Emergency Coronary Artery Bypass Graft Surgery Research Articles

Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching

To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. At a tertiary care teaching hospital. A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. None. Propensity-matched post-ERAS (n=565) versus pre-ERAS patients (n=330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p=0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p=0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p=0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n=1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β2 coefficient -1.943 [-3.766 to -0.121], p=0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.

Trends, Outcomes, and Predictive Score For Emergency Coronary Artery Bypass Graft Surgery After Elective Percutaneous Coronary Intervention (from a Nationwide Dataset)

The temporal trends and preprocedural predictors of emergency coronary artery bypass graft surgery (ECABG) after elective percutaneous coronary intervention (PCI) in the contemporary era are largely unknown. From January 2003 to December 2014 elective hospitalizations with PCI as the primary procedure were extracted from the Nationwide Inpatient Sample. ECABG was identified as CABG within 24 hours of elective PCI. Temporal trends of elective PCI, ECABG, comorbidities, and in-hospital mortality were analyzed. Logistic regression model was used to identify preprocedural independent predictors of ECABG and post-PCI ECABG risk score was developed using the regression coefficients from the logistic regression model in the development cohort. The score was then validated in the validation cohort. Of 1,605,641 elective PCI procedures included in the final analysis, 5,561 (0.3%) patients underwent ECABG. The incidence of ECABG, co-morbidities and overall in-hospital mortality increased over the study period, whereas the in-hospital mortality after ECABG remained unchanged. An increasing trend of elective PCI performed at facilities without on-site CABG was noted, with a higher unadjusted in-hospital mortality in this cohort. ECABG risk score, performed well with a significantly higher risk of ECABG in those patients with a score in the highest tertile compared with those with lower ECABG score (0.6% vs 0.3%, p = 0.0005). In conclusion, an increasing trend of adverse outcomes after elective PCI is observed. We describe an easy-to-use predictive score using preprocedural variables that may allow the operator to triage the patient to an appropriate setting in an effort to improve outcomes.

Relationship between maximum clot firmness in ROTEM® and postoperative bleeding after coronary artery bypass graft surgery in patients using clopidogrel.

Background:The aim of the present study was to investigate the relationship between maximum clot firmness (MCF) in rotational thromboelastometry (ROTEM®) and postoperative bleeding in patients on clopidogrel after emergency coronary artery bypass graft surgery (CABG).Methods:This observational study recruited 60 patients posted for emergency CABG following unsuccessful primary percutaneous coronary intervention (PCI) while on 600 mg of clopidogrel. The study population was divided into 2 groups on the basis of their MCF in the extrinsically activated thromboelastometric (EXTEM) component of the (preoperative) ROTEM® test: patients with MCF <50 mm (n = 16) and those with MCF ≥50 mm (n = 44). Postoperative chest tube drainage amount, need for blood product transfusion, postoperative complications, and duration of mechanical ventilation after CABG were recorded.Results:No significant differences were observed between the two groups regarding duration of surgery, cardiopulmonary bypass, and aortic cross-clamp time. Chest tube drainage at 6, 12, and 24 h after Intensive Care Unit admission were significantly higher in the patients with MCF below 50 mm. The need for blood product transfusion was higher in the group with MCF <50 mm. In patients who experienced postoperative bleeding of 1000 mL or more, the ROTEM® parameters of INTEM (Intrinsically activated thromboelastomery) α and MCF, EXTEM α and MCF, and HEPTEM (INTEM assay performed in the presence of heparinase) MCF (but not FIBTEM (Thromboelastometric assay for the fibrin part of the clot) values) were significantly lower than those with postoperative bleeding <1000 mL (P ≤ 0.05).Conclusions:When platelet aggregometry is not available, the ROTEM® test could be useful for the prediction of increased risk bleeding after emergency CABG in patients who have received a loading dose of clopidogrel.

