Coronary Artery Bypass Grafting Registry Research Articles

Concomitant Mitral Valve Surgery Versus No Intervention in Patients with Moderate Ischemic Mitral Regurgitation Undergoing Coronary Artery Bypass Grafting: A Propensity Score Analysis

Objectives Ischemic mitral valve regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) is associated with worse long-term outcomes. This study aimed to assess the impact of mitral valve repair with CABG in patients with moderate IMR.Materials This observational study enrolled 3,215 consecutive patients from the Juntendo CABG registry with moderate IMR and multivessel coronary artery disease who underwent CABG between 2002 and 2017.Methods The CABG alone and CABG with mitral valve surgery (MVs) groups were compared. The propensity score was calculated for each patient. Long-term all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were compared.Results Our database had 101 patients who underwent CABG with moderate IMR. Propensity score matching selected 40 pairs for final analysis. MVs was associated with increased risks of postoperative atrial fibrillation, blood transfusion, and longer hospitalization. Long-term outcomes, including all-cause mortality, cardiac mortality, and the incidence of MACCEs were similar.Conclusion Surgical treatment of moderate IMR combined with CABG was related to increased risk of several non-fatal short-term complications when compared to CABG alone, with similar long-term outcomes. Further studies are needed to determine the effects of MVs in patients with moderate IMR and severe coronary artery disease.

Ten years survival benefit of CABG or PCI based on individual prediction

Abstract Background To compare the observed and individual predicted mortalities according to the SYNTAX score II 2020 (SSII-2020) in the all-comers SYNTAX population, and retrospectively assess the appropriateness of revascularization with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with three vessel disease (3VD) and/or left main disease (LMCAD). Methods Internal and external validation of the SSII-2020 to predict 10-year all-cause death was performed in the respective randomized and registry SYNTAX populations. Differences in individual predicted mortalities following CABG or PCI were ranked and displayed with the observed mortalities. The proportions of screened patients deriving a survival benefit from CABG or PCI were determined retrospectively. Results A total of 2602 participants (as-treated population) were included in the randomized and registry cohorts. In the randomized cohort, all-cause mortality at 10 years, as an average treatment effect, was 23.8% (199/865) with CABG and 28.6% (249/901) with PCI, with a differential survival benefit of 4.6% (95% CI: 0.58% to 8.7%, log-rank p value=0.023). In the CABG and PCI registries, mortalities were 27.8% (167/644) and 55.4% (99/192), respectively. Calibration and discrimination of the SSII-2020 was helpful in CABG and PCI patients in the randomized and registry cohorts. In the PCI registry, the SSII-2020 underestimated mortality since specific comorbidities that entail high mortality are not included in the formula (C-index: 0.72, intercept: 0.38, slope: 0.66), whilst in the CABG registry, it predicted mortality with a helpful calibration and discrimination (C-index: 0.70, intercept: 0.00, slope: 0.76). The proportions of patients with a predicted survival benefit following CABG and PCI were respectively 78.3% (1383/1766) and 21.7% (383/1766) in the randomized cohort, and 82.4% (2143/2602) and 17.7% (459/2602) in the whole SYNTAX trial population. Conclusion In the randomized and registry cohort of this all-comers population with 3VD and/or LMCAD, there was reasonable agreement between the individual predicted and observed mortalities after CABG or PCI, such that the predicted 10-year survival benefit might be helpful in determining the appropriateness of each modality of revascularization. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The SYNTAX Extended Survival study was supported by the German Foundation of Heart Research (Frankfurt am Main, Germany). The SYNTAX trial, during 0-5 years follow-up, was funded by Boston Scientific Corporation (Marlborough, MA, USA). Both sponsors had no role in the study design, data collection, data analyses, and interpretation of the study data, nor were involved in the decision to publish the final manuscript. The principal investigators and authors had complete scientific freedom.

