Surgical Coronary Artery Bypass Grafting Research Articles

TransCatheter aortic valve implantation and fractional flow reserve-guided percutaneous coronary intervention versus conventional surgical aortic valve replacement and coronary bypass grafting for treatment of patients with aortic valve stenosis and complex or multivessel coronary disease (TCW): an international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial

Patients with severe aortic stenosis present frequently (∼50%) with concomitant obstructive coronary artery disease. Current guidelines recommend combined surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) as the preferred treatment. Transcatheter aortic valve implantation (TAVI) and fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) represent a valid treatment alternative. We aimed to test the non-inferiority of FFR-guided PCI plus TAVI versus SAVR plus CABG in patients with severe aortic stenosis and complex coronary artery disease. This international, multicentre, prospective, open-label, non-inferiority, randomised controlled trial was conducted at 18 tertiary medical centres across Europe. Patients (aged ≥70 years) with severe aortic stenosis and complex coronary artery disease, deemed feasible for percutaneous or surgical treatment according to the on-site Heart Team, were randomly assigned (1:1) to FFR-guided PCI plus TAVI or SAVR plus CABG according to a computer-generated sequence with random permuted blocks sizes stratified by site. The primary endpoint was a composite of all-cause mortality, myocardial infarction, disabling stroke, clinically driven target-vessel revascularisation, valve reintervention, and life-threatening or disabling bleeding at 1 year post-treatment. The trial was powered for non-inferiority (with a margin of 15%) and if met, for superiority. The primary and safety analyses were done per an intention-to-treat principle. This trial is registered with ClinicalTrials.gov (NCT03424941) and is closed. Between May 31, 2018, and June 30, 2023, 172 patients were enrolled, of whom 91 were assigned to the FFR-guided PCI plus TAVI group and 81 to the SAVR plus CABG group. The mean age of patients was 76·5 years (SD 3·9). 118 (69%) of 172 patients were male and 54 (31%) patients were female. FFR-guided PCI plus TAVI resulted in favourable outcomes for the primary endpoint (four [4%] of 91 patients) versus SAVR plus CABG (17 [23%] of 77 patients; risk difference -18·5 [90% CI -27·8 to -9·7]), which was below the 15% prespecified non-inferiority margin (pnon-inferiority<0·001). FFR-guided PCI plus TAVI was superior to SAVR plus CABG (hazard ratio 0·17 [95% CI 0·06-0·51]; psuperiority<0·001), which was driven mainly by all-cause mortality (none [0%] of 91 patients vs seven (10%) of 77 patients; p=0·0025) and life-threatening bleeding (two [2%] vs nine [12%]; p=0·010). The TCW trial is the first trial to compare percutaneous treatment versus surgical treatment in patients with severe aortic stenosis and complex coronary artery disease, showing favourable primary endpoint and mortality outcomes with percutaneous treatment. Isala Heart Centre and Medtronic.

Extended use of axillary impella 5.5 as a bridge to post-infarct ventricular septal defect repair.

Post-infarct ventricular septal defect (VSD) carries high mortality. Since emergent repair of post-infarct VSD is challenging, hemodynamic stabilization utilizing temporary mechanical circulatory support crucially provides time to delay intervention and allows necessary scar tissue formation which improves the fragility of myocardium and leads to a definitive repair. To date, there remains no standard for achieving hemodynamic stability, including usage and mode of temporary mechanical circulatory support. We describe a patient with acute post-infarct VSD in cardiogenic shock successfully supported with Impella 5.5 for 67days as a bridge to surgical repair and coronary artery bypass grafting.

