High-risk Coronary Artery Bypass Grafting Research Articles

Propensity score-based comparison of high-risk coronary artery bypass grafting vs. left ventricular assist device implantation in patients with coronary artery disease and advanced heart failure

ObjectivesRevascularization in patients with severely reduced left ventricular function and coronary artery disease (CAD) is associated with a high perioperative risk. In this setting, implantation of a durable left ventricular assist device (LVAD) might be an alternative.MethodsWe retrospectively compared the outcomes of adult patients with CAD and a left ventricular ejection fraction (LVEF) ≤ 25% who underwent coronary artery bypass grafting (CABG) vs. LVAD implantation. Propensity score (PS) matching was performed for statistical analysis, resulting in 168 pairs.ResultsIn the PS-matched cohorts, the mean age was 62 years; one third had a history of myocardial infarction, 11% were resuscitated, half of the patients were on inotropic support, and 20% received preoperative mechanical circulatory support. LVAD patients required significantly longer ventilation (58 h [21, 256] vs. 16 h [9, 73], p < 0.001) and had a longer ICU stay (11d [7, 24] vs. 4d [2, 10], p ≤ 0.001) compared to CABG patients The incidence of postoperative renal replacement therapy (2 [1.2%] vs.15 [8.9%], p = 0.002) and temporary mechanical circulatory support was lower in the LVAD group (1 [0.6%] vs. 51 [30.4%], p ≤ 0.001). The in-hospital stroke rate was similar (LVAD 7 [5.4%] vs. CABG 8 [6.2%], p = 0.9). In-hospital survival, 1-year survival, and 3-year survival were 90.5% vs. 85.5% (p = 0.18), 77.4% vs. 68.9% (p = 0.10) and 69.6% vs. 45.9% (p < 0.001), for CABG and LVAD patients respectively.ConclusionPatients with CAD and advanced HF demonstrate better mid-term survival if they undergo CABG rather than LVAD implantation.

Is preoperative IABP insertion significantly reducing postoperative complication in augmented high-risk coronary artery bypass grafting patients?

BackgroundThe aim of this study was to determine whether pre-operative intra-aortic balloon pump (IABP) insertion improves surgical outcomes in high-risk coronary artery bypass grafting (CABG) patients.MethodsPatients with a EuroSCORE II greater than 1.2% who underwent CABG from 2009 to 2016 were included in the study, while those who utilized intra-operative or post-operative IABP were excluded. The analysis included a total of 2907 patients, with 377 patients undergoing preoperative IABP insertion (EuroSCORE II > 5.018%) and 1198 patients in the non-IABP group before matching; after propensity score matching (PSM), both groups consisted of a matched cohort of 250 patients.Results30-day mortality events occurred in 9 (3.6%) non-IABP group and in 12 (4.8%) IABP patients (OR: 1.33 95%CI: 0.52–3.58). Kaplan-Meier survival curve analysis showed no significant differences between the two groups in mortality up to one year after the operation (p = 0.72). On multivariate analysis, IABP usage among the PSM patients was associated with lower 30-day mortality (OR: 0.28, 95%CI: 0.07–0.92, P-value = 0.043), 90-day mortality (OR: 0.26, 95%CI: 0.08–0.78, P-value = 0.022) and reduced risk of developing severe respiratory disorders (OR: 0.10, 95%CI:0.01–0.50, P-value = 0.011).ConclusionPre-operative IABP use in high-risk patients reduces 30- and 90-day mortality rates, along with a notable decrease in rates of severe respiratory disorders.

Perioperative use of Impella device in very high-risk coronary artery bypass grafting

ABSTRACT This case study presents a high-risk coronary artery bypass grafting (CABG) patient with a recent anterior wall myocardial infarction and severely impaired left ventricular function. The patient underwent on-pump CABG with prolonged cardiopulmonary bypass support. The management strategy used hybrid mechanical circulatory support, intra-aortic balloon pump, and Impella CP, improved postoperative recovery, and prevented low cardiac output syndrome development.

