Time CABG Research Articles

Frequency of unplanned re-admissions after coronary artery bypass grafting. Experience at a tertiary care hospital.

Objective: To study the re-admission rate after coronary artery bypass grafting performed through a median sternotomy. Study Design: Retrospective study. Setting: Punjab Institute of Cardiology, Lahore. Period: January 2018 and December 2022. Methods: Patients above the age of 18 who underwent first time CABG were included in the study. Patients with additional procedures like valve surgery were excluded. Re-admission was defined as unplanned re-hospitalization within 30 days after discharge. Data was collected on Excel sheets from the available electronic medical record system of the hospital. The data was then transported to and analyzed using IBM SPSS software (version 23, SPSS Inc., Chicago, IL, USA). Patients were divided into re-admission group and no re-admission group and various perioperative variables were compared between the two groups. Results: After applying the exclusion criteria, the final analysis included 503 patients. Of the cohort, 29 (5.77%) were re-admitted. Mean age of the patients in readmission group was 54.3 ± 10 years while that in the no-readmission group 52 ± 8.3 years (p=0.144). The main reasons for readmissions were superficial chest wound infection (24.14%), pericardial effusion (24.14%) and deep sternal wound infection (10.34%). Conclusion: Coronary artery bypass grafting is associated with re-admissions after planned discharge of the patients. Wound infections are the commonest cause of re-admission. Large scale multi center studies are needed to study the rate as well as financial impact of re-admissions after CABG.

Risk Factors and Outcomes in Redo Coronary Artery Bypass Grafting

Reoperative coronary artery bypass grafting (redo-CABG) has declined during the last decade, while use of percutaneous coronary intervention (PCI) has increased. The aim of this retrospective study was to evaluate risk factors, in-hospital mortality, and long-term survival between first-time CABG and redo-CABG. From January 2009 to December 2015, 2,581 patients underwent first-time CABG procedures while 132 underwent isolated redo-CABG. Logistic regression was used to identify risk factors predictive of redo-CABG and after propensity matching the in-hospital morbidity and long-term all-cause mortality were compared. Risk factors for redo-CABG were prior PCI, dyslipidaemia, diabetes and hypertension. After propensity matching there were no significant differences between the redo-CABG (n = 126) and first-time CABG groups (n = 232) in baseline characteristics. The adjusted in-hospital mortality was 3.1% for redo-CABG and 2.1% for first-time CABG (p = 0.55). Redo-CABG required significantly more intraoperative red blood cells (p = 0.03), platelets (p < 0.001), cryoprecipitate (p < 0.007) and fresh frozen plasma (p < 0.001) than first-time CABG. There was no significant difference in reoperation for bleeding (p = 0.72), prolonged ventilation (p = 0.98), postoperative stroke (p = 0.92) or dialysis (p = 0.44). The survival at 1, 3 and 5 years for redo-CABG was 93.5%, 90%, and 85% respectively, and 95.5%, 94.5%, 93% for first-time CABG, respectively (p = 0.2). Prior PCI after first time CABG and the risk factors for atherosclerotic disease are predictive for redo-CABG. An increased use of blood products is required during redo-CABG. After propensity matching, in-hospital mortality and long-term survival for redo-CABG is comparable to first-time operation. Re-sternotomy does not impact the survival in redo-CABG.

The enhanced recovery programme pilot: can we achieve better outcomes and shorter stays for cardiac surgical patients?

Background Enhanced recovery programmes (ERP) reduce hospital stay and improve outcomes through a structured approach to perioperative care. We present our tailored protocol and results for first time AVR and CABG patients enrolled on ERP. Key elements are optimising co-morbidities, discharge planning, reduced starvation with carbohydrate loading. Intra-op focus is on minimally invasive techniques and analgesic planning. Post-op protocol aims to extubate early, reduce opiate analgesia using other agents, rapid mobilisation and return to normal diet and function.

Evaluation of EuroSCORE II for elective isolated first time CABG patients

Results Of a total of 341 patients, 286 (83.9%) were males. The mean age was 65.85 ± 9.9 years. The overall 30 day mortality was 1.47% (5 deaths). The mean EuroSCORE II was 1.3 whereas the mean additive and logistic EuroSCORE I were 3.29 and 3.22 respectively. The area under curve (AUC) for ROC analysis were (in brackets) for EuroSCORE II (0.68 ± .12), additive EuroSCORE I (0.77 ± 0.08) and logistic EuroSCORE I (0.76 ± 0.09).