Reoperative approach after extra-anatomic ascending-to-descending aortic bypass graft

BackgroundExtra-anatomic ascending-to-descending aortic bypass grafts have historically been utilized as a safe and effective solution for repairs of complex coarctation of the aorta. However, reports on reoperation in these patients remain rare. We present a case of an aortic valve replacement and coronary artery bypass grafting in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.Case presentationThe patient is a 59-year-old male with a complex aortic history, including repair of aortic coarctation with an ascending-to-descending aortic bypass graft 13 years prior, was admitted to the hospital for shortness of breath and chest pain that had developed over the past year. On further workup, he was found to have severe bileaflet aortic valve stenosis, non-ST elevation myocardial infarction, and moderate coronary artery disease. He underwent surgical aortic valve replacement and coronary artery bypass grafting. Given his unique anatomy, cardiopulmonary bypass approach involved separate cannulation of the right axillary and left common femoral arteries with cross-clamp of both the aorta and the extra-anatomic graft. Using this approach, the redo operation was successfully performed.ConclusionsReports on reoperation after ascending-to-descending aortic bypass grafting are rare. We describe our approach to cardiopulmonary bypass and reoperation in a patient with an extra-anatomic ascending-to-descending aortic bypass graft.

Standardized exposure of the lateral and posterior wall in off-pump minimally invasive cardiac surgical coronary artery bypass grafting

Standardized exposure of the lateral and posterior wall in off-pump minimally invasive cardiac surgical coronary artery bypass grafting

Understanding Perioperative Acute Myocardial Ischemia Following Coronary Artery Bypass Grafting.

Surgical revascularization and coronary artery bypass grafting are often pursued as treatment for obstructive coronary artery disease. Despite trends of increased referrals for complex percutaneous coronary intervention, surgical revascularization often remains the standard of care for patients with multivessel or complex coronary artery disease. Myocardial ischemia during the perioperative and postoperative periods during coronary artery bypass grafting remains a challenge. Nuanced consideration is necessary to decide on interventions that include conservative management and percutaneous or repeat surgical revascularization.

B-55 | Trends and Outcomes of Intra-Aortic Balloon Pump Use in Patients with Concomitant Surgical Aortic Valve Replacement and Coronary Artery Bypass Graft: A 5-Year Cohort Study

B-55 | Trends and Outcomes of Intra-Aortic Balloon Pump Use in Patients with Concomitant Surgical Aortic Valve Replacement and Coronary Artery Bypass Graft: A 5-Year Cohort Study

Handgrip exercise in patients scheduled for cardiac surgery to attenuate troponin release: a feasibility study.

Cardiac surgery, including surgical aortic valve repair (SAVR) and coronary artery bypass grafting (CABG), are associated with ischemia-reperfusion (I/R) injury. Single bouts of exercise, including handgrip exercise, may protect against I/R injury. This study explored 1) the feasibility of daily handgrip exercise in the week before SAVR and/or CABG and 2) its impact on cardiac I/R injury, measured as postoperative cardiac troponin-T (cTnT) release. Sixty-five patients undergoing elective SAVR and/or CABG were randomized to handgrip exercise + usual care (intervention, n = 33) or usual care alone (control, n = 32). Handgrip exercise consisted of daily 4 × 5-min handgrip exercise (30% maximal voluntary contraction) for 2-7 days before cardiac surgery. Feasibility was assessed using validated questionnaires. Postoperative cTnT release was assessed at 0, 6, 12, 18, and 24 h [primary outcome area under the curve (cTnTAUC)]. Most patients (93%) adhered to handgrip exercise and 77% was satisfied with this intervention. Handgrip exercise was associated with lower cTnTAUC (402,943 ± 225,206 vs. 473,300 ± 232,682 ng · min/L), which is suggestive of a medium effect size (Cohen's d 0.31), and lower cTnTpeak (313 [190-623] vs. 379 [254-699] ng/L) compared with controls. We found that preoperative handgrip exercise is safe and feasible for patients scheduled for SAVR and/or CABG and is associated with a medium effect size to reduce postoperative cardiac I/R injury. This warrants future studies to assess the potential clinical impact of exercise protocols before cardiac surgery.NEW & NOTEWORTHY Daily handgrip exercise in the week before elective cardiac surgery is safe and feasible. Handgrip exercise is associated with a medium effect size for less troponin-T release. Future larger-sized studies are warranted to explore the impact of (handgrip) exercise prior to cardiac surgery on clinical outcomes and direct patient benefits.

Novel concept of less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting avoiding full median sternotomy.