Abstract 18046: Emergency Coronary Artery Bypass Grafting for Cardiogenic Shock Complicating Acute Myocardial Infarction is Associated With Satisfactory Long-term Outcomes in Hospital Survivors

Introduction: Cardiogenic shock (CS), which is one of the most dreadful complications following acute myocardial infarction (AMI), is an indication for emergent coronary artery bypass graft surgery (CABG) in patients not amenable for percutaneous coronary intervention. Our study aimed to identify risk factors for 30-day and long-term mortality in patients presenting with AMI complicated by CS requiring emergency CABG. Methods: Preoperative characteristics, operative parameters, and postoperative outcomes were prospectively collected for 508 patients undergoing CABG for CS complicating AMI (ST-elevation MI [STEMI]:42.9%;non-STEMI:57.1%) in our database between January 2000 and June 2014. Predictors of 30-day and long-term mortality were identified by logistic and Cox regression analyses, respectively. Results: Mean age was 69±10 years. 78.3% of patients had 3-vessel and 47% left main disease. Almost 50% of patients had left ventricular function &lt;30% with 29.6%, 37.9%, 46.7% and 9.8% requiring preoperative resuscitation, ventilator, intra-aortic balloon pump and extracorporeal membrane oxygenation support (ECMO), respectively. 30-day mortality was 31.9% and was independently predicted by peripheral vascular disease [PVD] (odds ratio [OR]:1.8; 95% confidence interval [CI]:1.1-2.9;p=0.02), STEMI (OR:1.9;95%CI:1.2-2.8;p=0.004), lactate levels &gt;4mmol/l (OR:3.3;95%CI:1.7-6.5;p&lt;0.0001) and ECMO support (OR:5.0;95%CI:2.6-9.9;p&lt;0.0001). Cumulative survival was 51% at 1 year, 44% at 3 years and 33% at 5 years and correspondingly improved to 74%, 64% and 48%, when 30-day mortality was excluded from the analysis. Incremental age (OR:1.04,p&lt;0.0001), STEMI (OR:1.3,p=0.02), PVD (OR:1.4,p=0.03), diabetes (OR:1.5,p=0.001), lactate levels &gt;4mmol/l (OR:2.3,p&lt;0.0001) and high preoperative inotropic (OR:1.3,p=0.02), and ECMO support (OR:3.3,p&lt;0.0001) predicted late mortality. Conclusion: Emergency CABG in patients with AMI complicated by CS was associated with high 30-day mortality, which was independently predicted by severe preoperative hemodynamic instability and presence of STEMI. Satisfactory long-term survival is observed in patients who survived the operation, demonstrating the benefit of emergency CABG.

Frequency and predictors of cognitive decline in patients undergoing coronary artery bypass graft surgery.

To determine the frequency of cognitive impairment and its predictors in patients, who underwent first time coronary artery bypass graft surgery (CABGS). An observational study. The National Institute of Cardiovascular Diseases (NICVD), Karachi, from December 2008 to December 2009. Study included patients > 18 years, who underwent first-time elective CABGS. Emergency CABGS, with additional cardiac procedures, myocardial infarction (MI) within one month and known psychiatric illness were excluded. Patients were evaluated for their socio-demographic profile, medical history, intra-operative, anesthetic and surgical techniques and postoperative complications/therapy in ICU. Cognitive functioning, before the surgery, at discharge, 6 weeks and 6 months post-CABG was evaluated by McNair's and MMSE scales. HDRS was added to see if depression was a confounding factor for cognitive decline. One hundred and thirty four patients were followed-up at discharge, 74 at 6 weeks and 73 at 6 months. There were 113 (84.3%) males and 21 (15.7%) females, with mean age of 53.7 ± 8.36 years. Prevalence of cognitive disturbance at baseline was 44.8%, which increased to 54.5% at discharge, and improvement was seen at 6 months, it was 39.7%. Older age, female gender, higher bleeding episodes, and high post-surgery creatinine level were more frequently associated with cognitive decline. Postoperative cognitive deficit was common and remained persistent at short-term. Older age, females and high postoperative creatinine were identified as its important predictors. There was high frequency of acute depression before surgery with significant reduction over time.