Assessing Safety of CABG in the Era Post Primary PCI, an Outcome Analysis of STEMI Population

Background: Primary PCI (PPCI) has replaced thrombolysis as the treatment of choice for STEMI. The effect of this change on outcomes of patients referred for subsequent CABG is unknown. Methods: All STEMI patients having thrombolysis or PPCI between 2000 and 2010 were identified. Of these, patients subsequently referred for isolated first time CABG form the cohort for this study. Results: 83 of 2476 (3.4%) patients from the PPCI cohort (median follow-up [FU] 3 years [range 6 m - 7.8 y]) and 49 of 528 (9.2%) from the thrombolysis cohort (median FU 9 y [range 1.5 - 10 y] were referred for subsequent CABG. In this referred group, initial reperfusion success (as defined) was: PPCI = 86%, lysis = 84%, p = 0.69. Surgical waiters with prior PPCI had less post infarct angina (1.2% vs. 25%, p 0.01) and late re-infarction (6% vs. 20%, p = 0.034) prior to surgery. Timing of CABG was: 6 m (PPCI 82%, lysis 73%), 6 m-1 y (PPCI 8.4%, lysis: 9%), >1 y (PPCI 9.6%, lysis 18%).Other than an increased prevalence of diabetes in the thrombolysis group, there were no differences in demographic details or risk profile. There were no post-operative deaths, MIs or CVAs. There were no significant differences in post-op AF (28% vs. 22% p = 0.5), respiratory failure (8% vs. 18%, p = 0.08), renal failure (5% vs. 6%, p = 0.5) or re-openings (0% vs. 6%, p = 0.8). Mortality at 3 years was 2.4% in the PPCI cohort and 4% in the thrombolysis cohort. Overall mortality during follow-up for the PPCI group was 3.6% (n = 3) (median FU 3 years), and for the lysis group was 24.5% (n = 12) (median FU 9 years). Conclusions: In patients awaiting CABG after STEMI, PPCI reduces the risk of post-infarct angina and re-infarction prior to surgery, but early surgical results were equally favorable in both groups. Additional follow-up is needed in the PPCI cohort to determine whether there are any significantly different longer-term outcomes.

Sampling conditions influence multiple electrode platelet aggregometry in cardiac surgery patients

Objectives. To investigate the importance of blood sampling conditions for multiple electrode platelet aggregometry (MEA) in cardiac surgery patients. Design. Eighty-one patients undergoing first time CABG surgery were included in three prospective, observational studies. MEA was used to analyze platelet aggregability after addition of adenosine-diphosphate (ADP) or thrombin activating peptide 6 (TRAP). In substudy 1, hirudin and citrate tubes were compared. In substudy 2, samples from peripheral vein, central venous catheter, and radial artery were compared and in substudy 3, the effect of surgery was investigated by analyzing pre- and postoperative samples. Results. Platelet aggregability values were 30% higher in hirudin tubes than in citrate tubes. There was a significant correlation between hirudin and citrate tubes in TRAP-induced aggregability (r = 0.84, p < 0.001) but not in ADP-induced aggregability (r = 0.25, p = 0.13). The blood sampling site did not influence platelet aggregability. Surgery reduced ADP-induced aggregability by 31% (p < 0.001) and TRAP-induced aggregability by 30% (p < 0.001) with large intraindividual variations. Conclusions. MEA results in cardiac surgery patients should not be compared between samples collected in test tubes with different anticoagulants. The choice of blood sampling site does not affect the results. The operation in itself reduces markedly mean platelet aggregability.

