 2000; 102: 2973-2977Crossref PubMed Scopus (192) Google Scholar]. Predictors for Early and Late Outcomes After Coronary Artery Bypass Grafting in Hemodialysis PatientsThe Annals of Thoracic SurgeryVol. 94Issue 6PreviewMarkedly higher hospital and long-term mortality after coronary artery bypass grafting (CABG) have been reported in hemodialysis (HD)-dependent patients. We tried to identify the predictors for short-term and long-term outcomes after CABG, which have not been well studied. Full-Text PDF

Radial artery grafting in women improves 15-year survival

Radial artery (RA) grafting has a clear survival advantage after coronary artery bypass grafting (CABG) in studies with predominantly male populations, but the impact on women's long-term survival is unclear. We sought to determine if the reported long-term survival benefit of RA versus saphenous vein (SV) grafting in the general CABG population is valid for women. Between 1995 and 2010, 1339 female patients were alive 30 days after primary, isolated CABG with left internal thoracic artery (LITA) and additional RA or SV conduits as needed. Patients were evaluated based on RA use: 332 patients had RA and 1007 patients had SV. Of these, 283 RA patients were matched to SV counterparts using a nonparsimonious propensity model based on 45 patient variables. Kaplan-Meier estimated survivals for the matched RA women at 1, 5, 10, and 15 years were 99%, 93%, 80%, and 70% versus 97%, 87%, 72%, and 58% for the SV women (log rank, P=.018). For symptomatic patients, overall RA patency was 80%, which was not different from the LITA patency rate of 84% but was superior to the SV conduits patency rate of 56% (P<.001). In women undergoing CABG with LITA grafting, use of an RA graft improves survival compared with use of an SV graft.

Delirium: A Cause for Concern Beyond the Immediate Postoperative Period

Delirium is a common neurologic complication after cardiac surgery, and may be associated with increased morbidity and mortality. Research has focused on potential causes of delirium, with little attention to its sequelae. Perioperative data were collected prospectively on all isolated cases of coronary artery bypass grafting (CABG) performed from 1995 to 2006 at a single center. The definition of delirium used in the study was that of the Society of Thoracic Surgeons. Characteristics of patients who became delirious postoperatively were compared with those of patients who did not. The outcomes of interest were long-term all-cause mortality, hospital admission for stroke, and in-hospital mortality, examined in all three cases through multivariate analysis. Of 8,474 patients who underwent CABG within the defined period, 496 (5.8%) developed postoperative delirium and 229 (2.7%) died while in the hospital. At baseline, patients who developed delirium were more likely to be older and to have a greater burden of comorbid illness. Delirium was an independent predictor of perioperative stroke (odds ratio [OR]; 1.96; 95% confidence interval [CI], 1.22 to 3.16), but was not associated with in-hospital mortality (OR, 0.81; 95%CI, 0.49 to 1.34). Delirious patients had a median postoperative hospital stay of 12 days (interquartile range [IQR], 8 to 21 days) versus 6 days (IQR, 5 to 8 days) for those who were nondelirious. Delirium was identified as an independent predictor of all-cause mortality (hazard ratio [HR], 1.52; 95%CI, 1.29 to 1.78) and hospitalization for stroke (HR, 1.54; 95%CI, 1.10 to 2.17). There was an association between delirium and adverse outcomes after CABG that persisted beyond the immediate perioperative period. Patients with delirium after CABG appear to have an increased long-term risk of death and stroke. The advancing age and rising rates of delirium in the CABG population make it necessary to address the prevention and management of delirium in this population.