Coronary endarterectomy for severe diffuse coronary artery disease.

To determine the outcome of Coronary Endarterectomy (CE) in patients undergoing Coronary Artery Bypass Graft (CABG) surgery for diffuse Coronary Artery Disease (CAD), in terms of postoperative mortality and morbidity, relief from angina and survival at one year. A case series. Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from January 2003 to November 2005. Included in the study were all patients with such diffuse CAD that conventional bypass grafting was not possible. Those with the diseased coronary artery supplying an akinetic myocardium and a fixed perfusion defect on perfusion scan, or with poor left ventricular function (ejection fraction<30%) in association with severe chronic hepatic disease and deranged liver function tests, permanent severe immune deficiency state, or poor results at lung function tests were excluded. Cardiopulmonary Bypass (CPB) was used in all patients. All patients were followed up for a mean time of one year, for assessment of postoperative mortality and morbidity, relief from angina and survival. Fifty five patients (3.2%) underwent CE of at least one major coronary artery for severe diffuse atheromatous disease. The mean age was 53.9+/-9.5 years. Twenty six (47.3%) had previous Myocardial Infarction (MI), 16 (29.1%) had unstable angina, 12 (21.8%) had poor Left Ventricular (LV) function, 5 (9.1%) underwent emergency CABG surgery for impending infarction, 39 (70.9%) had angina Canadian Cardiovascular Society (CCS) class II/III, 11 (20%) had critical left main stem disease and 12 (21.8%) required Intra-Aortic Balloon Pump (IABP) for hemodynamic support. There were 2 (3.6%) early deaths and 2 (3.6%) cases of non-fatal infarctions. Three (5.4%) patients had low Cardiac Output (CO) after operation. At one year follow-up, there were no late deaths and 43 patients (91.5% of those reporting for follow-up) did not have angina. CE acted as an adjunct to CABG surgery with acceptable operative risks and satisfactory results at one year in terms of mortality and angina relief.

The predictive value of white blood cell count on the success of primary percutaneous intervention of the left anterior descending artery in patients admitted with acute anterior wall myocardial infarction

Background: Epidemiological studies have shown correlations between the white blood cell (WBC) count and the risk of acute myocardial infarction (AMI) and stroke. The risk of AMI is four times as great in patients with WBC counts in the high-normal range (>9000/μl) as it is in those in the low-normal range (<6000/μl). A high WBC count also predicts a greater risk of re-infarction and in-hospital death. Data are still missing about the role of WBC count in the success rate of primary angioplasty. Methods: A total of 125 consecutive patients aged 40–65 years (mean age 54±8 years) had a primary percutaneous coronary intervention (PCI) as their first-line therapy for AMI. We evaluated interrelationships between WBC count, hemoglobin (Hg), platelets (PLT), heart rate (HR), left ventricular systolic (LVS) pressure, left ventricular diastolic (LVD) pressure, and the success rate of primary angioplasty to the occluded left anterior descending artery (LAD) in patients with AMI. Results: Of the 125 patients (30 females and 95 males), 72 underwent primary PCI to the LAD and 31 patients were referred for an emergency coronary artery bypass graft surgery (CABG). One patient died. Twenty-one patients had non-occluded arteries, most of them with a fresh thrombus and after spontaneous reperfusion. Multiple logistic dregression analysis demonstrated that low ejection fraction ( p=0.01) and high WBC counts ( p=0.04) were correlated with failure of angioplasty and referral for an emergency CABG. WBC counts were positively correlated with heart rate ( p=0.005), platelet count ( p=0.0006), and Hg level ( p=0.001). Conclusions: These data suggest that measuring WBC count on admission to the catheterization laboratory for primary angioplasty provides clinically important prognostic information.