In the last decades, minimally invasive procedures have been developed in the therapy of aortic valve disorders. Recently, a novel concept of minimally invasive coronary revascularization in multivessel disease via left anterior mini-thoracotomy demonstrated promising results. Full median sternotomy, as a very invasive procedure, is the standard approach in concomitant surgical aortic valve replacement (sAVR) and coronary bypass grafting (CABG). The aim of our study was to show that the combination of minimal invasive aortic valve replacement via upper mini-sternotomy and coronary artery bypass grafting via left anterior mini-thoracotomy is feasible to avoid full median sternotomy. From 07/2022 to 09/2022, concomitant sAVR via upper partial sternotomy and CABG via left anterior mini-thoractomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in six consecutive patients (6 males; 69.8 ± 7.4 [60-79] years). All patients had severe aortic stenosis (MPG 45.5 ± 17.3mmHg) and a significant coronary artery disease (three-vessel: 33%, two-vessel: 33%, one-vessel: 33%) with indication to cardiac surgery. Mean EuroScore2 was 3.2. All patients underwent successful less invasive concomitant biological sAVR and CABG. 67% of patients received a 25mm, 33% received a 23mm biological aortic valve replacement (Edwards Lifesciences Perimount). A total of 11 distal anastomoses (1.8 ± 1.0 [1-3] per patient) were performed by using left internal artery mammary (50%), radial artery (17%) and saphenous venous graft (67%) for grafting the left anterior descending (83%), circumflex (67%) and right (33%) coronary artery. Hospital mortality was 0%, stroke rate was 0%, myocardial infarction was 0% and repeat revascularization rate was 0%, ICU stay was 1day in 83% of all patients and 50% left hospital within 8days after surgery. Less invasive concomitant surgical aortic valve replacement and coronary artery bypass grafting using upper mini-sternotomy and left anterior mini-thoracotomy is feasible without compromises in surgical principles and complete coronary revascularization while maintaining thoracic stability by avoiding full median sternotomy.

Outcomes of del Nido cardioplegia after surgical aortic valve replacement and coronary artery bypass grafting.

The use of del Nido cardioplegia (DNC) was initially adopted in the field of pediatric cardiac surgery. Several studies in adult patients suggested there were no differences in early postoperative outcomes as compared to blood-based cardioplegia. We sought to evaluate the impact of DNC as compared to modified Buckberg cardioplegia (BC) on early postoperative outcomes in patients undergoing surgical aortic valve replacement with and without coronary artery bypass grafting (SAVR ± CABG). All SAVR ± CABG procedures were switched from BC to DNC at our institute in 2012. We compared outcomes of BC (November 2007-October 2012; n = 1037) with DNC (November 2012-December 2017; n = 1067). Significant baseline differences were observed between the two groups and such differences were adjusted via inverse propensity treatment weighting. After adjustment, SAVR ± CABG patients who received DNC required longer aortic cross-clamp times, while postoperative peak troponin I and creatinine kinase-MB isotype were significantly lower in the BC group. Length of hospital and intensive care unit stay were significantly shorter in the DNC group. The incidence of postoperative complications was lower in the DNC cohort. Thirty-day mortality rate was significantly lower in the DNC group (3.0% vs 4.9%, p = 0.002). The use of DNC cardioplegia in our cohort of adult patients who underwent SAVR ± CABG was safe and associated with improved postoperative outcomes. However, the use of DNC may be associated with higher degrees of myocardial injury.

The impact of coronary artery bypass grafting added to aortic valve replacement on long-term outcomes in octogenarian patients: a reconstructed time-to-event meta-analysis.

