Similar In-hospital Mortality Rates Research Articles

Off-pump Coronary Artery Bypass Surgery with Multiple Arterial Grafts in Diabetic Patients: Short and Long-term Results

IntroductionDiabetes mellitus has been identified as a strong independent predictor of cardiovasculardisease onset and progression and acknowledged as a mortality risk factorafter coronary artery surgery. Off-pump coronary artery bypass grafting has been establishedas an efficient alternative to coronary revascularization, comparable to theconventional technique, with results evidencing a reduction in procedure morbidityand, in high risk patients, lower postoperative mortality.ObjectiveThe aims of this study were to compare short and long-term postoperative results ofoff-pump coronary artery revascularization surgery with multiple arterial grafts inpatients with or without diabetes mellitus and to determine if postoperative hyperglycemiais an independent predictor of early morbidity and mortality.MethodsOff-pump coronary revascularization surgery with multiple arterial grafts was consecutivelyperformed on 1002 patients between January 2004 and December 2008.The population was divided in diabetes mellitus (n: 234) and non-diabetes mellitus(n: 768) patients. Post-operative complications were analyzed and independent predictorsof in-hospital mortality were identified. The average follow-up period of 1038± 517 days was completed by 95.7% of patients.ResultsDiabetes mellitus patients had lower cardiac output (p=0.005), atrial fibrillation(p=0.005) and deep sternal wound infection (p=0.005). Age (OR= 1.11), non-electivesurgery (OR=5.88) and blood glucose level > 200 mg/dL (OR= 6.9) were significantpredictors of in-hospital mortality. Five-year survival was lower in diabetesmellitus patients (p=0.01). Diabetes mellitus (HR = 2.1), age (HR= 1.06), left ventricularejection fraction 1.6 mg/dL(HR=2.46) were significant predictors of decreased long-term survival.ConclusionsDiabetes mellitus and non-diabetes mellitus patients had similar in-hospital mortalityrates. Postoperative hyperglycemia was a predictor of greater in-hospital mortality.Diabetes mellitus and creatinine > 1.6 mg/dL were independent predictors ofdecreased long-term survival.

Prognostic significance of electrocardiographic-determined left ventricular hypertrophy and associated ST-segment depression in patients with non–ST-elevation acute coronary syndromes

Left ventricular hypertrophy (LVH) is frequently associated with ST depression (STD) on the electrocardiogram (ECG), a so-called strain pattern. Although STD is a well-established adverse prognosticator in non-ST-elevation acute coronary syndrome (NSTE-ACS), the relative prognostic importance of LVH and associated STD has not been elucidated. A total of 7,761 patients with NSTE-ACS in the Global Registry of Acute Coronary Events (GRACE) and ACS-I registries had admission ECGs analyzed at a core laboratory. Left ventricular hypertrophy (determined by Sokolow-Lyon and/or Casale criteria) was observed in 296 (3.8%) patients. We examined the independent association between LVH (determined by the admission ECG) and outcomes in relation to STD. Patients with LVH were older, had more comorbidities and STD, and presented with a higher Killip class. They were less likely to undergo cardiac catheterization (43.1% vs 51.2%, P = .006) and percutaneous coronary intervention (18.3% vs 24.6%, P = .014). Patients with LVH had higher unadjusted mortality at 6 months (10.5% vs 7.1%, P = .038), but similar rates of in-hospital mortality (4.1% vs 3.4%, P = .54) and reinfarction (7.1% vs 7.6%, P = .75). Patients with LVH were more likely to have heart failure in-hospital (21.8% vs 11.8%, P < .001). Among LVH patients, degree of quantitative STD did not predict higher short- or long-term mortality, but was associated with in-hospital heart failure. Multivariable analysis adjusting for other clinical prognosticators of the GRACE risk models revealed that LVH was not a significant independent predictor of in-hospital mortality (adjusted odds ratio = 0.75, 95% CI 0.40-1.41, P = .37) or 6-month mortality (adjusted odds ratio = 0.83, 95% CI 0.52-1.35, P = .44). In contrast, STD remained a strong independent predictor of adverse outcomes. There was no significant interaction between STD and LVH. Across the broad spectrum of NSTE-ACS, LVH is associated with adverse prognostic factors including STD. Electrocardiographic-determined LVH provides no significant additional prognostic utility beyond comprehensive risk assessment using the GRACE risk score. The adverse prognosis associated with LVH in NSTE-ACS may be attributable to other prognosticators such as STD.