Gender-related changes in the practice and outcomes of percutaneous coronary interventions in northern New England from 1994 to 1999

ObjectivesWe sought to determine whether the changing practice of interventional cardiology has been associated with improved outcomes for women, and how these outcomes compare with those for men. BackgroundPrevious work from the early 1990s suggested women are at a higher risk than men for adverse outcomes after percutaneous coronary interventions (PCIs). MethodsFrom 1994 to 1999 data were collected on 33,666 consecutive hospital admissions for a PCI in Northern New England. Multivariate models were used to adjust for differences in case-mix across year of procedure when comparing outcomes. Direct standardization was used to calculate adjusted rates. ResultsFrom 1994 to 1999, the case-mix worsened for both women and men, although women had more co-morbidities than did men throughout the period. Stent use increased over time (>75% in 1999). Concomitantly, the need for emergency coronary artery bypass graft surgery (CABG) decreased significantly (ptrend≤ 0.001; in 1999: 0.06% for women, 0.05% for men). Although the emergency CABG rates were higher for women at the beginning of the study, by the end, they were comparable (adjusted odds ratio 1.34, 95% confidence interval 0.76 to 2.38, p = 0.315). The myocardial infarction (MI) rates decreased over time for both women (by 29.7%, ptrend= 0.378) and men (by 37.6%, ptrend= 0.009) and did not differ by gender. The mortality rates did not decrease significantly over time and were not significantly different between the genders (mean 1.21% for women, 1.06% for men; p = 0.096). ConclusionsConcurrent with the changing practice of PCI, and despite treating sicker patients, there have been important improvements in post-PCI CABG and MI rates for women, as well as for men. Unlike in earlier years, there are no longer significant differences in outcomes by gender.

Changing outcomes in percutaneous coronary interventions: A study of 34,752 procedures in Northern New England, 1990 to 1997

OBJECTIVESWe sought to evaluate the changing outcomes of percutaneous coronary interventions (PCIs) in recent years.BACKGROUNDThe field of interventional cardiology has seen considerable growth in recent years, both in the number of patients undergoing procedures and in the development of new technology. In view of recent changes, we evaluated the experience of a large, regional registry of PCIs and outcomes over time.METHODSData were collected from 1990 to 1997 on 34,752 consecutive PCIs performed at all hospitals in Maine (two), New Hampshire (two) and Vermont (one) supporting these procedures, and one hospital in Massachusetts. Univariate and multivariate regression analyses were used to control for case mix. Clinical success was defined as at least one lesion dilated to <50% residual stenosis and no adverse outcomes. In-hospital adverse outcomes included coronary artery bypass graft surgery (CABG), myocardial infarction and mortality.RESULTSOver time, the population undergoing PCIs tended to be older with increasing comorbidity. After adjustment for case mix, clinical success continued to improve from a low of 88.2% in earlier years to a peak of 91.9% in recent years (p trend <0.001). The rate of emergency CABG after PCI fell in recent years from a peak of 2.3% to 1.3% (p trend <0.001). Mortality rates decreased slightly from 1.2% to 1.1% (p trend 0.007).CONCLUSIONSThere has been a significant improvement in clinical outcomes for patients undergoing PCIs in northern New England, including a significant decline in the need for emergency CABG.

Prevention of distal embolization during saphenous vein graft lesion angioplasty. Experience with a new temporary occlusion and aspiration system.

