First-time Coronary Artery Bypass Grafting Research Articles

Does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does intermittent cross-clamp fibrillation provide equivalent myocardial protection compared to cardioplegia in patients undergoing bypass graft revascularisation? Altogether, 58 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We identified 13 studies, of which eight were randomised prospective trials. None of these studies found increased mortality, seven analyzed serum cardiac enzymes and showed that intermittent ischemic arrest provides equal or better protection compared to cardioplegic techniques. Two studies found an increased usage of inotropes and intra aortic balloon pump (IABP) in the intermittent ischemic arrest group. We conclude that intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate postoperative outcome comparable to cardioplegic arrest in first-time coronary artery bypass graft (CABG). The ischaemic duration associated with intermittent cross-clamp fibrillation is invariably shorter than that associated with cardioplegic arrest, and this may be one explanation for the comparable outcomes. There may also be an element of preconditioning protection during the intermittent cross-clamp fibrillation method, as has been shown experimentally. During elective CABG in patients with no clinical evidence of aortic or cerebro-vascular disease, the incidence of peri-operative microemboli (ME) and postoperative neuropsychological disturbances are shown to be comparable with both techniques of myocardial preservation.

Symptoms of chest pain and dyspnoea during a period of 15 years after coronary artery bypass grafting

To describe changes in chest pain and dyspnoea during a period of 15 years after coronary artery bypass grafting (CABG) and to define factors at the time of operation that were associated with the occurrence of these symptoms after 15 years. Prospective observational study in western Sweden. All patients who underwent first-time CABG, without simultaneous valve surgery, between 1 June 1988 and 1 June 1991. There were no exclusion criteria. All patients were followed up prospectively for 15 years. The evaluation of symptoms took place through postal questionnaires prior to and 5, 10 and 15 years after the operation. Totally, 2000 patients were included in the survey and 904 (45%) of them survived to 15 years. Among these 904 survivors, the percentage of patients with chest pain increased from 44% to 50% between the 5- and 15-year follow-up (p=0.004). The percentage of patients who reported symptoms of dyspnoea increased from 60% after 5 years to 74% after 15 years (p<0.001). Factors at the time of surgery that independently tended to predict chest pain after 15 years were higher age (p=0.04) and prolonged duration of symptoms prior to surgery (p=0.04). Predictors of dyspnoea after 15 years were higher age (p<0.0001), the use of inotropic drugs at the time of surgery (p=0.001), a history of diabetes (p=0.01) and obesity (p=0.01). After CABG, relief from chest pain and dyspnoea is generally maintained over a long period of time. Eventually, however, functional-limiting symptoms tend to recur and about half the patients report symptoms of chest pain, while three-quarters report dyspnoea after 15 years. Even if no clear predictor of chest pain was found at the time of surgery, age, the use of inotropic drugs, diabetes and obesity predicted dyspnoea.

Ability of B-Type Natriuretic Peptide in Predicting Postoperative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Grafting

Atrial fibrillation (AF) is still the most frequent rhythm disturbance after coronary artery surgery. Our aim was to evaluate the predictive value of preoperative brain natriuretic peptide (BNP) levels for determining postoperative new-onset AF in patients undergoing isolated first-time coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB). We recruited 144 consecutive patients (51 women and 93 men) who underwent isolated CABG. Preoperative and postoperative data were collected. Preoperative BNP levels were measured the day before surgery. The median preoperative BNP level was 68 pg/mL. Postoperative AF occurred in 36 (25%) of the patients. Univariate analyses showed that both advanced age and median preoperative BNP levels were associated with postoperative AF (63.9 +/- 8 years versus 57.3 +/- 9.8 years, P < .001; 226 pg/mL versus 65.2 pg/mL, P <.001). Both variables remained independent predictors of postoperative AF after multivariate logistic regression analyses. For advanced age, the odds ratio was 1.074 (95% confidence interval [CI], 1.019-1.131; P = .008); for preoperative BNP level, the odds ratio was 1.004 (95% CI, 1.001-1.006; P = .002). A receiver operating characteristic (ROC) curve demonstrated that preoperative BNP level was a predictor of postoperative AF, with an area under the ROC curve of 0.750. A cutoff value of 135 pg/mL for AF demonstrated a 72.2% sensitivity, a 71.2% specificity, a 45.6% positive predictive value, a 88.5% negative predictive value, and a 71.5% accuracy for predicting postoperative AF. Elevated preoperative BNP levels and advanced age together are significant predictors for the development of postoperative AF in patients undergoing isolated CABG with CPB.