Low Mortality After Treatment for Esophageal Perforation: A Single-Center Experience

Historically, esophageal perforation has been associated with significant mortality. Improvements in diagnosis, critical care, and surgical and endoscopic techniques may lead to lower mortality rates in the modern era. We reviewed our experience with the management of esophageal perforation to determine whether outcomes have improved. We retrospectively reviewed all cases of esophageal perforation from 1997 through 2008 at our institution. Univariate and propensity-matching analysis were performed. We reviewed the charts of 147 patients, and 97 met eligibility criteria. There were 45 women, (46.4%); mean age was 60.7 ± 15.6 years. Etiologies included iatrogenic in 50 (51.6%), spontaneous in 23 (23.7%), and idiopathic in 22 (22.7%). Treatment within 24 hours of presentation occurred in 55.2% of patients; 22.7% of patients were septic on presentation. Treatment included surgery in 72 patients (74.2%) and nonoperative management in 25 (25.8%). Forty-one patients (42.3%) underwent primary repair, 5 (6.9%) underwent esophageal resection, 4 (5.6%) underwent exclusion, and 22 (22.7%) underwent drainage or stent placement. Thirty-day mortality rate for the entire cohort was only 8.3% (8 patients). The mortality rate for the primary repair patients was 7.7%, and none of the resection patients died. There was similar in-hospital mortality rate between operative and nonoperative treatment groups (p = 0.96). Propensity-matching analysis showed equal morbidity (p = 0.74) and 30-day mortality (p = 0.35) between operative and nonoperative treatment groups. Our study represents a large series of patients treated for esophageal perforation. The results demonstrate that the overall mortality from esophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Nonoperative management, in appropriate patients, can also lead to good success rates and low mortality.

Difference in Patient Profiles and Outcomes in Japanese Versus American Patients Undergoing Coronary Revascularization (Collaborative Study by CREDO-Kyoto and the Texas Heart Institute Research Database)

Although coronary revascularization is common in both Japan and the United States (US), no direct comparison has been performed to demonstrate differences in the clinical characteristics and long-term outcomes of patients in these 2 countries. We analyzed the preprocedural, in-hospital, and long-term data from the Coronary Revascularization Demonstrating Outcome registry (Kyoto, Japan) and the Texas Heart Institute Research Database (Houston, Texas) of 16,100 patients who had undergone elective, initial percutaneous coronary intervention or coronary artery bypass grafting. The Japanese procedures were performed from 2000 to 2002 (n = 8,871, follow-up period 3.5 years, interquartile range 2.6 to 4.3) and the US procedures from 1999 to 2003 (n = 7,229, follow-up period 5.2 years, interquartile range 3.8 to 6.5). The Japanese patients tended to be older (mean age 67.2 vs 62.7 years; p <0.001), to smoke (52.9% vs 46.0%; p <0.001), and to have diabetes (39.2% vs 31.0%; p <0.001) and stroke (16.4% vs 5.0%; p <0.001). The US patients were more obese (body mass index 23.7 vs 29.3 kg/m(2); p <0.001), with greater rates of systemic atherosclerotic disease. Both groups had a similar in-hospital mortality rate (Japanese patients 0.9% vs US patients 1.1%; p = 0.19) and crude long-term mortality rate (Japanese patients 27.7/1,000 person-years, US patients 28.2/1,000 person-years; p = 0.35). After adjustment for known predictors, the US group had greater long-term mortality than the Japanese group (hazard ratio 1.71, 95% confidence interval 1.50 to 1.95; p <0.001). This finding was consistent among all high-risk subgroups. In conclusion, the 2 registries showed similar crude outcomes but important differences in patient risk factors such as obesity. In the adjusted analysis, the Japanese patients had better outcomes than did the US patients. Additional study is needed to assess the effect of ethnic and risk factor variations on coronary artery disease.