Summary The long-term results in studies comparing octogenarian patients who received either isolated surgical aortic valve replacement (i-SAVR) or coronary artery bypass grafting (CABG) in addition to SAVR are still debated. We performed a reconstructed time-to-event data meta-analysis of studies comparing i-SAVR and CABG+SAVR to evaluate the impact of CABG and to analyse the time-varying effects on long-term outcome. We performed a systematic review of the literature from January 2000 through November 2021, including studies comparing i-SAVR and CABG+SAVR, which reported at least 3-year follow-up and that plotted Kaplan–Meier curves of overall survival. The primary endpoint was overall long-term survival; secondary endpoints were in-hospital/30-day mortality and postoperative outcomes. The pooled hazard ratio (HR) and odds ratio) with 95% confidence interval (CI) were calculated for primary and secondary endpoints, respectively. Random-effect model was used in all analyses. Sixteen retrospective studies were included (5382 patients, i-SAVR = 2568 and CABG+SAVR = 2814). I-SAVR showed a lower incidence of in-hospital mortality compared to CABG+SAVR (odds ratio = 0.73; 95% CI= 0.60–0.89; P = 0.002). Landmark analyses showed a significantly higher all-cause mortality within 1 year from surgery in CABG+SAVR (HR = 1.17; 95% CI = 1.01–1.36; P = 0.03); after 1 year, no significant difference was observed (HR = 0.95; 95% CI = 0.87–1.04; P = 0.35). Landmark analysis was confirmed by time-varying trend of HR. Late survival of octogenarians did not differ significantly between the 2 interventions. Interestingly, CABG added to SAVR was associated with both higher in-hospital and within 1-year mortality after surgery, whereas this difference was statistically non-significant at long-term follow-up.

Complete transcatheter versus complete surgical management for combined aortic stenosis and coronary artery disease: A false dichotomy?

Coronary artery disease and aortic stenosis often occur concomitantly owing to their shared risk factor profile. While standard management of these patients has been through surgical methods including surgical aortic valve replacement and coronary artery bypass grafting, recent studies have investigated the potential role of complete transcatheter management (i.e., transcatheter aortic valve implantation and percutaneous coronary intervention) for these patients. In this editorial, we discuss the growing body of evidence suggesting long-term risks of transcatheter interventions despite their short-term benefits and also look to the future of hybrid approaches for multifaceted structural heart pathologies.

C91. “Successful management of ventricular septal rupture after myocardial infarction in elderly: the role of intra-aortic balloon pump and timing for surgery”: A Case Report

Abstract Background Ventricular septal rupture (VSR) after myocardial infarction (MI) is a case with a high mortality rate, early diagnosis and appropriate treatment are essential. Surgical VSR closure though challenging and associated with high mortality, remains one of the main therapy in VSR closure. Case Presentation A 70-year-old woman had a complaint about the shortness of breath (SoB). From anamnesis, 17 days before admission, she complained of chest pain. 15 days before admission, she was taken to a local hospital and got hospitalized for 7 days in the intensive care unit. ECG showed anterior MI. During admission, patient developed SoB. From echocardiography, it showed VSR at apical. She was referred to dr. Kariadi hospital for further management. Coronary angiography showed total occlusion in mid LAD. An intra-aortic balloon pump (IABP) was inserted for stabilized hemodynamic and as bridging. Inotropic support was given and afterload reduction was also administered. Surgical VSR closure and coronary artery bypass grafting (CABG) was successfully performed on the 22nd day after the onset of MI. The patient was discharged 10 days after surgery in a good condition. Discussion The mortality of VSR varied significantly depending on the timing of surgery. Patients who underwent surgery within 7 days of presentation had a 54.1% mortality compared with 10 % mortality if the repair was delayed until after 21 days. The cornerstone of preoperative management of VSR is afterload reduction. IABP provides mechanical afterload reduction and augmentation of cardiac output.

C91. “Successful management of ventricular septal rupture after myocardial infarction in elderly: the role of intra-aortic balloon pump and timing for surgery”: A Case Report