Beneficial Effect of Preventative Intra‐Aortic Balloon Pumping in High‐Risk Patients Undergoing First‐Time Coronary Artery Bypass Grafting—A Single Center Experience

Although intra-aortic balloon pumping (IABP) has been used widely as a routine cardiac assist device for perioperative support in coronary artery bypass grafting (CABG), the optimal timing for high-risk patients undergoing first-time CABG using IABP is unknown. The purpose of this investigation is to compare preoperative and preventative IABP insertion with intraoperative or postoperative obligatory IABP insertion in high-risk patients undergoing first-time CABG. We reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG patients who received IABP treatment perioperatively. Of 311 cases, 41 high-risk patients who had first-time on-pump or off-pump CABG (presenting with three or more of the following criteria: left ventricular ejection fraction less than 0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis greater than 70%) entered the study. We compared perioperatively the clinical results of 20 patients who underwent preoperative IABP placement (Group 1) with 21 patients who had obligatory IABP placement intraoperatively or postoperatively during CABG (Group 2). There were no differences in preoperative risk factors, except left ventricular aneurysm resection, between the two groups. There were no differences in indications for high-risk patients between the two groups. The mean number of grafts was similar. There were no significant differences in the need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective complications postoperatively. There were no IABP-related complications in either group. Major adverse cardiac event (severe hypotension and/or shock, myocardial infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%] vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was shorter than in Group 2 (72.5 +/- 28.9 h vs. 97.5 +/- 47.7 h, P < 0.05). The duration of ventilation and intensive care unit stay in Group 1 was significantly shorter than in Group 2, respectively (22.0 +/- 1.6 h vs. 39.6 +/- 2.1 h, P < 0.01 and 58.0 +/- 1.5 h vs. 98.5 +/- 1.9 h, P < 0.005). There were no differences in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2). Preoperative and preventative insertion of IABP can be performed safely in selected high-risk patients undergoing CABG, with results comparable to those in patients who received obligatory IABP intraoperatively and postoperatively. Therefore, earlier IABP support as part of surgical strategy may help to improve the outcome in high-risk first-time CABG patients.

Perceptions of Recovery, Physical Health, Personal Meaning, Role Function, and Social Support After First-Time Coronary Artery Bypass Graft Surgery

Coronary artery bypass graft surgery is one of the most frequently performed major surgeries in the United States. Because of fast-track protocols and decreased lengths of stay, critical care nurses have even more demanding challenges in the care of these patients. Critical care nurses are well aware that these patients still have health needs that extend beyond discharge from the hospital, but these needs are now addressed by the patient's caregiver. This descriptive, comparative study was conducted to examine perceptions of recovery by these patients and the relationships among physical health, personal meaning, role function, and social support. The results of the study are presented, as well as the implications for critical care nurses.

The Erythropoietin NeuroProtective Effect: Assessment in CABG Surgery (TENPEAKS)

