Undergoing Coronary Artery Bypass Surgery Surgery Research Articles

Ethnic Disparities in Major Adverse Cardiac and Cerebrovascular Events (MACCEs) and Postoperative Outcomes Following Coronary Artery Bypass in Northeastern Iran (2007-2016).

Turkmens are an ethnic group mainly living in northeastern Iran. Despite previous studies on coronary artery bypass surgery (CABG) outcomes among different ethnicities, the effect of Turkmen ethnicity on outcomes of CABG surgery is still unknown. We aimed to assess the association between Turkmen ethnicity and postoperative outcomes following CABG. We used the CABG data from two heart centers in northeastern Iran between 2007 and 2016. We included adult patients undergoing CABG surgery. The study outcomes were in-hospital major adverse cardiac and cerebrovascular events (MACCEs), consisting of myocardial infarction (MI), stroke, and cardiovascular death, and postoperative outcomes, including postoperative arrhythmia, acute atrial fibrillation (AF), major bleeding, and acute renal failure (ARF). Over the course of one decade, 3632 patients, with an average age (standard deviation) of 59.0 (9.8) years, were studied. Of these, 3,331 patients were of non-Turkmen ethnicity, and 301 patients were Turkmens. According to adjusted analysis, ethnicity was not associated with MACCEs (OR: 1.15, 95 % CI: 0.61, 2.16; P=0.663), postoperative arrhythmia (OR: 1.10, 95% CI: 0.78, 1.54; P=0.588), acute AF (OR: 1.17, 95 % CI: 0.83, 1.66; P=0.359), major bleeding (OR: 1.21, 95 % CI: 0.55, 2.67; P=0.636), or ARF (OR: 2.60, 95 % CI: 0.60, 11.75, P=0.224). This study found that despite ethnic disparity and preoperative differences, Turkmen ethnicity was not associated with in-hospital MACCEs, AF, major bleeding, or ARF after coronary artery bypass.

Tranexamic acid is associated with improved hemostasis in elderly patients undergoing coronary-artery surgeries in a retrospective cohort study.

More elderly patients undergo coronary artery bypass surgery (CABG) than younger patients. Whether tranexamic acid (TA) is still effective and safe in elderly patients undergoing CABG surgeries is still unclear. In this study, a cohort of 7,224 patients ≥70 years undergoing CABG surgery were included. Patients were categorized into the no TA group, TA group, high-dose group, and low-dose group according whether TA was administered and the dose administered. The primary endpoint was blood loss and blood transfusion after CABG. The secondary endpoints were thromboembolic events and in-hospital death. The blood loss at 24 and 48 h and the total blood loss after surgery in patients in the TA group were 90, 90, and 190 ml less than those in the no-TA group, respectively (p < 0.0001). The total blood transfusion was reduced 0.38-fold with TA administration compared to that without TA (OR = 0.62, 95% CI 0.56-0.68, p < 0.0001). Blood component transfusion was also reduced. High-dose TA administration reduced the blood loss by 20 ml 24 h after surgery (p = 0.032) but had no relationship with the blood transfusion. TA increased the risk of perioperative myocardial infarction (PMI) by 1.62-fold [p = 0.003, OR = 1.62, 95% CI (1.18-2.22)] but reduced the hospital stay time in patients who were administered TA compared to that of patients who did not receive TA (p = 0.026). We revealed that elderly patients undergoing CABG surgeries had better hemostasis after TA administration but increased the risk of PMI. High-dose TA was effective and safe compared with low-dose TA administration in elderly patients undergoing CABG surgery.

Endoscopic Saphenous Vein Harvesting and Surgical Site Infections after Coronary Artery Bypass Surgery (CABG)