Del Nido vs. Cold Blood Cardioplegia for High-Risk Isolated Coronary Artery Bypass Grafting in Patients with Reduced Ventricular Function.

The evidence for using del Nido cardioplegia protocol in high-risk patients with reduced ejection fraction undergoing isolated coronary surgery is insufficient. The institutional database was searched for isolated coronary bypass procedures. Patients with ejection fraction < 40% were selected. Propensity matching (age, sex, infarction, number of grafts) was used to pair del Nido (Group 1) and cold blood (Group 2) cardioplegia patients. Investigation of biomarker release, changes in ejection fraction, mortality, stroke, perioperative myocardial infarction, composite endpoint (major adverse cardiac and cerebrovascular events), and other perioperative parameters was performed. Matching allowed the selection of 45 patient pairs. No differences were noted at baseline. After cross-clamp release, spontaneous sinus rhythm return was observed more frequently in Group 1 (80% vs. 48.9%; P=0.003). Troponin values were similar in both groups 12 and 36 hours after surgery, as well as creatine kinase at 12 hours. A trend favored Group 1 in creatine kinase release at 36 hours (median 4.9; interquartile range 3.8-9.6 ng/mL vs. 7.3; 4.5-17.5 ng/mL; P=0.085). Perioperative mortality, rates of myocardial infarction, stroke, or major adverse cardiac and cerebrovascular events were similar. No difference in postoperative ejection fraction was noted (median 35.0%; interquartile range 32.0-38.0% vs. 35.0%; 32.0-40.0%; P=0.381). There was a trend for lower atrial fibrillation rate in Group 1 (6.7% vs. 17.8%; P=0.051). The findings indicate that del Nido cardioplegia provides satisfactory protection in patients with reduced ejection fraction undergoing coronary bypass surgery. Further prospective trials are required.

A Frailty Index to Predict Mortality, Resource Utilization and Costs in Patients Undergoing Coronary Artery Bypass Graft Surgery in Ontario

BackgroundPeople living with frailty are vulnerable to poor outcomes and incur higher health care costs after coronary artery bypass graft (CABG) surgery. Frailty-defining instruments for population-level research in the CABG setting have not been established. The objectives of the study were to develop a preoperative frailty index for CABG (pFI-C) surgery using Ontario administrative data; assess pFI-C suitability in predicting clinical and economic outcomes; and compare pFI-C predictive capabilities with other indices. MethodsA retrospective cohort study was conducted using health administrative data of 50,682 CABG patients. The pFI-C comprised 27 frailty-related health deficits. Associations between index scores and mortality, resource use and health care costs (2022 Canadian dollars [CAD]) were assessed using multivariable regression models. Capabilities of the pFI-C in predicting mortality were evaluated using concordance statistics; goodness of fit of the models was assessed using Akakie Information Criterion. ResultsAs assessed by the pFI-C, 22% of the cohort lived with frailty. The pFI-C score was strongly associated with mortality per 10% increase (odds ratio [OR], 3.04; 95% confidence interval [CI], [2.83,3.27]), and was significantly associated with resource utilization and costs. The predictive performances of the pFI-C, Charlson, and Elixhauser indices and Johns Hopkins Aggregated Diagnostic Groups were similar, and mortality models containing the pFI-C had a concordance (C)-statistic of 0.784. Cost models containing the pFI-C showed the best fit. ConclusionsThe pFI-C is predictive of mortality and associated with resource utilization and costs during the year following CABG. This index could aid in identifying a subgroup of high-risk CABG patients who could benefit from targeted perioperative health care interventions.

Coronary artery bypass grafting in active or recent COVID-19 infection: a systematic review.