Differences Among Clinical Trials and Registries on Surgical and Percutaneous Coronary Interventions

BackgroundA need exists for systematic evaluation of the differences in baseline characteristics and early outcomes between patients enrolled in randomized controlled trials (RCTs) and clinical practice for coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). MethodsSystematic searches were conducted to identify RCTs comparing CABG vs PCI and CABG or PCI registries. Sixteen predefined baseline characteristics and 30-day mortality were extracted from the included studies. Pooled proportion and mean with 95% CI were calculated for binary and continuous outcomes, respectively, by using the random effects model. ResultsFourteen RCTs and 10 registries including more than 2 million patients were included. Registry patients who underwent CABG had a higher prevalence of hypertension, smoking, reduced left ventricular ejection fraction, and prior myocardial infarction, but a lower prevalence of single-vessel disease when compared with CABG-treated patients included in RCTs. Regarding PCI, hypertension, hyperlipidemia, left main coronary artery disease, triple-vessel coronary disease, and NYHA functional class <IV were significantly more prevalent among patients in RCTs, whereas age, reduced left ventricular ejection fraction, and smoking were more represented among PCI registry patients. Thirty-day mortality was higher in registries for both PCI-treated and CABG-treated patients. ConclusionsThere were significant differences in baseline characteristics and 30-day mortality between patients enrolled in RCTs comparing CABG vs PCI and CABG and PCI registries. However, results were mixed, and the discrepancy was less than seen in other fields.

Using real-world data to monitor and improve quality of care in coronary artery disease: results from the Netherlands Heart Registration.

Worldwide, quality registries for cardiovascular diseases enable the use of real-world data to monitor and improve the quality of cardiac care. In the Netherlands Heart Registration (NHR), cardiologists and cardiothoracic surgeons register baseline, procedural and outcome data across all invasive cardiac interventional, electrophysiological and surgical procedures. This paper provides insight into the governance and processes as organised by the NHR in collaboration with the hospitals. To clarify the processes, examples are given from the percutaneous coronary intervention and coronary artery bypass grafting registries. Physicians who are mandated by their hospital to instruct the NHR to process their data are united in registration committees. The committees determine standard sets of variables and periodically discuss the completeness and quality of data and patient-relevant outcomes. In the case of significant variation in outcomes, processes of healthcare delivery are discussed and good practices are shared in a non-competitive and safe setting. To create new insights for further improvement in patient-relevant outcomes, quality projects are initiated on, for example, multivessel disease treatment, cardiogenic shock and diagnostic intracoronary procedures. Moreover, possibilities are explored to expand the quality registries through additional relevant indicators, such as resource use before and after the procedure, by enriching NHR data with other existing data resources.Supplementary InformationThe online version of this article (10.1007/s12471-022-01672-0) contains supplementary material, which is available to authorized users.

Abstract 11988: Trends and Variation of Red Blood Cell Transfusion in Coronary Artery Bypass Grafting in China, 2014-2019

Introduction: Red blood cell (RBC) transfusion is common for cardiac surgeries, but safety problems are of concern, and some countries have taken initiatives to limit RBC use. The trends and variation of RBC transfusion in coronary artery bypass grafting (CABG) across China remain unknown, which is essential for quality control on reducing unnecessary transfusion. Hypothesis: To assess recent trends of perioperative RBC transfusion and variation across hospitals and surgeons among patients undergoing elective isolated CABG. Methods: We used data from a national CABG registry with detailed clinical information of patients undergoing elective isolated CABG between 2014 and 2019. The overall and hospital-level rates of perioperative RBC transfusion were described and compared across study years. Hierarchical models were used to make risk-adjusted between-hospital comparison, and to quantify variations derived from hospitals and surgeons. Results: A total of 47554 CABG patients from 72 hospitals were included, with a mean age of 62.7 (standard deviation [SD]: 8.8) years and 75.4% were male. The overall perioperative RBC transfusion rate was 43.9% during the study period. A remarkable decline of RBC transfusion from 51.6% in 2014 to 39.8% in 2019 (P for trend&lt;0.001) was observed, along with the mean hospital-level transfusion rate declined from 56.6% (SD: 26.9%) to 48.1% (SD: 26.1%), and minimal amounts (1-2 units) of RBC declined from 21.9% (SD: 16.3%) to 18.3% (SD: 13.1%). Hospital-level intraoperative transfusion had a similar decreasing amplitude (from 34.8% to 28.7%) with postoperative transfusion (from 38.7% to 32.4%), and the Pearson correlation coefficient was 0.32 (P&lt;0.01). After risk adjustment of patient characteristics, the median odds ratio (MOR) of perioperative RBC transfusion between hospitals was 3.9 in 2014 and reduced to 3.2 in 2019. Furtherly, the relative proportion of variation hospitals explained decreased from 88.0% to 76.0% while increased for surgeons from 12.0% to 24.0%. Conclusions: There is a considerable decline of perioperative RBC transfusion in CABG patients in China during last few years, with notable reductions in between-hospital variation. However, strategies to narrow between-surgeon variation are required.