Neurocognitive dysfunction complicates coronary artery bypass surgery. Erythropoietin may be neuroprotective. We sought to determine whether human recombinant erythropoietin would reduce the incidence of neurocognitive dysfunction after surgery. We randomly assigned 32 elective first-time coronary artery bypass graft patients to receive placebo or 375 U/kg, 750 U/kg, or 1500 U/kg of recombinant human erythropoietin divided in 3 daily doses, starting the day before surgery. Primary outcomes were feasibility and safety, and secondary outcomes were neurocognitive dysfunction at discharge and 2 months. All subjects were male, mean age 60 years (range 46 to 73). No significant differences were found in pump time, cross-clamp time, or hospital length of stay. Mortality and pure red cell aplasia were not observed. One patient in the 375 U/kg group had ST changes compatible with myocardial injury immediately postoperative, but no other thrombotic complications were observed. Neurocognitive dysfunction occurred in 21/32 (66%) of patients at discharge and 5/32 (16%) at 2 months. Neurocognitive dysfunction at discharge by group was: placebo 6/8 (75%), 375 U/kg 4/8 (50%), 750 U/kg 6/8 (75%), and 1500 U/kg 5/8 (63%). Neurocognitive dysfunction at 2 months by group was: placebo 3/8 (38%), 375 U/kg 1/8 (13%), 750 U/kg 1/8 (13%), and 1500 U/kg 0/8 (0%). Neurocognitive dysfunction at 2 months for erythropoietin at any dose was 2/24 (8.3%) versus 3/8 (38%) for placebo (P=0.085). This study demonstrates feasibility and safety for the use of human recombinant erythropoietin as a neuroprotectant in coronary artery bypass graft surgery. A trend in the reduction of neurocognitive dysfunction at 2 months was associated with erythropoietin use. A multicenter randomized controlled trial is warranted.

Is Gender an Independent Risk Factor for Coronary Bypass Grafting?

Postoperative mortality after coronary artery bypass grafting (CABG) surgery is traditionally considered to be influenced by gender. However, the data are conflicting and it is not clear whether gender is a true independent risk factor for death in this setting. We analyzed our database to determine whether gender is an independent risk factor for death after CABG. A retrospective analysis of 1 758 isolated first-time coronary artery bypass graft patients treated between 2003 and 2005 was conducted in the Department of Cardiothoracic Surgery of Rabin Medical Center, a major tertiary facility in Israel. The female patients had a distinctly different pre- and intraoperative profile compared with the male patients, and significantly higher postoperative mortality (p < 0.05). On a propensity scoring of 359 matched pairs, the risk factors for death were found to be severe left ventricular dysfunction, chronic obstructive pulmonary disease, and use of an intra-aortic balloon pump (p < 0.05). The addition of intraoperative data to the model yielded only cardiopulmonary bypass time and use of an intra-aortic balloon pump as risk factors for death (p < 0.05). Validation with the bootstrap technique revealed that strong predictors of death (> 50 % of the sample) were cardiopulmonary bypass time, use of an intra-aortic balloon pump, and, to a lesser extent, chronic obstructive pulmonary disease. Female gender was not found to be an independent risk factor for death after coronary artery bypass graft. Female gender is apparently not an independent risk factor for coronary artery bypass graft mortality in this patient group.

Using the cardiac depression scale in men recovering from coronary artery bypass surgery

To examine the utility and validate the use of the Cardiac Depression Scale in patients who had first-time coronary artery bypass graft surgery. The Beck Depression Inventory, though frequently used, may not be sufficiently sensitive for use in cardiac patients. The Cardiac Depression Scale has been shown to identify the range of depression in medical cardiac patients. Survey. The Beck Depression Inventory and Cardiac Depression Scale were administered to 120 men at hospital discharge, as well as six, 12 and 36 weeks postoperatively. Cronbach's alpha scores were calculated for the measures at each point. Changes in scores over time were analysed using repeated measures analysis of variance. Associations between the measures scores were calculated using Pearson product-moment correlations. Agreement between the measures' dichotomised scores (depression/no depression) was examined using Cohen's Kappa statistic. Internal consistency was similar for the Beck Depression Inventory (0.793-0.904) and Cardiac Depression Scale (0.859-0.910). Depression scores decreased over time with the Beck Depression Inventory [F(2.50, 175.29) = 22.27, p < 0.001] and Cardiac Depression Scale [F(2.68, 190.37) = 13.18, p < 0.001]. The measures had similar power [Cohen's f = 0.65 (Beck Depression Inventory) and 0.43 (Cardiac Depression Scale)] to reveal changes over time. The continuous scores were highly correlated at each point [0.737 (p < 0.001)-0.819 (p < 0.001)]. However, when dichotomised scores were compared, the chance corrected level of agreement was less impressive [0.198 (p = 0.014)-0.381 (p < 0.001)]. The Cardiac Depression Scale may have utility for use with surgical cardiac patients. However, continued examination of this measure of depression is warranted. Given the prevalence of depression and its negative impact on coronary artery disease, it is important to identify even mild depression in cardiac patients. Using a measure of depression specifically for cardiac patients, rather than a generic measure, may best accomplish this goal.