Impact of Preoperative Renal Dysfunction in Patients Undergoing Off-Pump Versus On-Pump Coronary Artery Bypass

The impact of the degree of renal dysfunction (RD) in patients undergoing coronary artery bypass grafting (CABG) ranging from normal to dialysis-dependence is not well defined. A retrospective review of 14,199 patients undergoing isolated, primary CABG from January 1996 to May 2009 at Emory Healthcare was performed. The estimated glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula: mild RD (eGFR 60 to 90 mL/min/1.73 m2), moderate RD (eGFR 30 to 59), severe RD (eGFR<30). A propensity scoring was used to balance the groups with 46 preoperative covariates. Multivariable logistic and Cox regression methods were used to determine the independent association of eGFR with mortality. Adjusted odds ratios were calculated for outcomes using the normal eGFR group as the reference. Kaplan-Meier curves were created to estimate long-term survival. A total of 8,086 patients (57.0%) underwent off-pump coronary artery bypass (OPCAB) while 6,113 (43.0%) underwent on-pump CAB. Preoperative RD was common: Normal eGFR (n=3,503/14,199 [24.7%]); mild RD (7,236/14199 [51.0%]); moderate RD (2,860/14,199 [20.1%]); severe RD (283/14,199 [2.0%]); and preoperative dialysis (317/14,199 [2.2%]). Moderate to severe RD or preoperative dialysis was associated with worse adjusted in-hospital mortality: mild RD (odds ratio [OR] 1.42; 95% confidence interval [CI] 0.93 to 2.16; p=not significant); moderate RD (OR 3.55; 95% CI 2.32 to 5.43; p<0.05]; severe RD (OR 8.84; 95% CI 4.92 to 15.9; p<0.05); and dialysis-dependent (OR 9.64; 95% CI 5.45 to 17.0; p<0.05). Adjusted long-term survival was worse across levels of RD. The OPCAB patients with moderate to severe RD had worse long-term survival than on-pump CAB patients; however, the surgery types were similar among normal, mild, and dialysis patients. Preoperative RD is common in the CABG population and is associated with diminished long-term survival. Improved early outcomes in patients with RD undergoing OPCAB diminished with worsening RD.

The Mattone Outcome-BYPASS study: short-term outcome in patients undergoing coronary artery bypass graft surgery in Italian hospitals. Final results

In early 2008, a new national prospective study on short-term outcomes of coronary artery bypass graft (CABG) procedures started in Italy. The aim was to describe short-term results in patients undergoing CABG and improve methodologies for comparative outcome evaluation. Only 26 Italian cardiac surgery centers participated in this survey. For each patient undergoing a CABG procedure, all centers were requested to provide specific data (type of procedure, hemodynamic conditions, comorbidities, recent myocardial infarction and unstable angina, ventricular function, emergency conditions, vital status at 30 days). Representativeness was tested by comparing characteristics of the enrolled population with information derived from national hospital discharge records. A multiple logistic regression analysis was used to perform indirect standardization; the mortality rate of the whole population was used as a reference standard. Comparison with the CABG model built on 34 310 patients in 2002-2004 was performed as well. The analysis of 7436 isolated CABG procedures showed a 30-day mortality of approximately 2%. The study population seemed to be representative of the Italian population of CABG patients. Using the new estimate model, two cardiac surgery centers showed significantly better risk adjusted mortality rates than the national reference standard, and two others showed significantly worse rates. The application of the "CABG model" yielded similar results. Our study shows a high-quality level of Italian cardiac surgery centers and confirms the good applicability of the CABG model to the Italian CABG population. Comparison between results from the two models highlights the usefulness of regular outcome studies either for updating risk adjustment procedures and monitoring quality of care in Italian hospitals.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Preoperative Prediction of Early Mortality in Patients with Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting

Patients with low ejection fraction (EF) undergoing coronary artery bypass grafting (CABG) usually have a higher incidence of mortality and morbidity. In this retrospective study, we sought to detect significant preoperative predictors of early mortality in these patients. Patients with an EF of ≤ 30% who underwent isolated CABG in Catharina Hospital, Eindhoven, the Netherlands, between January 1998 and December 2008 (n = 413) were included in this study. All the preoperative patient-related risk factors were entered into a logistic regression analysis model to detect the significant predictors of early mortality. Patients with an EF of ≤ 30% represent 4.1% of the whole CABG population. The overall early mortality in this patient group was 9.1%. Risk factors for early mortality as identified by the univariate analysis were age, chronic obstructive pulmonary disease (COPD), prior CABG, New York Heart association (NYHA) class, emergency operation, preoperative serum creatinine (SeCr), and preoperative hemoglobin (Hb) level. These factors were entered into the multivariate analysis and were all identified as independent risk factors for early mortality. This study confirmed the impact of some well-known preoperative risk factors on early outcome in patients with low EF undergoing CABG. In addition, we have shown the predictive value of preoperative SeCr and hemoglobin level that have not yet been described.