Coronary Artery Bypass Grafting in Patients With High Risk of Bleeding

Postoperative bleeding after cardiac surgery is associated with increased morbidity and mortality. We tested the hypothesis that patients with a preoperatively estimated high risk of severe perioperative bleeding may have impaired early outcome after on-pump versus off-pump coronary artery bypass grafting (CABG). Data from 7,352 consecutive patients who underwent isolated CABG from January 2015 to May 2017 were included in the multicentre European Coronary Artery Bypass Grafting registry. The postoperative bleeding risk was estimated using the WILL-BLEED risk score. Of all included patients, 3,548 had an increased risk of severe perioperative bleeding (defined as a WILL-BLEED score ≥4) and were the subjects of this analysis. We compared the early outcomes between patients who underwent on-pump or off-pump CABG using a multivariate mixed model for risk-adjusted analysis. Off-pump surgery was performed in 721 patients (20.3%). On-pump patients received more packed red blood cell units (on-pump: 1.41 [95% confidence interval {CI} 0.99-1.86]; off-pump: 0.86 [95% CI 0.64-1.08]; p<0.001), had a longer stay in the intensive care unit (on-pump: 4.4 [95% CI 3.6-8.1] days; off-pump: 3.2 [95% CI 2.0-4.4] days; p=0.049), and a higher rate of postoperative atrial fibrillation (on-pump: 46.5% [95% CI 34.9-58.1]; off-pump: 31.3% [95% CI 21.7-40.9]; p=0.025). Furthermore, on-pump patients showed a trend towards a higher rate of postoperative stroke (on-pump: 2.4% [95% CI 0.9-4.1]; off-pump: 1.1 [95% CI 0.2-2.7]; p=0.094). Our data suggest that in patients with an increased risk of bleeding, the use of cardiopulmonary bypass is associated with higher morbidity. These patients may benefit from off-pump surgery if complete revascularisation can be ensured.

Current trends in routine myocardial revascularization

Highlights. A 12-year experience of myocardial revascularization at the Research Institute of Complex Issues of Cardiovascular Diseases is reported. An increase in the number of patients with comorbidities resulted in more complex surgeries. Perioperative mortality and complication rates are consistent with the reported global data.Aim. To assess the temporal changes in baseline characteristics of patients with coronary artery disease (CAD), the range of surgical interventions, and the structure of significant in-hospital complications following coronary artery bypass grafting (CABG).Methods. 9,043 patients who underwent CABG between 2006 and 2018 were identified from a prospective CABG registry. 1,847 (20.4%) were women (the mean age of 63.11±7.4 years) and 7,196 (79.6%) were men (the mean age of 59.0±7.9 years). The main parameters on the underlying cardiovascular disease and comorbidities, the prevalence and extent of non-cardiac atherosclerosis, the type of CABG, and the volume of associated surgical interventions as well as the structure of perioperative complications were included in the statistical analysis.Results. We determined several trends characterizing the temporal changes in the clinical, morphological, and functional status of patients. The number of women undergoing CABG has increased 2.7-fold. The mean age of patients undergoing CABG has increased by 7.3 years. Patients are present with higher rates of comorbidities, including AF, diabetes (a 2.5-fold increase), hypertension (a 12% increase), as well as severe BCA stenoses (a 2.7-fold increase), a positive history of stroke, or TIA (a 2.1-fold increase). The number of combined surgical procedures during CABG has increased by 2.9. The prevalence of perioperative neurological and hemorrhagic complications requiring revision surgery, and deep wound infection have increased 4.3-fold. Waiting time for elective CABG has significantly reduced. The number of patients with a history of myocardial infarction (a 14.5% decrease) and severe peripheral artery disease has decreased. In-hospital mortality has decreased over the past decade.Conclusion. Over the past decade, the number of patients with comorbidities who require more complex surgeries has increased at the Research Institute for Complex Issues of Cardiovascular Diseases. Perioperative mortality tends to decrease. However, an increase in the number of neurological, hemorrhagic, and infectious perioperative complications requires the initiation of new preventive measures.