Abstract Background Ventricular septal rupture (VSR) after myocardial infarction (MI) is a case with a high mortality rate, early diagnosis and appropriate treatment are essential. Surgical VSR closure though challenging and associated with high mortality, remains one of the main therapy in VSR closure. Case Presentation A 70-year-old woman had a complaint about the shortness of breath (SoB). From anamnesis, 17 days before admission, she complained of chest pain. 15 days before admission, she was taken to a local hospital and got hospitalized for 7 days in the intensive care unit. ECG showed anterior MI. During admission, patient developed SoB. From echocardiography, it showed VSR at apical. She was referred to dr. Kariadi hospital for further management. Coronary angiography showed total occlusion in mid LAD. An intra-aortic balloon pump (IABP) was inserted for stabilized hemodynamic and as bridging. Inotropic support was given and afterload reduction was also administered. Surgical VSR closure and coronary artery bypass grafting (CABG) was successfully performed on the 22nd day after the onset of MI. The patient was discharged 10 days after surgery in a good condition. Discussion The mortality of VSR varied significantly depending on the timing of surgery. Patients who underwent surgery within 7 days of presentation had a 54.1% mortality compared with 10 % mortality if the repair was delayed until after 21 days. The cornerstone of preoperative management of VSR is afterload reduction. IABP provides mechanical afterload reduction and augmentation of cardiac output.

Quality of life in patients with long-standing persistent atrial fibrillation after surgical ablation and simultaneous coronary artery bypass grafting

Aim. To analyze quality of life (QOL) of patients with coronary artery disease (CAD) in combination with long-standing persistent atrial fibrillation (AF) in the long-term postoperative period, depending on chosen surgical strategy for concomitant pathology.Material and methods. The analysis of QOL changes in the long-term postoperative period (12 and 24 months) in 116 patients with CAD and concomitant long-term persistent AF who selectively underwent biatrial (BA) or isolated left atrial (LA) ablation with simultaneous on-pump coronary artery bypass grafting. To assess QOL, a non-specific Medical Outcomes Study 36-Item Form Health Status Survey (SF-36) questionnaire was used. Patients were questioned in preoperative and long-term postoperative periods (12 and 24 months).Results. All SF-36 parameters significantly improve after open surgical treatment in the long-term postoperative period (24 months) with both treatment strategies (BA and LA ablation) for AF. In the BA ablation group, 74% of patients did not have arrhythmia after 12 months, and only 38,5% of patients in the LA ablation group belonged to European Heart Rhythm Association (EHRA) score class 1 (p=0,001). After 24 months, a comparison revealed a significant diff erence between the two groups in arrhythmia symptoms (p=0,014), with maintaining the advantage of the BA ablation group. After 12 and 24 months, none of the patients in both compared groups had severe class IV angina.Conclusion. SF-36 parameters were improved 24 months after surgical treatment of CAD and long-standing persistent AF, regardless of the ablation strategy. Elimination of angina symptoms and long-term maintenance of sinus rhythm can improve the QOL of patients in the long-term postoperative period.

Associations Between the Severity of Influenza Seasons and Mortality and Readmission Risks After Elective Surgical Aortic Valve Replacement and Coronary Artery Bypass Graft Surgery in Older Adults

This cross-sectional study uses Centers for Medicare and Medicaid Services claims data to investigate associations between influenza season severity and mortality and readmission risks after elective surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) among older adults.

Automated Prediction of Surgical Site Infection Coronary Artery Bypass (CABG) Grafting Surgery

Background: In 5 hospitals located in Belo Horizonte city (&gt;3,000,000 inhabitants) a focused survey on surgical site infection (SSI) was performed in patients undergoing CABG surgery. We statistically evaluated such incidences to enable study of the prediction power of SSI through pattern recognition algorithms, in this case the multilayer perceptron (MLP) artificial neural networks. Methods: Data were collected between July 2016 and June 2018 on SSI by the hospital infection control committees (CCIHs) of the hospitals involved in the research. We collected all data used in the analysis during their routine SSI surveillance procedures. The information was forwarded to the NOIS (Nosocomial Infection Study) Project, which uses the SACIH (Automated Hospital Infection Control System) software to collect data from a sample of hospitals participating voluntarily in the project. After data collection, 3 procedures were performed: (1) a treatment of the collected database for use of intact samples; (2) a statistical analysis on the profile of the hospitals collected; and (3) an assessment of the predictive power of 5 types of MLP (ie, backpropagation standard, momentum, resilient propagation, weight decay, and quick propagation) for SSI prediction. MLPs were tested with 3, 5, 7, and 10 hidden layer neurons and a database split for the resampling process (65% or 75% for testing and 35% or 25% for validation). They were compared by measuring the AUC (area under the curve; range, 0–1) presented for each of the configurations. Results: From 666 initial data, only 278 were able for analysis. We obtained the following statistics: 9.35% manifested SSIs; length of stay varied from 1 to 119 days, with ~40% staying between 10 and 19 days; 15.1% of the patients died. Regarding the prediction power of SSI, the experiments have a maximum value of 0.713. Conclusions: Despite the considerable loss rate of &gt;50% of the database samples due to the presence of noise, it was possible to have a relevant sampling to evaluate the profile of hospitals in Belo Horizonte. In addition, for the predictive process, although some configurations had results equal to 0.5, others reached 0.713, which indicates that the automated SSI monitoring framework for patients undergoing coronary artery bypass grafting surgery is promising. To optimize data collection and to enable other hospitals to use the SSI prediction tool (available at www.sacihweb.com), a mobile application was developed.Funding: NoneDisclosures: None