Introduction: Coronary artery bypass grafting (CABG) surgery remains the most common procedure in adult cardiac surgery for coronary artery disease. Objectives: The main objective of the study is to find the infection in open vs endoscopic saphenous vein harvest for patients undergoing CABG surgery. Material and method: This comparative analysis was conducted at Rawalpindi Institute of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi and Shifa International Hospital, Islamabad from October 2019 to 2021. The data was collected with the permission of the ethical committee of hospital. The data was collected with the permission of the ethical committee of the hospital. Patients undergoing CABG or combined valve/CABG with EVH and OVH were differentiated from each other in the MHCCSR as of the start of the study period. The OVH was performed by either a continuous, longitudinal incision or through multiple smaller incisions. Results: The data were collected from 122 patients, from these 22 patients were not extubated and none of them survived. The most common indication for surgery was myocardial revascularization (30.6%), followed by valve replacement (22.7%) and thoracic aortic aneurysm repair. Practical implication: EVH is now considered not to be the best method in CABG surgery. Conclusion: It is concluded that, patients undergoing CABG surgery with EVH presented with worse systolic function and more recent myocardial infarction. Keywords: CABG, Procedure, EVH, Systolic, Myocardial infarction, Endoscopic

Decreased brain-derived neurotrophic factor levels may predict early perioperative neurocognitive disorder in patients undergoing coronary artery bypass surgery: A prospective observational pilot study

Study objectiveTo determine the prognostic value of the change in intraoperative BDNF (Brain-derived neurotrophic factor) levels during cardiac surgery with cardiopulmonary bypass (CPB) on early perioperative neurocognitive disorder (PND). DesignProspective observational pilot study. SettingThe study was performed in the Medical Faculty Hospital, from January 2020 to August 2020. Patients45 adult patients undergoing elective coronary artery bypass surgery (CABG) with CPB. InterventionsNone. MeasurementsCognitive function was evaluated 1 day before and 4 days after the surgery. Serum BDNF levels were measured at four time points (T1: after induction; T2: with aortic cross-clamp; T3: without aortic cross-clamp; T4: 4 days after surgery) by enzyme-linked immunosorbent assay. Main resultsThe incidence of PND was 37.8% four days after surgery. Serum BDNF (T2 and T4) levels were significantly lower in PND group compared to non- PND group (p = 0.003 and p = 0.016, respectively). Moreover, lactate, rSO2 (regional cerebral oxygen saturation), aortic cross-clamp time, CPB duration, and the amount of blood transfusion differed between the groups. Logistic regression analysis identified serum BDNF-T2, age, cross-clamp time, and rSO2-T2 as independent risk factors for PND. Based on the ROC analysis, the area under curve (AUC) of BDNF-T2 concentration for prediction of PND was 0.759 with sensitivity of 71.4% and specificity of 64.7% (p < 0.01). ConclusionIntraoperative BDNF serum levels may be a useful biomarker in predicting PND in patients undergoing CABG surgery. More comprehensive studies is needed in order to confirm the effect of decreasing intraoperative BDNF serum levels on the development of PND. Trial registration numberNCT04250935 www.clinicaltrials.gov.

Effect of Low Triiodothyronine (T3) Hormone Levels on Atrial Fibrillation Development After Coronary Artery Bypass Surgery

Aim: Atrial fibrillation (AF) after coronary artery bypass surgery (CABG) is the most common type of arrhythmia and it causes serious morbidity. Low levels of triiodothyronine (T3) hormone are thought to be a strong determinative factor on poor prognosis of cardiac patients. This study was planned to investigate the effect of low levels of T3 on the development of AF after off-pump coronary artery bypass surgery (OPCAB) and conventional CABG surgery. Methods: The study was prospectively planned on 60 patients undergoing CABG surgery. Thirty of them were randomly selected among the patients undergoing OPCAB, and the other 30 were randomly selected among the patients undergoing conventional CABG surgery. Thyroid function profiles of all patients were evaluated before the operation and on the first day of postoperative period. Results: The average age of the patients was 58.7± 8. After the operation, 3 patients from each group, 6 patients in total, developed AF. Postoperatively measured TT3 levels of the patients who developed AF after the operation (0.39±0.09) were found to be significantly lower than the preoperatively measured TT3 levels (0.97± 0.06) (p=0.042). Moreover, postoperatively measured fT3 levels of the patients who developed AF after operation (1.58± 0.30) were found to be significantly lower than the preoperatively measured fT3 levels (2.95±0.37) ( p=0.001). However, by univariate logistic regression analysis, it was seen that the variables that were thought to be risk factors for AF were not significantly effective. Also, when the effects of the variables were examined together by multivariate regression analysis, no significant result was found.Conclusion: In our study, it was seen that low levels of thyroid hormone in patients undergoing OPCAB and conventional CABG surgery had no effect on AF development.