Jiangsu Province Coronary Artery Bypass Grafting Registry study: a report of 4 661 patients in 13 centers

Objective: To examine the overall status of the Jiangsu Province Coronary Artery Bypass Grafting Registry database. Methods: The patients date of Jiangsu Province Coronary Artery Bypass Grafting Registry database from October 2017 to December 2019 was collected retrospectively.Risk factors, history, cardiac function (New York Heart Association class), extent of coronary artery lesion, European system for cardiac operative risk evaluation Ⅱ (EuroSCORE Ⅱ), cardiopulmonary bypss, arterial grafts, the numbers and flow of grafts and postoperative major adverse cardiac and cerebrovascular event(MACCE) information were analyzed. The clinical data of patients underwent on-pump CABG(ONCABG) or off-pump CABG (OPCAB) were compared by t test or χ(2) test. Results: Up till December 2019, the database enrolled 7 138 patients, in which 4 661 patients receiving primary isolated CABG. There were 3 486 males and 1 175 females with the age of (64.6±8.1) years (range:31 to 87 years). There were coronary left main disease in 960 patients, triple vessel disease in 3 934 patients, both left main and triple vessel disease in 837 patients, ejection fraction>50% in 3 841 patients, cardiac function class Ⅲ to Ⅳ in 1 664 patients. EuroSCORE Ⅱ was (2.3±0.7)% (range: 0.5% to 35.8%). There were 2 731 patients (58.59%) underwent ONCABG and 1 930 patients (41.41%) underwent OPCAB. There were 4 144 patients (88.91%) for whom the left internal thoracic artery was harvested. Seven centers (2 centers routinely) used left radial artery, 5 centers (3 centers routinely) used the transit time flow meter. The graft was 3.4±0.7 (range:1 to 7), the aortic crossclamp time was (65.0±20.4) minutes (range: 21 to 196 minutes), the cardiopulmonary bypass time was (90.0±24.2) minutes (range: 33 to 227 minutes). In-hospital death ocurred in 84 patients(1.80%), while re-operation in 93 patients (2.00%), myocardial infarction in 71 patients (1.52%), cerebral infarction in 33 patients (0.71%) and dialysis in 56 patients (1.20%). There were 2 936 patients prescribed with secondary prevention drugs(62.99%).Comparing with OPCAB group, ONCABG group had younger age, more female, more diabetes mellitus, more history of myocardial infarction and percutaneous transluminal coronary angioplasty, poorer cardiac function and coronary lesions, higher EuroSCORE Ⅱ, preoperatively (all P<0.05), and was associated with higher MACCE (135/2 731 vs. 71/1 930, χ(2)=4.280, P=0.039), and of more grafts, transfusion and intra-aortic balloon counterpulsation application (all P<0.05). Conclusions: Jiangsu Province Coronary Artery Bypass Grafting Registry database is generally in good operation, and some parameters still need to be improved. Comparing with OPCAB group, ONCABG has more severe preoperative general conditions, while the outcomes is acceptable.

Outcome of Percutaneous Coronary Intervention in Relation to the Institutional Volume of Coronary Artery Bypass Surgery.

Background: Percutaneous coronary intervention (PCI) is performed in a wide range of institutions. We sought to assess the relationship between coronary artery bypass grafting (CABG) volume relative to PCI volume and clinical outcome using nationally representative PCI and CABG registries in Japan. Methods: This was a collaborative, registry-based cohort study enrolling patients undergoing percutaneous coronary intervention in 2013–2014 using Japanese nationwide registry (J-PCI) with follow up until discharge. The absolute volume of CABG for each hospital was calculated using additional data from Japan CardioVascular Surgery Database (JCVSD). Patients undergoing their first PCI registered in the registry (N = 220,934), at 943 facilities were studied. Main outcomes were in-hospital mortality, and incidence of composite of in-hospital death and postprocedural complications. Results: Among the 220,934 patients, 162,411 were men, with a mean age of 69.7 (SD 11.6) years. Patients underwent PCI at hospitals with varying CABG volume: The overall in-hospital mortality and composite event rate for PCI patients was 0.9% and 2.4%, respectively. CABG volume was associated with the in-hospital mortality of PCI at facilities performing less than 200 PCIs per year, but not at facilities performing 200 or more. Similarly, in-hospital mortality or complication was associated with PCI volume <200 only if no CABG is done at the facility. The result remained largely consistent in subgroup of patients presenting with acute coronary syndrome or even after excluding these institutions with extremely low number of PCI (<50 cases/year) or CABG (<15 cases / year). Conclusions: In a nationwide registry-based analysis, the surgical volume was associated with patients’ clinical outcome after PCI, when limited number of PCIs were performed at the facility.