Video-Assisted Thoracoscopic Versus Open Thoracotomy Lobectomy in a Cohort of 13,619 Patients

Video-assisted thoracoscopic surgery (VATS) is becoming increasingly popular for lung resection in some centers. However, the issue of whether VATS or open thoracotomy is better remains controversial. We compared outcomes of open and VATS lobectomy in a national database. Using the 2004 and 2006 Nationwide Inpatient Sample database, we identified 13,619 discharge records of patients who underwent pulmonary lobectomy by means of thoracotomy (n = 12,860) or VATS (n = 759). Student's t and chi(2) tests were used to compare the two groups. Multivariable analysis was used to identify independent predictors of outcome measures. The two groups of patients had similar demographics and preoperative comorbidities. They also had similar in-hospital mortality rates (3.1% versus 3.4%; p = 0.67); lengths of stay (9.3 +/- 0.1 versus 9.2 +/- 0.4 days; p = 0.84); hospitalization costs ($23,862 +/- $206 versus $25,125 +/- $1,093; p = 0.16); and rates of wound infection (0.8% versus 1.3%; p = 0.15), pulmonary complications (32.2% versus 31.2%; p = 0.55), and cardiovascular complications (3.4% versus 3.9%; p = 0.43). However, multivariable analysis showed that the VATS group had a significantly higher incidence of intraoperative complications than the thoracotomy group (odds ratio, 1.6; 95% confidence interval, 1.0 to 2.4; p = 0.04). A higher percentage of patients with annual income greater than $59,000 underwent VATS lobectomy than patients with income less than $59,000 (35.7% versus 25.4%; p < 0.0001). Patients who underwent VATS lobectomy were 1.6 times more likely to have intraoperative complications than patients who underwent open lobectomy. However, short-term mortality, lengths of stay, and hospitalization costs were similar between the two groups of patients. There seems to be a socioeconomic disparity between VATS and open thoracotomy patients.

On-Pump Versus Off-Pump Coronary Artery Bypass Grafting in a Cohort of 63,000 Patients

The best approach to surgical myocardial revascularization remains controversial. We compared outcomes of conventional on-pump coronary artery bypass grafting (CABG) and off-pump coronary artery bypass (OPCAB) by using a nonvoluntary national database. In the 2004 Nationwide Inpatient Sample database, we identified 63,047 discharge records of patients who underwent CABG (n = 48,658) or OPCAB (n = 14,389). We analyzed seven preoperative variables, including the Deyo comorbidity index and five outcome measures. Multivariable logistic regression was used to identify independent predictors of outcomes. CABG and OPCAB patients had similar demographics and comorbidities. They also had similar rates of in-hospital mortality (3.0% vs 3.2%; p = 0.14) and postoperative stroke (1.8% vs 1.7%; p = 0.53). However, OPCAB patients had longer hospital stays (10.2 +/- 9.4 vs 9.9 +/- 8.5 days; p < 0.0001) and higher hospital costs ($38,793 +/- $30,830 vs $37,806 +/- $28,705; p = 0.0005) than CABG patients. Multivariable regression analysis showed that OPCAB independently predicted 0.6 more days of hospital stay (95% confidence interval [CI], 0.4 to 0.8 day; R(2) = 0.09; p < 0.0001) and $1,497 more in hospital costs (95% CI, $779 to $2,216; R(2) = 0.09; p < 0.01) per patient. OPCAB does not produce lower postoperative mortality or stroke rates than CABG. Furthermore, OPCAB is associated with longer hospital stays and higher hospital costs.

Ischemic stroke in patients with intermittent claudication: a clinical study of 142 cases.