Meta-Analysis of n-3 Polyunsaturated Fatty Acid Supplementation for the Prevention of Post-Operative Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Surgery

Background Several randomized clinical trials (RCTs) have evaluated whether pre-operative supplementation of omega-3 (n-3) polyunsaturated fatty acids (PUFA) protects against postoperative atrial fibrillation (POAF) after coronary artery bypass surgery (CABG). However, the efficacy of this intervention remains controversial. We performed a meta-analysis to determine if PUFA supplementation prevents POAF. Methods A systematic literature search was performed (through December 20, 2018) using PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials to identify RCTs evaluating PUFA supplementation for post-CABG POAF prevention. The primary outcome was the incidence of POAF. For each study, the incidence of AF in the intervention and placebo groups was extracted to calculate odds ratio and 95% confidence intervals (CIs). Mantel-Haenszel random effects model was used to summarize data across treatment arms. Heterogeneity between the studies was assessed using the chi square test and was considered significant if p values 50%. Results We identified 11 RCTs that included a total of 3,127 participants (1,557 in the PUFA group and 1,570 in the placebo group). Pooled analysis demonstrated a significant reduction in POAF in patients treated with PUFA as compared to placebo (OR 0.66; 95% CI, 0.48-0.90; p=0.008). The estimated number-needed-to-treat was 18 (95% CI 11.53-45.67). The test of heterogeneity was significant (I262%, p = 0.003). Conclusions Preoperative supplementation of omega-3 (n-3) polyunsaturated fatty acids reduces the incidence of POAF in patients undergoing CABG surgery.

Refractory Hypotension post Coronary Artery Bypass Graft Unmasking Hypoaldosteronism: Case Report and Literature Review

The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of cardiovascular adaptation. The simultaneous presence of disorders involving both is not uncommon, especially in patients with coronary artery disease undergoing coronary artery bypass surgery (CABG). This is the case of a patient with both hyporeninemic hypoaldosteronism and autonomic dysfunction. This article describes his clinical course before and after CABG surgery, along with a literature review of those interrelated entities. Our patient is a 63-year-old male with a history of hypertension and hyperlipidemia presenting for CABG for triple vessel disease. On the day of admission, the patient had sudden unprovoked loss of consciousness along with hypotension and bradycardia. He reported having had similar episodes in the past at times of emotional stress. After stabilization, the patient underwent CABG surgery the next day and it was uneventful. Four hours later, he developed another episode of hypotension with bradycardia which resolved upon administration of fluids. On postoperative day 2, while removing the jugular line, he had loss of consciousness with 5 seconds pause recorded on his bedside monitor. A carotid massage confirmed carotid sinus hypersensitivity, which necessitated the insertion of a pacemaker. However, patient continued to have similar episodes despite a functioning device. Workup revealed hyporeninemic hypoaldosteronism with an undetectable aldosterone level, although patient was not diabetic, had normal cortisol level, and had no other risk factors for those findings. Patient was started on fludrocortisone 0.1 mg daily; his hemodynamics improved markedly, and his symptoms resolved permanently. Our patient has hyporeninemic hypoaldosteronism caused most likely by his autonomic dysfunction, rather than having of two separate entities. A review of the literature showed that primary autonomic insufficiency with reduced circulating norepinephrine levels prevent renin activation and subsequently aldosterone release, leading to hyporeninemic hypoaldosteronism. Coronary artery disease is a known cause of autonomic dysfunction and CABG surgery unmasks this entity, which explains the exacerbation of our patient’s symptoms during this phase.

Relationship between Vitamin D and the development of atrial fibrillation after on-pump coronary artery bypass graft surgery.