Coronary artery ectasia presenting with ST-elevation myocardial infarction in a young indigenous man: a case report

BackgroundCoronary artery ectasia (CAE) is often an incidental finding on angiography, however, patients can present with acute coronary syndrome due to a large thrombus burden requiring treatment with percutaneous coronary intervention or with emergency surgery.Case summaryA 26-year-old Indigenous Australian male was admitted with anterior ST-elevation myocardial infarction associated with an out of hospital ventricular fibrillation arrest. Coronary angiography demonstrated thrombotic occlusion of the proximal left anterior descending (LAD) artery with heavy thrombus burden and prominent vascular ectasia of all three coronary arteries. He was managed with surgical thrombectomy and coronary artery bypass graft of his LAD.DiscussionThis is the first case of triple CAE in an Indigenous Australian. The case highlights the lack of consensus approach in the management of CAE due to paucity of prospective studies.

Transcatheter aortic valve replacement and percutaneous coronary intervention versus surgical aortic valve replacement and coronary artery bypass grafting in patients with severe aortic stenosis and concomitant coronary artery disease: A systematic review and meta‐analysis

We performed a systematic review and meta-analysis to evaluate the early and midterm outcomes of patients who underwent surgical aortic valve replacement (SAVR) and coronary artery bypass grafting (CABG) against patients who had transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI). Contemporary guidelines suggest that surgical or percutaneous revascularization of significant coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is a reasonable strategy. We conducted a comprehensive search of Medline and Embase to identify studies comparing a percutaneous transcatheter versus a surgical approach. Random effects meta-analyses using the Mantel-Haenszel method were performed to estimate the effect of percutaneous compared surgical strategies using aggregate data. Six studies reporting on 1770 participants were included in the meta-analysis. There were no significant differences in effect estimates for early and midterm mortality (OR: 0.78; 95% CI, 0.50-1.20 and OR: 1.09; 95% CI, 0.80-1.49, respectively) or myocardial infarction (OR: 0.52; 95% CI, 0.20-1.33 and OR: 1.34; 95% CI, 0.67-2.65, respectively). No significant difference was shown for peri-procedural stroke (OR: 0.80; 95% CI, 0.35-1.87). A transcatheter approach had a higher rate of major vascular complications (OR: 14.44; 95% CI, 4.42-47.16), but a lower rate of acute kidney injury (OR: 0.41; 95% CI, 0.19-0.91). Our analysis suggests that a percutaneous transcatheter approach confers similar outcomes compared to a surgical approach in patients with severe AS and CAD. However, our findings are based on low quality studies and should serve as hypothesis generating. In the absence of adequately powered studies yielding high level evidence, individualized decision making should be based on surgical risk assessment.

A comparison of surgical, total percutaneous, and hybrid approaches to treatment of combined coronary artery and valvular heart disease.