The clinical features, risk factors, neuroimaging findings, and outcome of acute ischemic stroke were assessed in patients with intermittent claudication. Data from 142 patients with ischemic stroke and intermittent claudication were collected from a prospective hospital-based stroke registry in which 2500 consecutive acute stroke patients attended over a 12-year period. Ischemic stroke in patients with intermittent claudication accounted for 7.7% of all ischemic strokes (n = 1840). Ischemic stroke with and without intermittent claudication showed a similar in-hospital mortality rate (16% vs 14%) and absence of functional limitation at hospital discharge (20.5% vs 18.5%). Ischemic stroke patients with intermittent claudication showed a significantly shorter length of stay than patients without symptomatic peripheral arterial disease (14.6 vs 18.8 days, p < 0.05). Ischemic heart disease, transient ischemic attack (TIA), renal dysfunction, and watershed infarct were significant independent predictors of ischemic stroke in patients with intermittent claudication. Although cerebral infarction in patients with intermittent claudication showed a clinical profile suggestive of poor outcome, the prognosis was similar to that of ischemic stroke without intermittent claudication.

Operator volume and outcomes in 12,998 percutaneous coronary interventions. Northern New England Cardiovascular Disease Study Group.

We sought to determine whether there is a relation between operator volume and outcomes for percutaneous coronary interventions (PCIs). A 1993 American College of Cardiology/American Heart Association task force stated that cardiologists should perform > or = 75 procedures/year to maintain competency in PCIs; however, there were limited data available to support this statement. Data were collected from 1990 through 1993 on 12,988 PCIs (12,118 consecutive hospital admissions) performed by 31 cardiologists at two hospitals in New Hampshire and two in Maine and one hospital in Massachusetts supporting these procedures. Operators were categorized into terciles based on annualized volume of procedures. Univariate and multivariate regression analyses were used to control for case-mix. Successful outcomes included angiographic success (all lesions attempted dilated to < 50% residual stenosis) and clinical success (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 (MI) and death. After adjustment for case-mix, higher angiographic (low, middle and high terciles: 84.7%, 86.1% and 90.3%, p-trend 0.006) and clinical success rates (85.8%, 88.0% and 90.7%, p-trend 0.025), with fewer referrals to CABG (4.54%, 3.75% and 2.49%, p-trend <0.001), were seen as operator volume increased. There was a trend toward higher MI rates for high volume operators (2.00%, 1.98% and 2.57%, p-trend 0.06); all terciles had similar in-hospital mortality rates (1.09%, 0.96% and 1.05%, p-trend 0.8). There is a significant relation between operator volume and outcomes in PCIs. Efforts should be directed toward understanding why high volume operators are more successful and encounter fewer adverse outcomes.

Treatment of patients with acute myocardial infarction at a veterans affairs (VA) hospital and a non-VA hospital

Comparisons of care in Veterans Affairs (VA) hospitals with care in non-VA hospitals are needed to define the future role of the VA health care system. Therefore, the authors conducted a retrospective cohort study of 385 patients who had acute myocardial infarctions and were admitted to a private nonprofit teaching hospital and to a university-affiliated VA hospital, which were staffed by attending and resident physicians from a single medicine department. Data were obtained from hospital databases and from patient records. The authors found that the 206 VA patients, compared with the 179 non-VA patients, were younger and more likely to be men. The VA patients also had higher comorbidity but lower admission severity of illness, according to previously validated measures. Although the VA patients were less likely than the non-VA patients to receive thrombolytic therapy (6% vs 20%, respectively; p < 0.05), they were more likely to undergo coronary angiography (67% vs 57%; p < 0.05) and echocardiography or gated blood pool scanning (54% vs 44%; p < 0.05) during hospitalization. Finally, the VA and the non-VA patients had similar rates of in-hospital mortality in univariate analysis (9% vs 11%, respectively; p = 0.4) and in multivariate analysis, adjusting for covariates. These results suggest that the VA and the non-VA patients who had acute myocardial infarction had similar outcomes and generally received care of similar qualities. Future studies are needed to explore the generalizability of these findings and to provide the data needed to adequately define the VA's future role in American health care.