Endothelial Activation After Coronary Artery Bypass Surgery: Comparison Between On-Pump and Off-Pump Techniques

The effects of off-pump coronary artery bypass (OPCAB) surgery on endothelial cell activation are poorly understood. Endothelial cell adhesion molecules (CAMs) are expressed and released when the endothelium is activated. We compared plasma CAMs (E-selectin, ICAM-1 and VCAM-1) and HUVEC expression of the same CAMs when exposed to plasma taken before, during and after OPCAB or on-pump coronary surgery (CABG). Patients undergoing first time CABG (n=10) or OPCAB (n=10) had 6 blood samples taken before surgery and up to 24h post-operatively. Plasma samples were assayed for E-selectin, ICAM-1 and VCAM-1. The same plasma samples were exposed to HUVEC cultures and cell-surface expression of E-selectin, ICAM-1 and VCAM-1 measured. Data are expressed as mean+/-SEM of n subjects. Plasma E-selectin was unchanged. Plasma ICAM-1 and VCAM-1 were elevated 24h post-operatively in both groups (P<0.01), with no differences between the groups. Twenty-four hours post-OPCAB plasma increased basal and IL-1beta induced expression of endothelial VCAM-1 by 133+/-16% and 140+/-27% (P<0.05), respectively. Plasma taken 3h post-CABG decreased endothelial VCAM-1 expression by 76+/-10% (P<0.05). Peri-operative plasma had no effect on endothelial expression of E-selectin or ICAM-1 in either group. OPCAB and CABG with CPB appear to generate qualitatively different inflammatory responses with respect to endothelial activation, which may have clinical implications.

Timing for Delivering Individualized Patient Education Intervention to Coronary Artery Bypass Graft Patients: An RCT

The primary focus of this study is on the timing of the delivery of education to patients who had CABG surgery. To determine the efficacy of an individualized telephone patient education intervention, delivered at two different points in time (1-2 days pre-discharge versus 1-2 days post-discharge) in enhancing the CABG patient's knowledge of self-care behaviours, performance of self-care behaviours, and symptom frequency. A randomized clinical trial that included a convenience sample of first time CABG patients. Individuals who received education pre-discharge were compared to individuals who received education post-discharge on the outcomes. Results indicated no statistically significant difference in outcomes between the two time points. As well, anxiety levels were found to be significantly higher in the pre-discharge group than the post-discharge group. The individualized nature of the educational intervention may have accounted for non-significant findings reported in outcomes between the two time points. Nurses may consider assessing anxiety levels prior to delivery of educational interventions, implement interventions aimed at reducing anxiety levels, and provide individualized teaching.

Do Patients Profit from Third Time CABG?

Introduction It has been shown that in experienced hands repeated CABG is doable procedure. However the quality of life after third time CABG has not been evaluated so far. Patients and Methods The peri-operative data of 25 (22 male, mean age of 65.5 ± 8.0 years) consecutive patients in a single centre undergoing third time-CABG from 4/96 to 11/06 were studied. Quality of life (QoL) was assessed by Short Form (SF)-36 Questionnaire. Results 30 day mortality was 12% (3/25). Seven died during follow-up. In 15 survivors median follow-up was 94 months (2–122 months). 1-, 5-, and 10-year survival were 77.8%, 65.0%, and 53.1%, respectively. Present NYHA status was significantly improved in comparison to preoperative values (2.4 ± 0.8 vs. 3.2 ± 0.56, p = 0.012). QoL was comparable with an age matched general population with heart insufficiency. Conclusion Third time CABG can be performed with acceptable peri-operative mortality. Significant improvement of NYHA status and acceptable quality of life results justifies our surgical approach in this challenging patient cohort.