Even though there have been few studies on coronary artery bypass grafting (CABG), data on patients with coronavirus disease-2019 (COVID-19) infection show that cardiac surgery has poor outcomes in this subset. From the available studies in the literature, we conducted a systematic review with the aim of determining the outcome of COVID-19 patients who underwent CABG. Between December 2019 and October 2022, searches were conducted in PubMed, the Directory of Open Access Journals, and Google Scholar to find studies reporting results of COVID-19 patients undergoing CABG. We extracted data on the clinical profile and outcomes of the patients from the eligible studies. The quality of the studies was assessed using a standardised tool. The total sample size across the 12 included studies was 99 patients who underwent CABG in active disease or within 30days of COVID-19 infection. The median and interquartile range (IQR) for the length of time spent on a mechanical ventilator, stay in the intensive care unit (ICU), and the total hospital stay were 0.9 (0.47-2), 4.5 (2.5-8), and 12.5 (8.5-22.5) days respectively. Seventy-six patients developed postoperative complications, and there were eleven deaths. The findings of the present study indicate that mortality risk goes down when the time between COVID-19 diagnosis and surgery increases. When compared to data from other high-risk urgent or emergent CABG patients around the world who were not infected with COVID-19, patients who underwent CABG in the COVID-19 subgroup had similar postoperative outcomes. The online version contains supplementary material available at 10.1007/s12055-023-01495-7.

Microarray Profiling of Differentially Expressed Genes in Coronary Artery Bypass Grafts of High-Risk Patients with Postoperative Cognitive Dysfunctions.

Postoperative cognitive dysfunction (POCD) is cognitive decline after surgery. The authors hypothesized that gene-level changes could be involved in the pathogenesis of POCD. The present study evaluated the incidence of POCD and its associated differentially expressed genes. This was a prospective cohort study conducted on high-risk coronary artery bypass graft patients aged 40 to 75 years. POCD classification was based on a one standard deviation decline in the postoperative scores compared to the preoperative scores. The differentially expressed genes were identified using microarray analysis and validated using quantitative RT-PCR. Forty-six patients were recruited and completed the study. The incidence of POCD was identified using a set of neurocognitive assessments and found to be at 17% in these high-risk CABG patients. Six samples were selected for the gene expression analyses (3 non-POCD and 3 POCD samples). The findings showed five differentially expressed genes in the POCD group compared to the non-POCD group. The upregulated gene was ERFE, whereas the downregulated genes were KIR2DS2, KIR2DS3, KIR3DL2, and LIM2. According to the results, the gene expression profiles of POCD can be used to find potential proteins for POCD diagnostic and predictive biomarkers. Understanding the molecular mechanism of POCD development will further lead to early detection and intervention to reduce the severity of POCD, and hence, reduce the mortality and morbidity rate due to the condition.

Insights from the thoracic surgery residents association early-career development series

Insights from the thoracic surgery residents association early-career development series

Computed Tomography Imaging Assessment of the Effect of Vancomycin Paste on Poststernotomy Healing.

PurposeTo assess vancomycin paste effect on poststernotomy healing in high-risk coronary artery bypass grafting (CABG) patients compared to bone wax using the 6-point computed tomography (CT) score. Additionally assessed the reliability of this score and its relationship to the occurrence of infection.Patients and MethodsA prospective comparative analysis included 126 high-risk CABG patients. The patients were randomly assigned into bone wax or vancomycin paste for sternal haemostasis. All patients were submitted to CT examinations 6-months postoperative. Two radiologists independently reviewed all CT scans to assess sternal healing using the 6-point CT score. The CT healing score of the two groups was compared. The kappa statistics were used to calculate the inter-reader agreement (IRA) of the 6-point CT score.ResultsThe final analysis included 61 patients in each group. The main CT score for sternal healing was 3.9±0.4 in the vancomycin group and 3.3±0.8 in the bone wax group. Patients in the vancomycin group had a higher statistically significant improvement in CT healing score than those in the bone wax group (p<0.001). There was no statistically significant relationship (p = 0.79) between the occurrence of infection and the 6-point CT score in the vancomycin group. The overall IRA of the 6-point CT score was good in two groups (κ = 0.79 in the vancomycin group and = 0.78 in the bone wax group).ConclusionVancomycin paste had a better CT healing score and can be used as a sternal haemostatic material instead of bone wax. The 6-point CT healing score is a reliable diagnostic tool for evaluating sternal healing.