Predictors of packed red cell transfusion after isolated primary coronary artery bypass grafting – The experience of a single cardiac center: A prospective observational study

BackgroundPreoperative patients' characteristics can predict the need for perioperative blood component transfusion in cardiac surgical operations. The aim of this prospective observational study is to identify perioperative patient characteristics predicting the need for allogeneic packed red blood cell (PRBC) transfusion in isolated primary coronary artery bypass grafting (CABG) operations.Patients and Methods105 patients undergoing isolated, first-time CABG were reviewed for their preoperative variables and followed for intraoperative and postoperative data. Patients were 97 males and 8 females, with mean age 58.28 ± 10.97 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of PRBC transfusion.ResultsPRBC transfusion was used in 71 patients (67.6%); 35 patients (33.3%) needed > 2 units and 14 (13.3%) of these needed > 4 units. Univariate analysis identified female gender, age > 65 years, body weight ≤ 70 Kg, BSA ≤ 1.75 m2, BMI ≤ 25, preoperative hemoglobin ≤ 13 gm/dL, preoperative hematocrit ≤ 40%, serum creatinine > 100 μmol/L, Euro SCORE (standard/logistic) > 2, use of CPB, radial artery use, higher number of distal anastomoses, and postoperative chest tube drainage > 1000 mL as significant predictors. The strongest predictors using multivariate analysis were CPB use, hematocrit, body weight, and serum creatinine.ConclusionThe predictors of PRBC transfusion after primary isolated CABG are use of CPB, hematocrit ≤ 40%, weight ≤ 70 Kg, and serum creatinine > 100 μmol/L. This leads to better utilization of blood bank resources and cost-efficient targeted use of expensive blood conservation modalities.

Social support, depression, functional status, and gender differences in older adults undergoing first-time coronary artery bypass graft surgery

Older adults have more difficulty with coronary artery bypass graft (CABG) surgery than younger adults, partly because of depression and social isolation. During hospitalization, older adult patients undergoing CABG name nurses as their primary source of social support. A secondary analysis was used to investigate the relationships among social support, depression, functional status, and postoperative length of stay. Included were 70 patients undergoing first-time CABG. Patients had a mean age of 72 years and were primarily white (94%) and male (66%). Complete data were collected on 63 participants. Social support was not related to any other variable. Preoperative depression and low functional status persisted postoperatively. Female patients had greater depression and poorer functional status than male patients both preoperatively and postoperatively. No other gender differences were found. Depression and functional status are amenable to intervention. The outcomes of older adult patients (especially female) undergoing CABG might improve if nurses preoperatively assess for and intervene to improve depression and functional status.

Presence of coronary collaterals is associated with a decreased incidence of cognitive decline after coronary artery bypass surgery☆