Total arterial myocardial revascularization: analysis of initial experience

BACKGROUNDTotal arterial myocardial revascularization is an attempt to overcome the problems of late vein graft atherosclerosis, occlusion and need for coronary re-operations. Despite increasing evidence of efficacy, the use of arterial conduits has not been accepted as a primary practice in most of the centers in Pakistan for various reasons. We analyze our initial experience to assess the feasibility of total arterial revascularization as a primary strategy in patients requiring first time coronary artery bypass grafting.METHODSTwo hundred patients undergoing first time CABG at our institution, from January 2000 to April 2001, were studied. Group 1 consisted of 100 patients undergoing total arterial revascularization (using bilateral internal thoracic and radial arteries) and Group 2 consisted of 100 patients undergoing conventional CABG (using one internal thoracic artery and supplemental veins). Thirty-day mortality and early morbidity with particular reference to resternotomy for bleeding, cerebrovascular accidents, renal failure, and sternal dehiscence were the main outcome measures.RESULTSPatients in Group 1 were younger (56.2±10.4 vs. 60.3±9.8 years; P<0.001), had lower Parsonnet scores (4.8±0.4 vs. 9.6±1.8; P<0.001), and had better left ventricular function. Both groups received a similar number of grafts. The percentage of patients undergoing total arterial revascularization rose from 20% in the first three months to over 65% in the three later three-month periods. Overall 30-day mortality was 1.5%, one patient (1%) in Group 1 and two patients (2%) in Group 2. There was a similar incidence of postoperative complications and length of median postoperative stay in both groups.CONCLUSIONTotal arterial revascularization can be adopted as a primary strategy in most patients undergoing CABG with no increase in mortality or morbidity.

Impact of tranexamic acid vs. aprotinin on blood loss and transfusion requirements after cardiopulmonary bypass: a prospective, randomised, double-blind trial

SummaryIntroduction: Aprotinin (AP) reduces blood loss and transfusions after cardiopulmonary bypass (CPB), but may sensitise patients and is expensive. Tranexamic acid (TA) has less side-effects, but data regarding its efficacy are controversial. The aim of our prospective, randomised, double-blind study was to compare the impact of AP vs. TA on drainage blood loss and transfusion requirements in patients undergoing first time CABG on CPB.Materials and Methods: One hundred and twenty adult patients were randomised to receive either high-dose AP according to Hammersmith or a total of 2 g TA. Perioperative blood products were transfused in a standardised fashion. Blood loss was measured up to 24 h. Demographic and clinical patient data were collected until hospital discharge.Results: The data from 118 patients (TA: n = 58, TA appears to be a cost-effective alternative to AP AP: n = 60) who completed the study according to protocol were analysed. Blood loss at 24 h postoperation in TA patients was significantly higher (896 ± 354 ml) as compared to AP patients (756 ± 347ml; p = 0.03). TA patients received 1.5 ± 1.5 units of red blood cells (AP: 1.5 ± 1.7, p = 1.0), 1.3 ± 2.0 units of fresh frozen plasma (AP: 1.0 ± 2.0, p = 0.38) and 0.5 ± 1.4 units of platelets (AP: 0.2 ± 0.7, p = 0.15). Clinical data, including perioperative myocardial infarction rate, acute renal failure, mechanical ventilation, hospital stay and mortality, were not significantly different between either group.Conclusion: Our data show a difference in blood loss between TA and high-dose AP. Although statistically significant, it has little clinical relevance, because perioperative transfusion requirements were similar for both groups. Thus, TA appears to be a cost-effective alternative to AP in primary CABG patients.

PORT-ACCESS MINIMALLY INVASIVE MULTI-VESSEL CABG IS ASSOCIATED WITH SHORT POST-OPERATIVE DURATION OF TRACHEAL INTUBATION, ICU STAY AND HOSPITAL STAY

Introduction: Avoidance of a median sternotomy with minimally invasive cardiac surgery may alter the duration of post-operative tracheal intubation, intensive care stay, and hospitalization. Port-Access minimally invasive cardiac surgery uses a system of catheters and cannulae which permit cardiopulmonary bypass and myocardial protection to be achieved without accessing the heart via a median sternotomy. With this system, coronary artery bypass grafting is accomplished through a small intercostal incision. Methods: A multi-center, prospectively collected database of Port-Access cardiac surgery patients was queried with respect to duration of post-operative tracheal intubation (TI), intensive care stay (ICU), post-operative length of hospital stay (POLOS), pre-operative medical history, and perioperative morbidity and mortality. Certain centers participated in data collection by completing a simplified case report form which did not include TI, ICU and some elements of pre-operative medical history. POLOS, morbidity, and mortality data were collected for all patients. The database is maintained by an independent contract research organization and analyses are directed by a steering committee of cardiac physicians. The identified population was patients who received multi-vessel Port-Access CABG in the United States. Results: Between June 2, 1997 and August 25, 1998, 804 patients had multi-vessel Port-Access CABG (mean grafts=2.6) at 75 institutions with 579 patients reported on the simplified form. There were 10 (1.2%) peri-operative deaths, and these patients were excluded from further analysis. The following Table 1 and Table 2 describes results from the present study. To facilitate interpretation of these data, results from a University HealthSystem Consortium (UHC) study of 1,094 non-emergent, non-fatal, first time CABG procedures performed at 40 academic hospitals are also shown [1]:Table 1Table 2Conclusions: Port-Access minimally invasive multi-vessel CABG is associated with short post-operative duration of tracheal intubation, ICU stay and hospital stay. Further investigation will permit direct comparison of various surgical methods.