The purpose of this review is to compare outcomes of surgical valve replacement (SVR) and coronary artery bypass grafting (CABG), minimally invasive cardiac surgery (MICS) SVR and percutaneous coronary intervention (PCI), and transcatheter aortic valve replacement and PCI for the treatment of combined coronary artery disease (CAD) and valvular heart disease (VHD). Several studies have attempted to identify key differences in outcomes with hybrid MICS SVR and PCI approaches to combined CAD and VHD. Recent studies have demonstrated that MICS SVR and PCI, when compared with conventional open SVR and CABG, demonstrate reduced or unchanged morbidity and mortality. However, the rate of bleeding in MICS SVR and PCI is consistently higher likely because of the effects of antiplatelet therapy. A shift toward MICS has occurred in the preceding decades, with outcomes improving in recent years. With limited ability to perform CABG through MICS approaches, attempts have been made at hybrid procedures to address multiple presenting concerns while allowing for the benefits of MICS approaches. Hybrid MICS SVR and PCI approaches may provide suitable alternatives to traditional surgical approaches with reduced intra and postoperative morbidity and mortality, with the notable exception of bleeding complications.

Abstract 266: Incidence, Predictors and Outcomes of Permanent Pacemaker Implantation Among Patients With Bradyarrhythmias Following Cardiac Surgery: Insights From the National Inpatient Sample Database

Introduction: Significant atrioventricular blocks and bradyarrhythmias are known complications of open-heart surgery. These are frequently transient, however, some patients go on to need a permanent pacemaker (PP). We sought to describe the incidence, predictors, and outcomes of PP implantation among patients admitted for cardiac surgery who develop bradyarrhythmias. Methods: We queried the National Inpatient Sample (NIS) database from 2010 to 2014 for adults admitted for surgical valve replacement, valvuloplasty or coronary artery bypass grafting (CABG) who had bradyarrhythmias during the admission using the appropriate ICD codes. We identified patients who had permanent pacemaker implantation documented during the admission. Categorical and continuous variables were compared using the chi-square and student's t-test. Predictors of PP implantation and in-hospital mortality were evaluated by logistic regression. Results: Of the 1402930 patients who underwent cardiac surgery, 94748 patients had bradyarrhythmias defined as sinoatrial node dysfunction (SND) and/or atrioventricular block (AVB) during hospitalization. The primary procedure was identified as valve replacement in 50.3% (47615 of 94748), CABG in 29.9% (27622 of 94748) and valvuloplasty in 8.7% (8248 of 94748). SND was found in 29.9% (28372 of 94748) and AVB in 76% (72017 of 94748). Permanent pacemaker implantation was done in 39.3% (37246 of 94748). Valve replacement was the most common surgery associated with PP implantation [58% (21682 of 37246) compared to 21.5% in CABG (8007 of 37246) and 7.7% in valvuloplasty (2882 of 37246), p &lt; 0.001). Female sex aOR 1.36 (95% CI 1.31 - 1.40), young age 18 - 44 years aOR 1.36 (95% CI 1.24 - 1.49), Asiatic and Hispanic origin aOR 1.36 (95% CI 1.23 - 1.51), aOR 1.25 (95% CI 1.17 - 1.34) respectively, diabetes mellitus with chronic complications aOR 1.16 (95% CI 1.09 - 1.24), drug abuse aOR 1.38 (95% CI 1.21 - 1.55) were associated with higher odds of pacemaker implantation. African American origin aOR 0.79 (95CI 0.74 - 0.85), AIDS aOR 0.33 (95% CI 0.17 - 0.67), south hospital region aOR 0.89 (95% CI 0.85 - 0.93), no-charge admissions aOR 0.66 (95% CI 0.49 - 0.89) were associated with a lower odds of PPM implantation. Death during hospitalization was found in 3% of the patients. After multivariable regression, PP implantation was associated with a lower likelihood of in-hospital death aOR 0.45 (95% CI 0.41 - 0.50). Conclusion: Approximately one-third of the patients hospitalized for cardiac surgery related to AVB and/or SND were implanted a permanent pacemaker. Factors like age, sex, race and comorbidities determine the likelihood of this procedure that has a significant impact on mortality. Having a better insight into these predictors would allow a better triage of patients who would benefit from its implantation.