Challenges of Difficult Airway in Treated Cancer Patient for High-risk Coronary Artery Bypass Graft Surgery

Challenges of Difficult Airway in Treated Cancer Patient for High-risk Coronary Artery Bypass Graft Surgery

Metoprolol versus low-dose sotalol for prevention of high-risk post coronary artery bypass grafting atrial fibrillation

Background: The optimal therapeutic strategy for high-risk postoperative atrial fibrillation (POAF) remains less well defined. Our objectives were to investigate the efficacy of prophylactic metoprolol versus low-dose sotalol regimens to prevent high-risk atrial fibrillation (AF) following coronary artery bypass surgery (CABG).&#x0D; Methods: We assigned 113 consecutive patients referred for CABG to either metoprolol or low-dose sotalol regimen. The primary end-point was the frequency of POAF during the 6-week follow-up.&#x0D; Results: Out of 113 patients enrolled, 52.2% % received metoprolol (n= 59) while 44.8% received sotalol (n= 54). The frequency of POAF at follow-up was significantly higher among the metoprolol group (59.3 % versus 50 %; P=0.017). The predictors of POAF were: age &gt; 60 years (OR: 1.86 (1.01-4.41); P= 0.03), EF (OR: 2 (1.05-3.83); P= 0.02), and sotalol was protective against POAF (OR= 0.49%; (95% CI=0.25 -0.97); P=0.02). The length of hospital stay was significantly higher in the metoprolol group (7.5±1.3 % versus 6.1±1.2 days; P&lt;0.001).&#x0D; Conclusion: Prophylactic low-dose sotalol could be superior to metoprolol for the prophylaxis of POAF in high-risk patients. However, Larger prospective multicenter randomized trials are needed to confirm our findings.

Use of intra-aortic balloon pump during coronary artery bypass graft surgery. Current questions and few answers.

The intra-aortic balloon pump (IABP) is used to prevent complications after coronary artery bypass grafting (CABG) surgery; although some results are controversial nowadays even contradictory. A new article on this field is published in this edition and shows that the risk factors for in-hospital mortality are the preoperative plasma creatinine level and cardiopulmonary bypass time in 177 patients. About the prophylactic use of the IABP regarding mortality the results reflected so far in meta-analyses have been highly contradictory between them, and the risk factors associated with it have been several and different. This lack of evidence has resulted in the continued variation of IABP use in these procedures. A large, multicenter RCT is certainly required to take the next step towards more definitive evidence, either for or against, the use of IABP in high-risk CABG. Until then, the unanswered questions regarding this topic will remain.

Aortic Valve Leaflet Disruption: A Severe Complication of Impella 5.5

A 73-year-old male with a history of severe coronary artery disease and prior coronary artery bypass grafting (CABG) presented with chest pain and elevated troponins. His workup revealed an ejection fraction of 15%, severe native coronary disease, as well as stenosis of his bypass grafts. He underwent a high-risk redo CABG with an Impella 5.5® (Abiomed, Danvers, MA) placement. The device was removed on postoperative day eight, at which time he went into cardiogenic shock from aortic valve leaflet injury. Given that he had no calcium deposits around the aortic valve annulus and severe aortic insufficiency, a multidisciplinary heart team decided he would be best served by a surgical aortic valve replacement. He was taken back to the operating room for a surgical aortic valve and intra-aortic balloon pump. His postoperative course was complicated by pneumonia, sepsis, and renal failure requiring continuous renal replacement therapy. He was discharged to a rehabilitation facility after 42 days. The following case encompasses the high morbidity risk of acute aortic valve insufficiency after Impella placement, never before documented in an Impella 5.5.

Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series.

Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 hpostoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.

The effect of remote patient monitoring on discharge outcomes in post-coronary artery bypass graft surgery patients.

Coronary artery bypass graft (CABG) surgery is a lifesaving procedure for patients with coronary artery disease but ranks highest (13.5%) for preventable hospital readmissions and second highest in average Medicare payment ($8,136) per readmission. Care transitions after hospital discharge warrant exploration to improve outcomes. The purpose of this brief report was to compare the effect of remote patient monitoring (RPM) on 30-day outcomes in Medicare beneficiaries after isolated CABG surgery. Results demonstrated no statistically significant difference in 30-day readmission (p = .568) or emergency department encounters (p = .785) between groups. However, time to achieve a cardiology follow-up appointment decreased from 19.8 to 13.7 days (p = .062) in the RPM group. Although the findings were not statistically significant, this study demonstrated a reduction in CABG readmissions and timely provider follow-up with RPM. In addition, study findings contribute to the body of nursing knowledge and support the need for further studies to identify high-risk CABG patients who may benefit from RPM after hospital discharge.

Low Wall Shear Stress Is Associated with Saphenous Vein Graft Stenosis in Patients with Coronary Artery Bypass Grafting.

Biomechanical forces may play a key role in saphenous vein graft (SVG) disease after coronary artery bypass graft (CABG) surgery. Computed tomography angiography (CTA) of 430 post-CABG patients were evaluated and 15 patients were identified with both stenosed and healthy SVGs for paired analysis. The stenosis was virtually removed, and detailed 3D models were reconstructed to perform patient-specific computational fluid dynamic (CFD) simulations. Models were processed to compute anatomic parameters, and hemodynamic parameters such as local and vessel-averaged wall shear stress (WSS), normalized WSS (WSS*), low shear area (LSA), oscillatory shear index (OSI), and flow rate. WSS* was significantly lower in pre-diseased SVG segments compared to corresponding control segments without disease (1.22 vs. 1.73, p = 0.012) and the area under the ROC curve was 0.71. No differences were observed in vessel-averaged anatomic or hemodynamic parameters between pre-stenosed and control whole SVGs. There are currently no clinically available tools to predict SVG failure post-CABG. CFD modeling has the potential to identify high-risk CABG patients who may benefit from more aggressive medical therapy and closer surveillance. Graphical Abstract.

The Impact of Statins before High-Risk CABG on Postoperative Multiple Organ Function.

Background The purpose of this cohort study was to investigate the independent relationship between preoperative statin therapy (PST) and postoperative severe multiorgan failure, measured by the Sequential Organ Failure Assessment (SOFA) maximum greater than 11, in high-risk patients undergoing isolated coronary artery bypass grafting (CABG). Methods The present study is a perspective, single-center, cohort analysis enrolling high-risk patients undergoing CABG from Jan 1, 2018, to Dec 31, 2018, in Beijing Anzhen hospital. Results Among a total of 880 high-risk patients undergoing isolated CABG included in this study, 503 (57.2%) experienced statin therapy before CABG. The SOFA maximum was significantly lower in the PST group compared with the control group (7.8 ± 3.0 v 9.2 ± 3.4, P < 0.0001). Multivariate logistic regression analysis demonstrated the incidence of the severe multiorgan dysfunction, measured by SOFA maximum ≥11, was dramatically reduced in the PST group (OR, 0.68, 95% CI 0.50–0.92, P=0.013). Furthermore, preoperative statin therapy (PST) might be associated with a decreased risk of postoperative major adverse cardiovascular and cerebral events and acute kidney injury, but an increased risk of postoperative hepatic inadequacy. Conclusion SOFA maximum was significantly lower in the PST group compared with the control group and the incidence of the severe multiorgan dysfunction was dramatically reduced in the PST group. The findings of this study might shed new light on questions of positive or negative effects of PST on multiple organ function after high-risk CABG, so as to ultimately improve high-risk patient in-hospital outcomes from CABG.