SummaryBackground:Vitamin D deficiency is associated with many diverse cardiovascular disorders, such as hypertension, heart failure, stroke, coronary artery disease and atrial fibrillation. The relationship between Vitamin D and the development of atrial fibrillation after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between Vitamin D and the development of postoperative atrial fibrillation (POAF) after CABG.Methods:Medical records of consecutive patients who underwent CABG surgery were retrospectively reviewed for the development of atrial fibrillation in the postoperative period. Vitamin D, other biochemical parameters, and clinical and echocardiographic parameters were evaluated in all patients. The independent variables for the development of postoperative atrial fibrillation were defined and their predictive values were measured.Results:The study group consisted of 128 patients, of whom 41 (32%) developed POAF. Age, diabetes mellitus, chronic obstructive pulmonary disease, history of transient ischaemic attack/stroke, heart failure, left atrial diameter, platelet:largecell ratio, and creatinine, urea, uric acid, calcium and potassium levels were identified as important variables for the development of POAF. However, with logistic regression analysis, chronic obstructive pulmonary disease (OR: 28.737, 95% CI: 0.836–16.118, p < 0.001), heart failure (OR: 15.430, 95% CI: 0.989–7.649, p = 0.006), diabetes mellitus (OR: 11.486, 95% CI: 0.734–11.060, p = 0.001) and left atrial diameter (OR: 1.245, 95% CI: 0.086–6.431, p = 0.011) appeared as independent variables predicting the development of POAF.Conclusion:In our study, although there was a significant negative correlation between Vitamin D and left atrial diameter, Vitamin D level was not an independent predictor for POAF.

Q10 supplementation effects on cardiac enzyme CK-MB and troponin in patients undergoing coronary artery bypass graft: a randomized, double-blinded, placebo-controlled clinical trial.

Introduction: Coronary artery bypass surgery (CABG) is associated with ischemia-reperfusion injury and tissue damage. CoQ10 as an antioxidant has an important role and may have cardio-protective effects after myocardial dysfunction and CABG. We aimed to evaluate whether CoQ10 has a myocardial cardio protective impact on cardiac biomarkers after CABG. Methods: In this double-blind study, 80 patients with coronary artery disease (CAD) who underwent CABG surgery were divided into intervention and control groups and received Q10 supplement or placebo, respectively. The surgical characteristics of the patients in the two groups were similar. The intervention group received 150 mg of Q10 supplement per day for 7 days before the surgery. The control group received placebo capsule. After operation the inter- and intra-group blood levels of CK-MB and troponin, before and after supplementation and 12 hours after the CABG, and postoperative outcomes such as intensive care unit (ICU) stay and hospital stay were compared. Results: In this study, 40 subjects were located in each group. The participation rate was 97.5% and men and women accounted for 52.5% and 47.5% respectively. The mean age of the subjects was 58.17 ± 8.55. The two groups were not significantly different in terms of basic variables. Within-group comparison showed a significant increase in the level of troponin enzymes over time (P < 0.001) and CK-MB (P < 0.001). However, between-group comparison showed no significant difference between the two groups in terms of CK-MB (P = 0.384) and troponin (P = 0.115). In the end, no interaction was observed between the intervention and time on CK-MB (P = 0.095) and troponin (P = 0.198) variables. Conclusion: Q10 supplementation 7 days before surgery was not effective in reducing CK-MB and troponin after CABG.

Is SYNTAX Score Predictive of Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery?

Background and ObjectivesThe relationship of synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score and development of atrial fibrillation (AF) after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between the SYNTAX score and development of AF after CABG (POAF).Subjects and MethodsThe medical records of consecutive patients, who underwent CABG surgery from January 2013 to September 2015, were retrospectively reviewed for the development of AF in the postoperative period. SYNTAX score, clinical and echocardiographic parameters were evaluated. The independent variables for the development of POAF were defined and their predictive values were measured.ResultsThe study group consisted of 106 patients, of which 36 (34%) developed POAF. Age, hypertension, stroke, chronic obstructive pulmonary disease (COPD), heart failure (HF), diabetes mellitus (DM), left atrial diameter, neutrophil/lymphocyte ratio, platelet large cell ratio, creatinine, blood urea nitrogen and SYNTAX score were identified as important variables for the development of POAF. However, in logistic regression analysis COPD (OR=19.313, 95% CI=2.416-154.407, p=0.005), HF (OR=28.362, 95% CI=2.034-395.515, p=0.013), SYNTAX score (OR=0.863, 95% CI=0.757-0.983, p=0.026), and DM (OR=20.770, 95% CI=3.791-113.799, p<0.001) appeared as independent variables predicting the development of POAF. In receiver operation characteristic analysis, SYNTAX score (≥22.25) (AUC=0.777, 95% CI=0.676-0.877, p<0.001) was one of the strongest predictors for the development of POAF.ConclusionThe SYNTAX score level was independently associated with the development of AF after CABG.