Repeat coronary artery bypass graft surgery (CABG) is associated with a high morbidity and mortality, rendering percutaneous treatment of saphenous vein graft (SVG) lesions an attractive alternative. However, percutaneous interventions of degenerated SVGs carries high risk of distal embolization. This study reports our initial experience with the PercuSurge GuardWire, a new device developed to prevent embolization during treatment of degenerated SVG. This device consists of a 190-cm-long, hollow 0.014-in guidewire with a central lumen connected to a distal occlusion balloon. A dedicated inflation device (the MicroSeal Adapter) was used to inflate the distal balloon and maintain complete lumen occlusion during balloon dilatation and stent implantation. A monorail aspiration catheter, connected to a vacuum syringe, was used to evacuate atherosclerotic and thrombotic debris. Angioplasty with stent implantation was performed in 15 degenerated SVGs (18 lesions). Procedural success was achieved in all patients with normal postprocedure flow (Thrombolysis in Myocardial Infarction grade 3). No distal embolization was observed. There were no major in-hospital adverse clinical events, including Q-wave or non-Q-wave myocardial infarction, emergency CABG, or death. All patients were asymptomatic at discharge. This preliminary series supports the feasible use of the PercuSurge GuardWire for retrieval of plaque debris and prevention of embolization in degenerated SVGs. The good tolerance of temporary occlusions without angiographic or clinical evidence of distal embolization represents encouraging early findings.

742-5 Population Trends In Emergency Coronary Artery Bypass Graft Surgery

In a population-based registry of all Minneapolis–St. Paul residents who had coronary artery bypass graft (CABG) surgery, emergency CABG surgery (ECS) as a proportion of the total surgery steadily increased from 2.4% in 197074 to 12% in 1985–90. Operative mortality (OM, death within 30 days of CABG surgery) for ECS was significantly higher than OM for elective and urgent CABG surgery (odds ratio, OR = 2.6). To understand the factors associated with ECS and the changes in these factors over time, the medical charts of 3,059 patients (814 women) randomly selected from 19,316 CABG surgery cases from 1970 to 1990 were reviewed. ECS cases (n = 264) were those described as emergent by the cardiologist or surgeon, or surgeries following cardiac arrest, immediately post infarction or within 24 hours of a cardiac procedure. Significant predictors of ECS were progressive/unstable angina (OR = 5.4), myocardial infarction (MI) within 30 days prior to CABG surgery (OR = 5.0), NYHA functional class III/IV (OR = 3.4), female gender (OR = 1.7). later year of CABG surgery (OR = 1.7), history of prior MI (OR = 1.61. moderate to severe left ventricular dysfunction (OR = 1.4), and increasing age (OR = 1.03). Factors that did not predict ECS included history of previous CABG surgery, history of diabetes, left ventricular aneurysm, left main coronary artery (LMCA) disease and increasing number of diseased vessels. In 1985–90, undergoing percutaneous transluminal coronary angio-plasty (PTCA) during the same hospitalization was highly predictive of ECS (OR 20.6,13.1–32.3). From 1970 to 1990 patients undergoing ECS showed increasing proportions of recent MI (30% vs. 50%; p = 0.02). increasing age (56 vs. 65 years; p &lt; 0.001). increasing number of diseased vessels (2.0 vs. 2.2; P &lt; 0.001), and decreasing LMCA disease (45% vs. 19%; p = 0.06). There were no significant trends in functional class, anginal status, or left ventricular dysfunction. We conclude that ECS is increasingly used on severely ill patients and those with failed PTCA. Mortality with ECS remains high.

Emergency Coronary Artery Bypass Surgery Following Failed Balloon Angioplasty: Role of the Internal Mammary Artery Graft

During a 4-year period (1986-1989), 3,502 patients had percutaneous transluminal coronary angioplasty (PTCA) in our institution. One hundred nineteen (3.4%) patients required emergency coronary artery bypass graft surgery (CABG) because of abrupt vessel closure following PTCA. Factors associated with vessel closure included lesion angulation greater than or equal to 90 degrees (p less than 0.007), the presence of thrombus (p less than 0.02), or a long (greater than or equal to 2 cm) lesion (p less than 0.03). Of these 119 emergency CABG patients, 108 (91%) arrived in the operating room in a stable condition (group I) and 11 (9%) were in cardiogenic shock (group II). Five (45%) of the group II patients were admitted to the hospital with an acute myocardial infarction and all 11 patients had a higher incidence of multivessel disease (p less than 0.05) and lower left ventricular ejection fraction (p less than 0.001) than group I patients. The overall surgical mortality was 10.1%; however, in group I the mortality was 5.6% and in group II it was 54.5% (p less than 0.001). The vessel that abruptly closed ("culprit vessel") was the left anterior descending (LAD) in 60%, the right coronary artery in 27%, and the left circumflex in 13%. The internal mammary artery was utilized to bypass the culprit artery in 51 (43%) patients, including 50% of the culprit LADs. With group I culprit LAD patients, when the left IMA was the bypass conduit, there were no hospital deaths nor strokes and there was a 6.3% incidence of perioperative infarction.