Concomitant temporary mechanical support in high-risk coronary artery bypass surgery.

Patients with low left ventricular ejection fraction (LVEF) undergoing high-risk coronary artery bypass grafting (CABG) are at increased risk for postcardiotomy cardiogenic shock. This report describes planned concomitant microaxial temporary mechanical support (MA-TMS) device placement as a viable bridge-to-recovery strategy for high-risk patients receiving surgical revascularization. A retrospective review was performed for all patients from October 2017 to May 2019 with low LVEF (<30%), New York Heart Association Class III or IV symptoms, and myocardial viability who underwent CABG with prophylactic MA-TMS support at a single institution (n = 13). Mean patient age was 64.8 years, and 12 patients (92%) were male. Eight patients (62%) presented with acute coronary syndrome. Mean predicted risk of mortality was 4.6%, ranging from 0.6% to 15.6%. An average of 3.4 grafts were performed per patient. Greater than 60% of patients were extubated within 48 hours and out-of-bed within 72 hours, and the average duration of MA-TMS was 5.7 days. Mean postoperative length of stay was 16.7 days. There were no postoperative myocardial infarctions or deaths. Prophylactic MA-TMS may allow safe and effective surgical revascularization for patients with severe left ventricular dysfunction who may otherwise be offered a durable ventricular assist device.

Outcomes with intra-aortic balloon pump in high risk cardiac surgery patients

ABSTRACT Introduction: In high-risk cardiac surgical patients the intra-aortic balloon pump (IABP) is the most frequent used tool for temporary mechanical circulatory support during the perioperative phase. The effects of IABP are an increase in diastolic blood pressure, an improvement in coronary perfusion and a reduction of ventricular afterload, so it increases the stroke volume and cardiac output. Objective: To study the effect of preoperative use of intra-aortic balloon pump (IABP) on the outcome of high-risk patients that were subjected to coronary artery bypass graft (CABG) surgery. Methods: From June 2009 to June 2011. Group of 100 patients considered as high-risk patients were subjected to elective bypass cardiac surgery at our center. Forty patients subjected to preoperative IABP as a prophylactic measure and 60 patients were not subjected to IABP. This is retrospective study of prospectively collected data .The definition of High risk was the presence of two or more known risk factors. The patient’s outcome is compared regarding the predicted mortality of the Euro SCORE. The preoperative effect of IABP on the outcome, mortality and 30 days follow-up was statistically analyzed. Results: Forty patients subjected to preoperative IABP as prophylactic measure due to higher Euro SCORE-predicted mortality than other 60 patients did not subject to IABP(60% vs 40 %, P = ˂0.05). Seventy patients (70%) were male while (30%) were female with a mean age of 58.62 ± 9.65 years. Patients subjected to preoperative IABP had increased a percentage of hospital mortality (P = ˂0.05) but this percentage is relatively lower than predicted by Euro SCORE. Patients subjected to preoperative IABP had lower rate of postoperative complication (acute kidney insult (P = 0.045), cardiac surgical intensive care unit (CSICU) stay (P = 0.032) and decrease the need for postoperative inotrope (P = 0.046)) compared to patients without preoperative IABP use. Other complications postoperative were low and similar in both groups. Conclusions: We conclude that patients have high-risk CABG, the preoperative IABP in this group with higher predicted mortality was associated with a relative reduction than predicted by Euro score. The preoperative IABP in this group has a reliable and acceptable outcome on postoperative complications. Keywords: intra-aortic balloon pump, High Risk, Cardiac Surgery

Evaluation of Prophylactic Use of a Preoperative IABP in High-Risk Coronary Artery Bypass Graft Surgery

Evaluation of Prophylactic Use of a Preoperative IABP in High-Risk Coronary Artery Bypass Graft Surgery