Coronary artery bypass grafting (CABG) is associated with significant cerebral morbidity, usually manifested as cognitive decline or stroke. The underlying mechanism leading to cognitive decline is still unclear. Presence of coronary collateral arteries, which may reflect an overall better cardiovascular condition, recently appeared to relate to a better cardiac outcome after CABG. In this study, we investigated the hypothesis that presence of coronary collaterals is associated with less cognitive decline after coronary artery bypass grafting. Data from 281 patients undergoing first-time coronary artery bypass grafting were used. Presence of coronary collaterals was determined on the preoperative angiogram. Cognitive function was evaluated before the operation, at 3 and 12 months and 5 years thereafter by standardised neuropsychological assessment. Cognitive decline in individuals was determined by calculating the reliable change score, a cognitive change score corrected for natural testing variability and practice effects. Cognitive decline was found in 19 (8%) patients at 3 months, in 31 (12%) patients at 12 months and in 82 (34%) at 5 years follow-up. Presence of coronary collaterals was independently associated with a better cognitive outcome at both 3 months (odds ratio (OR) 0.30; 95% confidence interval (CI) 0.09-0.95; p=0.04) and 12 months (OR 0.42; 95% CI 0.18-0.97; p=0.04) after coronary artery bypass grafting. At 5 years, the OR was 0.57 (95% CI 0.31-1.05; p=0.07). In patients undergoing first-time coronary artery bypass grafting, presence of coronary collaterals is associated with a decreased risk of cognitive decline at both 3 and 12 months of follow-up. This trend persists at 5-year follow-up. Preoperative differences in the cardiac vascular condition may therefore predict cognitive outcome in patients undergoing coronary artery bypass grafting.

A Randomized Controlled Trial of Cell Salvage in Routine Cardiac Surgery

Previous trials have indicated that cell salvage may reduce allogeneic blood transfusion during cardiac surgery, but these studies have limitations, including inconsistent use of other blood transfusion-sparing strategies. We designed a randomized controlled trial to determine whether routine cell salvage for elective uncomplicated cardiac surgery reduces blood transfusion and is cost effective in the setting of a rigorous transfusion protocol and routine administration of antifibrinolytics. Two-hundred-thirteen patients presenting for first-time coronary artery bypass grafting and/or cardiac valve surgery were prospectively randomized to control or cell salvage groups. The latter group had blood aspirate during surgery and mediastinal drainage the first 6 h after surgery processed in a cell saver device and autotransfused. All patients received tranexamic acid and were subjected to an algorithm for red blood cell and hemostatic blood factor transfusion. There was no difference between the two groups in the proportion of patients exposed to allogeneic blood (32% in both groups, relative risk 1.0 P = 0.89). At current blood products and cell saver prices, the use of cell salvage increased the costs per patient by a minimum of $103. When patients who had mediastinal re-exploration for bleeding were excluded (as planned in the protocol), significantly fewer units of allogeneic red blood cells were transfused in the cell salvage compared with the control group (65 vs 100 U, relative risk 0.71 P = 0.04). In patients undergoing routine first-time cardiac surgery in an institution with a rigorous blood conservation program, the routine use of cell salvage does not further reduce the proportion of patients exposed to allogeneic blood transfusion. However, patients who do not have excessive bleeding after surgery receive significantly fewer units of blood with cell salvage. Although the use of cell savage may reduce the demand for blood products during cardiac surgery, this comes at an increased cost to the institution.

Higher IL-6 levels but not IL6 −174G > C or −572G > C genotype are associated with post-operative complication following coronary artery bypass graft (CABG) surgery

Large increases in inflammatory markers, particularly IL-6, occur after cardiac surgery. However, despite interventions to reduce the inflammatory response, great variability still remains which could in part be attributable to genetic predisposition. Since increased IL-6 levels following surgery are also associated with poorer outcome we sought to determine whether baseline and post-operative levels of Interleukin-6 (IL-6) and functional common variants of the Interleukin-6 ( IL6) gene are associated with post-operative outcome following coronary artery bypass grafting (CABG). Caucasian patients undergoing first-time elective CABG were studied. IL-6 levels were measured pre-, 6 h and 24 h following surgery and genotypes for IL6 gene variants −174G > C and −572G > C were obtained. Clinical data was collected daily until patient discharge. Patient outcome was categorised as with (ICUC, n = 177) and without (NICUC, n = 189) a post-operative complication during the ICU period and with (POC, n = 215) and without (NC, n = 151) a post-operative complication during hospitalisation. IL-6 levels pre- and at 24 h were greater in POC and ICUC than NC and NICUC, respectively. Pre- IL-6 levels independently predicted (for 1 standard deviation increase in log IL-6) POC (OR 1.4, 95% CI 1.1–1.7, p = 0.008) and ICUC (OR 1.3, 95% CI 1.0–1.6, p = 0.02) outcomes. Overall, the IL6-572G > C had an effect over time on IL-6 levels ( p = 0.04) and on IL-6 levels in NC (P = 0.008) and NICUC ( p = 0.006). However, no associations were found with the IL6 −572G > C or −174G > C variants on IL-6 levels at individual time-points or by outcome group. Thus, in conclusion, elevated pre-operative IL-6 levels, but not IL6 gene variants predict poor patient outcome following CABG.