Ventricular arrhythmia following successful myocardial revascularization: incidence, predictors and prevention.

We estimated the risk of sudden cardiac death (SCD), from a spontaneous episode of ventricular arrhythmia (VT/VF), after a successful surgical myocardial revascularization (coronary artery bypass grafting; CABG) procedure. Predictors of these events were identified, and long term benefits of the prophylactic regimes, that were used to control these events, were evaluated. We selected 8642 consecutive patients, who had undergone an isolated and first time CABG procedure, between 1/3/1980 and 1/3/1995. A standard hazard function model (1) was used for statistical analysis. Efficacy of the prophylactic regimes, was examined in a group of 350 high risk patients, with a preoperative left ventricular ejection fraction 30% or less, who were recently operated since 1/1/1988. Electrophysiologic (EP) guided prophylaxis was used in 92 (26%) patients, who had survived a documented episode of SCD, and remaining 258 patients were maintained on antiarrhythmic medication on an empirical basis. A sequential EP evaluation was performed, when indicated. During an early phase of hazard, which mainly lasted for up to 3 months after CABG, incremental risk factors were preoperative LVEF 30% or less (P = 0.0007) and preoperative episodes of VT/VF (P = 0.04). This phase was followed by a constant phase with a low risk of the events, which merged into a slowly rising late phase after 6 years. EP guided prophylaxis, reduced the risk of SCD in high risk patients (P = 0.03). A sequential EP evaluation, helped to detect the problems of drug resistance and a cross over from non-sustained to sustained runs of VT/VF. Despite a successful CABG surgery, risk of VT/VF persists. A routine EP evaluation before and after a CABG procedure is recommended in all patients with a poor left ventricular function.

CABG in chronic stable angina pectoris patients: indications and outcomes (SECOR/SBU). Swedish Societies for Cardiology, Thoracic Radiology and Thoracic surgery/Swedish Council for Technology Assessment in Health Care.

In order to ascertain the reasons why coronary revascularisation is performed, the appropriateness of these procedures and their outcomes, a national collaborative study encompassing 7 of 8 hospitals performing CABG in Sweden was undertaken. This article presents the indications and outcomes in the largest intervention group, chronic stable angina pectoris treated by first time CABG. A prospective multi-centre study was carried out during a 3.5 month period in each centre. Patients (1039) with chronic stable angina pectoris undergoing first time CABG were enrolled. Patients' quality of life was recorded at the time they underwent angiography and again 6 months post-operatively. Mortality and serious peri-and post-operative complications were recorded. The study was designed and carried out by an independent government agency, the Swedish Council for Technology Assessment in Health Care (SBU) with a project group of representatives for the Swedish Societies for Cardiology, Thoracic Radiology and Thoracic Surgery. Median age was 66 years. A total of 80% were males. The mortality rates at 30 days and 6 months were 1.0 and 1.9%, respectively. A balloon pump was used for 0.9% of patients and 1.4% of them were on a respirator for more than 24 h. At recruitment, 43.9% of the patients reported having severe angina (CCS II/IV), 70.1% had angina > or = 3 times per week, and 53.1% used sublingual nitrates > or = 3 times per week. The corresponding results at 6 months were 6.7, 10.5 and 3.3%, respectively. Patient satisfaction with operative treatment was high. In comparison with the pre-operative status, quality of life was markedly improved after surgery. This study shows that CABG in chronic stable angina pectoris yields good outcomes with a low mortality and morbidity and a high degree of patient satisfaction and quality of life.

Intermittent cross clamp fibrillation is a cost effective technique for first time CABG

Intermittent cross clamp fibrillation is a cost effective technique for first time CABG