Evaluation of Long-Term Changes in the Levels of Inflammatory Factors during Postoperative Period in Patients with Acute Coronary Syndrome without STSegment Elevation Undergone Coronary Artery Bypass Surgery

Objective: One of the most effective and widely used methods of myocardial revascularization in patients with acute coronary syndromes is coronary artery bypass surgery (CABG). Chronic inflammation plays a significant role in the destabilization of atherosclerotic plaques in acute forms of ischemic heart disease and also in relapse of myocardial ischemia after myocardial revascularization. Ischemic myocardial injury is associated with activation of molecular and cellular inflammatory factors, the most important of which are cytokines, cell adhesion molecules (CAM) and leukocytes. Changing in the concentration of these agents during postoperative period reflects the intensity of the inflammatory and reparative processes in the myocardium. In this context, it is relevant to evaluate the long-term dynamics of inflammatory markers in the patients undergone coronary artery bypass grafting to predict the possible exacerbation of coronary heart disease. Methods: The study involved 130 patients who underwent CABG surgery with acute coronary syndrome without ST-segment elevation. The comparison group consisted of 28 patients who suffered from stable coronary artery disease (average age 50.9 ± 1.2 years) with a history of MI, no earlier than 6 months prior to study entry. The levels of serum inflammatory markers (ICAM-1, TNF-α, IL-6, leukocytes) were measured before operation and 6.12, 24 and 48 months after CABG. Results: The study showed that soluble intercellular adhesion molecule-1 (ICAM-1) and leukocyte levels in patients with non-ST elevation acute coronary syndrome gradually decreased during follow-up period in comparison with preoperative rates. sICAM-1 level increased up to 48 month and tended to preoperative value. There were no changes in tumor necrosis factor- alpha (TNF-α) and interleukin-6 (IL-6) levels during the whole follow-up period. TNF-α level in the patients with NSTE ACS before surgery have not differed from the level in the patients with stable ischemic heart disease (62.0 ± 9.8 pg/ml and 51.0 ± 6.8 pg/ml; p>0.05). TNF-α serum level has remained unchanged in the patients after CABG. Preoperative levels of IL-6 did not differ significantly among the patients with NSTE ACS and stable coronary artery disease (34.5 ± 3.6 pg/ml and 28.6 ±3.1 pg/ml; p>0.05). The IL-6 levels remained practically unchanged over time. Conclusion: According to the results we can suggest, that further maintenance and development of the inflammatory process after CABG will contribute to the progression of coronary heart disease preserving the risk of exacerbation and reocclusion of coronary blood vessels.

THE CARDIOVASCULAR EFFECTS OF HYPEROXIA DURING AND AFTER CABG SURGERY

Hyperoxia is frequently encountered in the intensive care unit (ICU) and during surgical procedures such as coronary artery bypass surgery (CABG). Higher oxygen concentrations intuitively provide a salutary oxygen reserve, but hyperoxia can induce adverse effects such as systemic vasoconstriction, reduction of cardiac output, increased microcirculatory heterogeneity and increased reactive oxygen species production. Previous studies in patients undergoing CABG surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). Here, we compare moderate hyperoxia to near-physiological values.

Cardiac Rehabilitation Program with High Intensity Aerobic Exercise Can Reverse Diastolic Impairment in Patients Undergoing Coronary Artery Bypass Surgery