Fate of Grafts Bypassing Nonischemic Versus Ischemic Inducing Coronary Stenosis

There is a lack of evidence regarding the efficacy of ischemia-guided coronary artery bypass grafting. We compared the incidence of graft failure between grafts bypassing ischemia-inducing and nonischemia-inducing stenoses. Between 1997 and 2011, 2,304 patients for whom baseline coronary angiography and myocardial perfusion imaging were available were identified from a single-center coronary artery bypass grafting registry. According to baseline myocardial perfusion imaging, each graft was assigned to either graft bypassing ischemia-inducing or nonischemia-inducing stenoses (ischemia-related grafts, n = 4,904; ischemia-unrelated grafts, n = 2,709). Graft failure was defined as total occlusion on coronary computed tomography angiography, performed at the discretion of the treating physician. The incidence of graft failure was compared on a per-graft basis. At 5 years, the incidence of graft failure was significantly higher in the ischemia-unrelated grafts (4.2% vs 2.9% in ischemia-related grafts; p = 0.003). Ischemia-related graft was an independent determinant of graft patency (adjusted hazard ratio 0.61; 95% confidence interval 0.44 to 0.84; p = 0.002). Increased risk of graft failure associated with ischemia-unrelated graft was observed only in the internal thoracic artery (3.3% vs 2.0%, p = 0.021) and arterial grafts (6.5% vs 4.3%, p = 0.020), but not in the venous grafts (2.7% vs 2.7%; p = 0.99). In terms of major adverse cardiac and cerebrovascular events, 5-year incidences were comparable between the patients with and without ischemia-unrelated grafts (219, 19.3% vs 160, 18.0%; p = 0.61). In conclusion, ischemia-unrelated grafts became dysfunctional more frequently than ischemia-related grafts, and were not preventive of adverse events.

Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting: results from the multicentre E-CABG registry.

No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG). This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6%) ranged from 0.7% to 24.8% between centres (adjusted P < 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2-3, OR 1.66, 95% confidence interval (CI) 1.27-2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3-4, OR 1.50, 95% CI 1.16-1.93]. The incidence of resternotomy for bleeding (overall 2.6%) ranged from 0% to 6.9% (adjusted P < 0.0001), and surgical site bleeding (overall 59.6%) ranged from 0% to 84.6% (adjusted P = 0.003). The rate of the UDPB bleeding grades 3-4 (overall 8.4%) ranged from 3.7% to 22.3% (P < 0.0001), and of the E-CABG bleeding grades 2-3 (overall 6.5%) ranged from 0.4% to 16.4% between centres (P < 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95% CI 2.85-8.92), UDPB bleeding grades 3-4 (adjusted OR 6.61, 95% CI 4.42-9.88), and E-CABG bleeding grades 2-3 (adjusted OR 8.71, 95% CI 5.76-13.15) were associated with an increased risk of hospital/30-day mortality. Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products.

IMPACT OF GENDER AND AGE ON IN-HOSPITAL OUTCOMES OF CORONARY ARTERY BYPASS GRAFTING

Aim. To evaluate the impact of age and gender on in-hospital outcomes of coronary artery bypass grafting (CABG) in patients with coronary artery disease. Methods. 538 (79.10 %) men and 142 (20.90 %) women ( n = = 680) in the CABG registry of the Research Institute for Complex Issues of Cardiovascular who were referred to CABG in the period from 2011 to 2012 were retrospectively reviewed to assess the prevalence of comorbidities and estimate the in-hospital outcomes. The mean age of patients was 59.12 ± 7.98 (33 to 78 years). All patients were assigned to 4 age groups: Group 1 - 70 years. The statistical analysis was performed using the software package SPSS 20.0.1. A p value of <0.05 was considered statistically significant. Results. Women were commonly older than men and had a positive history of hypertension, chronic heart failure and higher angina class, obesity, type 2 diabetes, impaired glucose tolerance, non-ulcerative lesions of the gastrointestinal (GI) tract (gastritis, cholecystitis and / or pancreatitis). The male group was superior to the female group in the number of smokers and prior myocardial infarction. The incidence of first detected atrial fibrillation, atrial flutter, as well as ischemic strokes, congestive pneumonia increased with aging in both men and women within the in-hospital period. However, women, particularly from the younger age group (<50 years), more frequently suffered from ischemic strokes, GI bleedings, exacerbation of erosive gastritis, compared with men. Women from the older age group commonly had hydrothorax requiring pleural puncture, surgical wound healing complications, and exacerbation or / the first detected duodenal and / or stomach ulcers, compared to men. Conclusion: Female gender is associated with a significantly higher rate of the in-hospital complications compared to men. However, the impact of gender is mediated by age differences between men and women undergoing CABG.