An Exploration of the Relationship Between Coronary Artery Bypass Graft Patients' Self-Sought Educational Resources and Outcomes

Postoperative coronary artery bypass graft (CABG) patients seek educational resources around discharge. There is limited research on the type and perceived effectiveness of self-sought educational resources. The purpose of this study was to describe the use of self-sought educational resources by patients around time of discharge and to explore relationships between use of self-sought educational resources and self-care knowledge, performance of self-care behavior, and symptom frequency. This study is a substudy of a randomized clinical trial that included a convenience sample of first-time CABG patients. Significant correlations were found between use of self-sought educational resources and greater frequency of patient's behavior (P <or= .05), and a decrease in symptom frequency (P <or= .05). This study represents a first step toward identifying the association between the use of self-sought educational resources after CABG and outcomes expected of education.

Plasma Brain Natriuretic Peptide after Isolated On-Pump Coronary Artery Bypass Grafting: Prediction of Postoperative Adverse Outcomes

The heart is an endocrine organ that synthesizes 2 different natriuretic peptides: atrial natriuretic peptide and brain natriuretic peptide (BNP). We assessed the relationship between preoperative BNP levels and postoperative complications and outcomes in patients who undergo isolated coronary artery bypass grafting (CABG). The study consisted of 85 patients undergoing first-time elective CABG. Preoperative BNP levels were significantly correlated with the preoperative ejection fraction (P = .004), the number of vessels grafted (P = .016), cross-clamp time (P = .041), and perfusion time (P = .032). Preoperative BNP levels were higher in patients who developed postoperative new-onset atrial fibrillation (AF) (median BNP, 197 pg/mL versus 65 pg/mL; P = .006), in patients requiring inotropic support (189 pg/mL versus 65 pg/mL; P = .004), and in patients who required an intra-aortic balloon pump (IABP) (325 pg/mL versus 68 pg/mL; P= .021). Analysis of receiver operating characteristic curves demonstrated the preoperative BNP level to be a predictor of new-onset AF, a need for inotropic support, and a requirement for an IABP (areas under the curve, 0.70, 0.70, and 0.79, respectively). BNP cutoff values of 100 pg/mL for AF, 185 pg/mL for inotropic support, and 235 pg/mL for requiring an IABP predicted these postoperative adverse outcomes with 65%, 73%, and 84% accuracy, respectively. This study suggests that a higher baseline plasma BNP concentration is associated with postoperative new-onset AF, a need for inotropic support, and an IABP requirement in patients who undergo first-time isolated CABG.

Coronary Artery Bypass Grafting: Patients' and Health Professionals' Views of Recovery After Hospital Discharge

Coronary artery bypass grafting (CABG) is effective in relieving symptoms and reducing mortality but some patients report no improvement or a decline in quality of life and hence do not experience a good recovery after surgery. Little published research has explored patients' and particularly health professionals' views on barriers and facilitators to recovery or the processes by which these factors affect recovery. To identify post-discharge facilitators and barriers to recovery after CABG. Semi-structured interviews were conducted with 11 patients who had previously undergone elective, isolated, first-time CABG and with 10 health professionals experienced in caring for these patients. Thematic analysis identified the following themes: person characteristics, including the impact on recovery of anxiety, depression, optimism and determination; rehabilitation classes; social support; and the effect of surgery. Findings indicate a complex relationship between the various barriers and facilitators to recovery and explore possible processes by which these influences on recovery operate. Findings have indicated areas where health professionals can intervene to aid patients' long-term recovery, and thereby maximise the benefits of CABG, by providing information, support and reassurance particularly to patients who appear anxious and/or depressed.