Post-CABG Coronary CT Angiography: Radiation Dose and Graft Image Quality in Retrospective Versus Prospective ECG Gating

The aim of this study was to compare effective radiation doses between prospective and retrospective electrocardiographic gating during coronary computed tomographic angiography for coronary artery bypass grafting evaluation. Fifty consecutive coronary computed tomographic angiographic exams for coronary artery bypass grafting evaluation, 25 prospectively gated and 25 retrospectively gated, were reviewed from January 8, 2008, to June 16, 2009. Body mass index and image quality were also compared between the two groups. To minimize the potential bias introduced by differences in torso length, the effective radiation dose from each exam was measured and normalized to a 24-cm z-axis scan length for all patients. Pooled t tests were used to compare the prospectively and retrospectively gated groups. The average effective doses delivered in the retrospective and prospective groups were 40.8 mSv (standard error [SE], 1.8 mSv) and 8.6 mSv (SE, 0.7 mSv), respectively. When normalized to the average z-axis scan length of 24 cm, the effective dose in the retrospective group, 38.4 mSv (SE, 1.3 mSv), was still >4 times greater than that in the prospective group, 9.1 mSv (SE, 0.7 mSv) (P < .0001). There was no significant difference in body mass index or image quality between the groups. Effective radiation dose in coronary computed tomographic angiography for coronary artery bypass grafting evaluation is very high because of long scan lengths. Prospective electrocardiographic gating significantly reduces effective radiation dose by an average of 76% compared to retrospectively gated scans (9.1 vs 38.4 mSv). In the coronary artery bypass grafting population, prospective electrocardiographic gating should be used whenever ventricular functional assessment is not required.

Delirium as a predictor of sepsis in post-coronary artery bypass grafting patients: a retrospective cohort study

IntroductionDelirium is the most common neurological complication following cardiac surgery. Much research has focused on potential causes of delirium; however, the sequelae of delirium have not been well investigated. The objective of this study was to investigate the relationship between delirium and sepsis post coronary artery bypass grafting (CABG) and to determine if delirium is a predictor of sepsis.MethodsPeri-operative data were collected prospectively on all patients. Subjects were identified as having agitated delirium if they experienced a short-term mental disturbance marked by confusion, illusions and cerebral excitement. Patient characteristics were compared between those who became delirious and those who did not. The primary outcome of interest was post-operative sepsis. The association of delirium with sepsis was assessed by logistic regression, adjusting for differences in age, acuity, and co-morbidities.ResultsAmong 14,301 patients, 981 became delirious and 227 developed sepsis post-operatively. Rates of delirium increased over the years of the study from 4.8 to 8.0% (P = 0.0003). A total of 70 patients of the 227 with sepsis, were delirious. In 30.8% of patients delirium preceded the development of overt sepsis by at least 48 hours. Multivariate analysis identified several factors associated with sepsis, (receiver operating characteristic (ROC) 79.3%): delirium (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6 to 3.4), emergent surgery (OR 3.3, CI 2.2 to 5.1), age (OR 1.2, CI 1.0 to 1.3), pre-operative length of stay (LOS) more than seven days (OR 1.6, CI 1.1 to 2.3), pre-operative renal insufficiency (OR 1.9, CI 1.2 to 2.9) and complex coronary disease (OR 3.1, CI 1.8 to 5.3).ConclusionsThese data demonstrate an association between delirium and post-operative sepsis in the CABG population. Delirium emerged as an independent predictor of sepsis, along with traditional risk factors including age, pre-operative renal failure and peripheral vascular disease. Given the advancing age and increasing rates of delirium in the CABG population, the prevention and management of delirium need to be addressed.