AGE PECULIARITIES OF COMORBID PATHOLOGY IN PATIENTS UNDERGOING PLANNED CORONARY ARTERYBYPASS GRAFTING

Background: The number of elderly patients undergoing coronary artery bypass grafting (CABG) is increasing worldwide. Therefore, the assessment of comorbidities based on the age factor in patients with coronary artery disease (CAD) is highly relevant.Aim: To assess the associations between the age factor and comorbidities in patients undergoing CABG. Material and Methods: Data of 680 patients [538 (79.10%) men and 142 (20.90%) women], undergoing elective CABG in the period 2011-2012, included in the CABG Registry were used to detect comorbidities.All patients were enrolled into 4 age groups: below 50 years, 51-60 years, 61-70 years, over 70 years.Results: Aging was associated with an increase in the proportion of women suffering from arterial hypertension (AH), and multivessel disease. Similarly, the proportion of patients with higher func-tional class (FC) of angina, heart failure (CH), and heart rhythm disturbances increased. The number of patients referred to elective CABG with previous myocardial infarction (MI) was the highest among young adults (77%). Aging was associated with an increase in the number of patients with chronic pyelonephritis (44.30%) and thyroid pathology (3.40%).Conclusion: Patients’ aging is associated with an increase in cardiovascular comorbidities, but not MI. Importantly, there was no any increase in the rate of non-cardiovascular comorbidities.

The impact of minor blood transfusion on the outcome after coronary artery bypass grafting

PurposeTo investigate the impact of minor perioperative bleeding requiring transfusion of 1–2 red blood cell (RBC) units on the outcome after coronary artery bypass grafting (CABG). MethodsSixteen cardiac surgical centers contributed to the prospective European CABG registry (E-CABG). 1014 patients receiving 1–2 RBC units during or after isolated CABG were compared to 2264 patients not receiving RBCs. ResultsIn 827 propensity score matched pairs, transfusion of 1–2 RBC units did not affect the risk of in-hospital/30-day death (p=0.523) or stroke (p=0.804). However, RBC transfusion was associated with an increased risk of acute kidney injury (p=0.008), sternal wound infection (p=0.001), postoperative use of antibiotics (p=0.001), prolonged use of inotropes (p<0.0001), use of intra-aortic balloon pump (p=0.012), length of intensive care unit stay (p<0.0001) and length of in-hospital stay (p<0.0001). Matched paired analysis excluding pre- and postoperative critical hemodynamic conditions showed that RBC transfusion was associated with an increased risk of major complications except in-hospital/30-day death. ConclusionMinor perioperative bleeding and subsequent transfusion of 1–2 RBC units did not affect the risk of early death, but increased the risk of other major adverse events. Minimizing perioperative bleeding and prevention of even low-volume RBC transfusion may improve the outcome after CABG.

The Effect of Preoperative Anemia on the Outcome After Coronary Surgery.

Preoperative anemia is associated with increased morbidity and mortality after cardiac surgery. Since anemia is ultimately treated with red blood cell transfusions, we investigated the independent impact of anemia and transfusion on the outcome after coronary artery bypass grafting (CABG). This study included 2761 consecutive patients who underwent isolated CABG. Anemia was defined as hemoglobin <12.0g/dL in women and <13.0g/dL in men. The main outcomes were 30-day and late mortality. Patients with preoperative anemia had an increased prevalence of significant comorbidities and were associated with higher unadjusted risk of early and late adverse events. Propensity score matching resulted in 560 pairs with similar baseline and operative characteristics. In these matched pairs, anemic patients had an increased risk of late all-cause death (P=0.047) and acute kidney injury (P<0.0001). However, when adjusted for the severity of perioperative bleeding, preoperative anemia was not associated with an increased mortality risk (HR 1.10, 95% CI 0.86-1.39). Instead, this regression model showed that the European CABG registry (E-CABG) bleeding classification was an independent predictor of late mortality (compared to grade 0: grade 1, HR 1.93, 95% CI 1.37-2.73, grade 2, HR 2.19, 95% CI 1.50-3.18, grade 3, HR 5.59, 95% CI 3.34-9.39, P<0.0001). When adjusted for important baseline characteristics and operative factors as well as for the severity of perioperative bleeding and the amount of transfused blood products, anemia was not associated with an increased risk of adverse events. Increased exposure to blood transfusion among anemic patients may be the determinant of their poorer late survival.