Case 1—2008 One Institution’s Decreasing Use of Aprotinin During Cardiac Surgery in 2006

APROTININ IS A SERINE protease inhibitor that decreases the inflammatory response to cardiac surgery and reduces bleeding through its antifibrinolytic- and platelet-protective properties.1 It was discovered in the 1930s in Germany and was approved by the Food and Drug Administration (FDA) in 1993 for repeat coronary artery bypass graft (CABG) surgery cases on cardiopulmonary bypass (CPB) and in 1998 for first-time CABG surgery cases.

Clinical evaluation of the Admiral 1.35m2 hollow-fibre membrane oxygenator

This prospective study was designed to evaluate the fundamental clinical performance of a new, small surface area oxygenator. Data were collected from twenty patients undergoing first-time coronary artery bypass grafting using this device. This study focuses on how the reduction of surface area and prime volume affects the essential function of the oxygenator in terms of oxygenation efficiency, heat transference, membrane pressure drops, haemolysis and safety. Oxygenation efficiency was deemed to be well within acceptable margins, even at high flows, over a temperature range of 32-36 degrees C. Heat-exchanger performance was assessed by recording the heater/chiller water temperature compared to retrospective data from a current standard oxygenator. Heater/ chiller water temperatures were on average 0.3 degrees C higher with the small surface oxygenator than the standard data. The air handling of the device was excellent and extremely safe. Haemolysis, measured as plasma free haemoglobin, did not increase during bypass (p > 0.05). This new oxygenator offers a reduced surface area and priming volume while still ensuring an acceptable safety reserve and performance.

Influence of volume therapy with a modern hydroxyethylstarch preparation on kidney function in cardiac surgery patients with compromised renal function: A comparison with human albumin*

There is continuing concern about the influence of hydroxyethylstarch on renal function in patients with compromised kidney function. Prospective, randomized, single-center study. University-affiliated hospital. Fifty patients undergoing elective, first-time coronary artery bypass grafting using cardiopulmonary bypass with a preoperative serum creatinine between 1.5 and 2.5 mg/dL. According to a prospective, randomized sequence, the patients received either hydroxyethylstarch with a low molecular weight (mean molecular weight 130 kD) and a low molar substitution (0.4) (6% hydroxyethylstarch 130/0.4) (n = 25) or 5% human albumin (n = 25). Volume was added to the priming (500 mL) and given perioperatively until the second postoperative day to keep pulmonary artery occlusion pressure or central venous pressure between 12 and 14 mm Hg. Serum creatinine and cystatin plasma levels were measured from arterial blood samples. From urine specimens, N-acetyl-beta-D-glucosaminidase, glutathione transferase-alpha, and neutrophil gelatinase-associated lipocalin were measured. Measurements were performed after induction of anesthesia, at the end of surgery, 5 hrs after surgery, and on the first and second postoperative days. A follow-up after discharge from the hospital (60 days) was also done. Similar amounts of hydroxyethylstarch and albumin were infused. Serum creatinine, glomerular filtration rate, and cystatin C plasma levels were without significant differences between the groups. Concentrations of kidney-specific proteins were elevated at baseline and increased significantly after surgery without showing group differences. Urinary levels of neutrophil gelatinase-associated lipocalin increased more in the albumin- than in the hydroxyethylstarch-treated patients. None of the patients developed acute renal failure requiring renal replacement therapy during the hospital stay and thereafter. A hydroxyethylstarch preparation with a low molecular weight and a low molar substitution given in cardiac surgery patients with preoperative compromised kidney function did not negatively influence kidney integrity compared with a human albumin-based volume replacement strategy.

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.