In-hospital morbidity and mortality in patients undergoing elective coronary angioplasty.

We prospectively recorded all in-hospital complications of the first 3500 consecutive patients to undergo elective coronary angioplasty (PTCA) at Emory University Hospitals from July 14, 1980, to August 28, 1984, by three operators. PTCA was attempted in a total of 3933 lesions, with a primary success rate of 91%. Multiple-lesion PTCA was performed in 401 patients, and PTCA of saphenous vein grafts was attempted in 172. No complications were recorded in 3116 (89%) cases, isolated minor complications occurred in 241 (6.9%), and major complications (emergency surgery, myocardial infarction, death) were observed in 145 (4.1%). Emergency coronary artery bypass graft surgery (CABG) was performed in 96 patients (2.7%), with a myocardial infarction rate of 49% (47/96), a Q wave infarction rate of 23% (22/96), and an emergency surgery mortality rate of 2% (2/96). Hospital discharge occurred within 2 weeks of attempted PTCA in 91% (87/96) of patients undergoing emergency CABG. The overall myocardial infarction rate was 2.6% (94/3500). There were two nonsurgical deaths, giving a total mortality rate of 0.1% (4/3500). Univariate and multivariate analysis of 3099 patients undergoing single-lesion PTCA identified five preprocedure predictors of a major complication: multivessel coronary disease, lesion eccentricity, presence of calcium in the lesion, female gender, and lesion length. Unstable angina, duration of angina, lesion severity, previous CABG, and vein graft dilatation were not associated with an increased incidence of major complications. The strongest predictor of a major complication was the procedural appearance of an intimal dissection. Intimal dissection was evident in 894/3099 (29%) patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal coronary angioplasty after previous coronary artery bypass surgery

To improve symptomatic status and avoid repeat coronary artery bypass graft surgery (CABG), 115 lesions were approached for transluminal coronary angioplasty (PTCA) in 94 patients (82 men, 12 women) with angina pectoris and prior CABG at a mean of 60 months (range 4 to 192) after CABG. Fifteen patients were in Canadian Cardiovascular Society functional class I, 32 were in class II, 31 were in class III, and 16 were in class IV. Patients were 37 to 76 years old (mean 57). PTCA was successful (at least a 40% reduction in stenosis diameter and improvement in symptomatic status) in 83 patients (88%) and 103 (90%) lesions. Mean stenosis was reduced from 80 ± 14% to 20 ± 16% (mean ± standard deviation) and mean pressure gradient from 41 ± 7 mm Hg to 14 ± 6 mm Hg. Seven patients had lesions that could not be crossed for technical reasons and these patients underwent non-emergency CABG. Four patients required emergency CABG after PTCA; 1 patients subsequently died and 2 survived acute myocardial infarction. One patient had a femoral artery laceration, which required surgical repair. At a mean follow-up of 8 ± 4 months, 63 patients (76%) with initially successful results were free of angina or in improved condition. Of the remaining 20 patients, 18 consented to repeat coronary angiography. Four patients did not have restenosis. Of the 14 patients with documented restenosis, 5 underwent successful repeat PTCA, 5 had repeat CABG, and 4 were treated medically. Thus, when coronary anatomy is suitable, PTCA is an effective alternative to reoperation in symptomatic patients with prior CABG.