Abstract 11233: Trends in Coronary Revascularization and Ischemic Heart Disease-Related Mortality in Israel

Introduction: This study investigated national trends in percutaneous coronary angioplasty (PCI), coronary artery bypass grafting (CABG) and ischemic heart disease (IHD)-related mortality in Israel. Methods: Using ICD-9 and 10 codes we linked 5 Israeli national databases: the Centers for Disease Control National PCI and CABG Registries, Ministry of Health Hospitalization Reports, Center of Bureau of Statistics and the Ministry of Interior Mortality Report to assess the annual PCI and CABG volume, procedural mortality, co-morbidities and IHD-related mortality between 2002 and 2014. Time trends were analyzed using linear regression, assuming a Poisson distribution. Results: A total of 341,056 revascularization procedures (PCI-298,390, CABG-42,666) were performed during the study period. The volume of PCI increased by 9% from 2002 to 2008 (378.0/100K to 423.2/100K) and then steadily decreased to 378.5/100K in 2014 (p=0.70 for the trend). CABG volume decreased by 58% (109.0/100K to 45.8/100K) from 2002 to 2012 leveling during the last 3 years to 46.3/100K (p&lt;0.0001). The PCI/CABG ratio increased from 3.6 in 2002 to 8.5 in 2012, slightly decreasing to 8.2 by 2014 (P&lt;0.0001). In-hospital procedural mortality remained stable (PCI- 1.2-1.6%, p=0.34, CABG- 3.7-4.4%, p=0.29) despite a significant change in patient characteristics. During the study period, annual IHD-related mortality decreased by 46% (84.6 to 46/100K, p&lt;0.001). Conclusions: We observed a dramatic change in coronary revascularization procedures type and volume with a parallel marked decrease in IHD-related mortality in Israel. Improvement in medical treatment, better patient selection related to data derived from large-scale clinical trials and adherence to appropriateness criteria, as well as improved procedural techniques and technology may account for these changes.

Comparison of 5-Year Outcomes After Coronary Artery Bypass Grafting in Heart Failure Patients With Versus Without Preserved Left Ventricular Ejection Fraction (from the CREDO-Kyoto CABG Registry Cohort-2)

Heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) is regarded as an independent risk factor for poor outcomes after coronary artery bypass grafting (CABG). However, the impact of HF with preserved EF (HFpEF) still has been unclear. We identified 1,877 patients who received isolated CABG of 15,939 patients who underwent first coronary revascularization enrolled in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) Registry Cohort-2. Of them, 1,489 patients had normal LV function (LVEF >50% without a history of HF; Normal group), 236 had HFrEF (LVEF ≤50% with HF), and 152 had HFpEF (LVEF >50% with HF). Preoperative LVEF was the lowest in the HFrEF group (62 ± 12%, 36 ± 9%, and 61 ± 7% for the Normal, HFrEF, and HFpEF groups, respectively; p <0.001). Unadjusted 30-day mortality rate was the highest in the HFrEF group (0.5%, 3.0%, and 0.7%; p= 0.003). However, cumulative incidences of all-cause death at 5-year was the highest in the HFpEF group (14%, 27%, and 32%, respectively; p <0.001). After adjusting confounders, the risk of all-cause death in the HFpEF group was greater than the Normal group (hazard ratio [HR] 1.42; 95% confidence interval [CI] 1.02 to 1.97; p= 0.04). The risk of all-cause death was not different between the HFpEF and the HFrEF groups (HR 0.88; 95% CI 0.61 to 1.29; p= 0.52). In addition, the risks of cardiac death and sudden death in the HFpEF group were greater than the Normal group (HR 2.14, 95% CI 1.32 to 3.49, p= 0.002; and HR 3.60, 95% CI 1.55 to 8.36, p= 0.003, respectively), and the risks of those end points were not different between the HFrEF and the HFpEF groups. Despite low 30-day mortality rate after CABG in patients with HFpEF, HFpEF was associated with high risks of long-term death and cardiovascular events. Patients with HFpEF, as well as HFrEF, should be carefully operated and followedup.