Trends in Cardiac Surgery-Associated Acute Renal Failure in the United States: A Disproportionate Increase after Heart Transplantation

Acute renal failure (ARF) is common after cardiac surgery and more frequent after complex cardiac surgery. While the incidence of ARF is increasing after coronary artery bypass graft (CABG) surgery, trends in other forms of cardiac surgery remain unclear. We investigated the trend of ARF in various cardiac procedures and compared patterns using CABG surgery as a reference group. The study population consisted of discharges from the Nationwide Inpatient Sample from 1988 to 2003, grouped according to surgery as: CABG, CABG with mitral valve, CABG with other valve, valve alone, and heart transplant. Standard diagnostic codes were used to identify ARF among discharges. Multivariable regression was used to determine trends in ARF among various procedures with CABG as a reference group. The incidence of ARF increased in all five groups (p < 0.001) over the 16-year period. The ARF incidence was highest in the heart transplant group (17%). Compared to the CABG population, patients following heart transplantation developed ARF at higher rates during the study period. In contrast, while ARF increased over time in other groups, the rates of rise were slower than in CABG patients. Among heart surgery procedures, ARF incidence is highest in heart transplantation. The incidence of ARF is also increasing at a faster rate in this group of patients in contrast to other procedure groups when compared to CABG surgery. The disproportionate increase in ARF burden after heart transplantation is a concern due to its strong association with chronic kidney disease and mortality.

Spondyloarthritis: a strong predictor of early coronary artery bypass grafting

Objectives: The main aim of the study was to examine whether patients with spondyloarthritides underwent their first coronary artery bypass grafting (CABG) at a younger age than those without spondyloarthritides.Methods: Patients who underwent their first CABG at the Feiring Heart Clinic during 2001–2005 were preoperatively screened for spondyloarthritides, and the cardiological assessment was registered. We compared the characteristics of patients with and without spondyloarthritides.Results: Of the 3852 patients undergoing their first CABG, 30 (0.78%) had spondyloarthritides. No statistically significant differences in traditional cardiovascular risk factors were found. The mean ages of patients with and without spondyloarthritides were 60.1 (SD = 8.7) and 66.9 (SD = 10.1) years, respectively. Spondyloarthritis was found by multivariate analysis to be a stronger independent predictor of early CABG than traditional cardiovascular risk factors [adjusted beta −6.2, p<0.001, 95% confidence interval (CI) −9.5 to −2.8]. Sixty per cent of spondyloarthritis patients and 52% of control patients had already suffered a myocardial infarction (p = 0.4).Conclusion: Spondyloarthritis was a stronger predictor of early CABG than most of the registered traditional cardiovascular risk factors. The prevalence of spondyloarthritis seemed to be higher in the CABG population than in the general population. These findings may indicate accelerated coronary artery disease (CAD) in spondyloarthritides.

Impact of an early recovery management intervention on functioning in postoperative coronary artery bypass patients with diabetes

Approximately 30% of patients undergoing coronary artery bypass graft (CABG) procedures have diabetes and, as such, are at increased risk for postoperative complications and a lengthy recovery. To test the feasibility of an in-home early recovery management intervention to improve physical and psychosocial functioning in the diabetic CABG population. This pilot study was a 2-group, randomized, experimental study. The 6-week in-home early recovery intervention was delivered by way of a device called the Health Buddy (Health Hero Network, Redwood City, CA). Subjects were 49 diabetic patients who had undergone a first-time CABG procedure. Although no statistical differences between groups were found, descriptively, the intervention group's baseline means on Medical Outcomes Study Short Form-36 subscales measuring physical functioning were lower but improved to levels comparable with that of the control group. Improvements in psychosocial functioning were comparable between the 2 groups. This in-home telehealth intervention may have promise for improving functioning outcomes in high-risk CABG patients with diabetes. However, weaknesses of the intervention and the need for a more focused, directive intervention were identified.