The Value of Adding Laboratory Data to Coronary Artery Bypass Grafting Registry Data to Improve Models for Risk-Adjusting Provider Mortality Rates

Clinical databases are currently being used for calculating provider risk-adjusted mortality rates for coronary artery bypass grafting (CABG) in a few states and by the Society for Thoracic Surgeons. These databases contain very few laboratory data for purposes of risk adjustment. For 15 hospitals, New York's CABG registry data from 2008 to 2010 were linked to laboratory data to develop statistical models comparing risk-adjusted mortality rates with and without supplementary laboratory data. Differences between these two models in discrimination, calibration, and outlier status were compared, and correlations in hospital risk-adjusted mortality rates were examined. The discrimination of the statistical models was very similar (c = 0.785 for the registry model and 0.797 for the registry/laboratory model, p =0.63). The correlation between hospital risk-adjusted mortality rates by use of the two models was 0.90. The registry/laboratory model contained three additional laboratory variables: alkaline phosphatase (ALKP), aspartate aminotransferase (AST), and prothrombin time (PT). The registry model yielded one hospital with significantly higher mortality than the statewide average, and the registry/laboratory model yielded no outliers. The clinical models with and without laboratory data had similar discrimination. Hospital risk-adjusted mortality rates were essentially unchanged, and hospital outlier status was identical. However, three laboratory variables, ALKP, AST, and PT, were significant independent predictors of mortality, and they deserve consideration of addition to CABG clinical databases.

SinoSCORE: a logistically derived additive prediction model for post-coronary artery bypass grafting in-hospital mortality in a Chinese population

This study aims to construct a logistically derived additive score for predicting in-hospital mortality risk in Chinese patients undergoing coronary artery bypass surgery (CABG). Data from 9839 consecutive CABG patients in 43 Chinese centers were collected between 2007 and 2008 from the Chinese Coronary Artery Bypass Grafting Registry. This database was randomly divided into developmental and validation subsets (9:1). The data in the developmental dataset were used to develop the model using logistic regression. Calibration and discrimination characteristics were assessed using the validation dataset. Thresholds were defined for each model to distinguish different risk groups. After excluding 275 patients with incomplete information, the overall mortality rate of the remaining 9564 patients was 2.5%. The SinoSCORE model was constructed based on 11 variables: age, preoperative NYHA stage III or IV, chronic renal failure, extracardiac arteriopathy, chronic obstructive pulmonary disease, preoperative atrial fibrillation or flutter (within 2 weeks), left ventricular ejection fraction, other elective surgery, combined valve procedures, preoperative critical state, and BMI. In the developmental dataset, calibration using a Hosmer-Lemeshow (HL) test was at P = 0.44 and discrimination based on the area under the receiver operating characteristic curve (ROC) was 0.80. In the validation dataset, the HL test was at P = 0.34 and the area under the ROC (AUC) was 0.78. A logistically derived additive model for predicting in-hospital mortality among Chinese patients undergoing CABG was developed based on the most up-to-date multi-center data from China.

Analysis of Stroke Occurring in the SYNTAX Trial Comparing Coronary Artery Bypass Surgery and Percutaneous Coronary Intervention in the Treatment of Complex Coronary Artery Disease

This study sought to analyze stroke rates in the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial's randomized and registry cohorts of patients being treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for treatment of complex coronary artery disease. The SYNTAX trial compared PCI to CABG in patients with de novo 3-vessel and/or left main coronary disease. The SYNTAX randomized trial was conducted at 85 U.S. and European sites (n = 1,800). All strokes (up to 4 years) were independently adjudicated by a clinical events committee that included a neurologist. An additional 1,077 (of which 644 were followed for 5 years) and 198 patients were included in the CABG and PCI registries, respectively. In the randomized cohort, 31 CABG and 19 PCI patients experienced 33 and 20 strokes post-randomization at 4-year follow-up, respectively (p = 0.062). Three strokes occurred pre-procedurally but following randomization in CABG-treated patients. After CABG, a large proportion of strokes occurred acutely (0 to 30 days: 9 of 33), whereas in the PCI arm, most strokes occurred >30 days after the procedure (18 of 20). Stroke resulted in death in 3 patients in both the PCI and CABG groups. Of the patients who developed stroke, 68% (21 of 31) in the CABG group had residual deficits at discharge; in the PCI group, 47% (9 of 19) had residual deficits. In a multivariate analysis, treatment with CABG was not significantly associated with increased stroke rates (odds ratio: 1.67, 95% confidence interval: 0.93 to 3.01, p = 0.089). The incidence and outcomes of stroke were similar in the randomized trial and registries. There is a higher risk of periprocedural stroke in patients undergoing CABG versus PCI; however, the risk converges over the first 4 years of follow-up. (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).