Background: Cardiac rehabilitation is known as a powerful non-pharmacological approach for improving functional capacity, and left ventricular systolic function; however, some limited data have suggested an attenuation of the decline in diastolic function with this program. This study investigated the effect of high intensity aerobic exercise following coronary artery bypass surgery (CABG) on diastolic dysfunction.&#x0D; Materials and Methods: Forty four patients with different levels of diastolic dysfunction who underwent CABG surgery were included. The participants attended the complete cardiac rehabilitation program three times per week for two months (totally 24 sessions). The patients underwent complete transthoracic echocardiographic studies including two-dimensional and spectral Doppler echocardiography immediately before attending rehabilitation program and also after the completion of rehabilitation sessions.&#x0D; Results: There was a significant decrease of isovolumic relaxation time (IVRT) after participating complete cardiac rehabilitation (94.0 to 89.0; P=0.001). The diastolic function parameters of early diastolic mitral inflow peak velocity to late diastolic mitral inflow peak velocity (E/A) ratio (0.94 to 1.04; P=0.001), deceleration time (DT) of the mitral E wave (192.7 to 219.0; P=0.011), and velocity of early diastolic mitral annular motion (Ea) (5.9 to 6.7; P=0.026) were improved after the rehabilitation, whereas mitral A duration to pulmonary A duration (MAD/PAD) ratio was slightly improved (1.07 to 1.12; P=0.056) and pulmonary veins systolic flow to pulmonary vein diastolic flow (PVS/PVD) ratio (0.89 to 1.04; P=0.345) remained unchanged.&#x0D; Conclusion: A complete cardiac rehabilitation program with high intensity aerobic exercise approach can reverse diastolic impairment in patients undergoing CABG.

124 MULTI-LIMB REMOTE ISCHAEMIC PRECONDITIONING REDUCES MYOCARDIAL INJURY IN DIABETIC PATIENTS UNDERGOING CORONARY ARTERY BYPASS SURGERY

<h3>Background</h3> Diabetic patients undergoing coronary artery bypass surgery (CABG) are at higher risk of peri-operative myocardial injury (PMI) with subsequent worse short and long-term clinical outcomes. Remote ischaemic preconditioning (RIPC), in which the application of one or more brief cycles of non-lethal ischaemia and reperfusion to an organ or tissue protects the heart against a lethal episode of acute ischaemia-reperfusion injury, has emerged as a non-invasive, low-cost therapeutic intervention for protecting the heart in patients undergoing CABG surgery. However, both experimental and clinical studies have demonstrated that the diabetic heart presents an increased resistance to the protective effects of RIPC. Whether by increasing the preconditioning stimulus we can protect diabetic patients undergoing CABG surgery is unknown. <h3>Methods and results</h3> 87 consecutive diabetic patients undergoing elective CABG surgery were recruited into two substudies. In the first substudy (N=53), patients were randomised to receive either standard RIPC protocol (3–5 min cycles of upper arm cuff inflation to 200 mm Hg with intervening 5 min deflation, N=26) or control (uninflated cuff placed on the upper arm for 30 min, N=27) following anaesthesia induction. In the second substudy (N=34), patients were randomised to receive either an enhanced RIPC stimulus (2–5 min cycles of simultaneous upper arm and thigh cuff inflation to 200 mm Hg with intervening 5 min deflation, N=17) or control (uninflated cuffs placed on the upper arm and thigh for 20 min, N=17). PMI was calculated as area-under-the-curve (AUC) of troponin-T (TnT), measured pre-operatively and 6, 12, 24, 48, 72 h post-surgery. In the first substudy with standard preconditioning protocol, there was no difference in the 72 h TnT AUC between control and RIPC (AUC was respectively 22.17 µg/l and 22.22 µg/l, p=0.98). However, in the second substudy and with the application of the enhanced preconditioning stimulus, we observed a significant reduction in the 72 h TnT AUC in the RIPC group compared to control (31.73 µg/l vs 19.63 µg/l respectively, p=0.022). <h3>Conclusions</h3> An enhanced preconditioning stimulus by multi-limb RIPC reduces PMI in diabetic patients undergoing CABG surgery. Larger multicentre studies are being conducted to confirm these studies.

Routine Intraoperative Completion Angiography After Coronary Artery Bypass Grafting and 1-Stop Hybrid Revascularization: Results From a Fully Integrated Hybrid Catheterization Laboratory/Operating Room

This study sought to report our experience with a routine completion angiogram after coronary artery bypass surgery (CABG) and simultaneous (1-stop) percutaneous coronary intervention (PCI) at the time of CABG performed in the hybrid catheterization laboratory/operating room. The value of a routine completion angiogram after CABG and 1-stop hybrid CABG/PCI remains unresolved. Between April 2005 and July 2007, 366 consecutive patients underwent CABG surgery, with (n = 112) or without (n = 254) concomitant 1-stop PCI (hybrid), all with completion angiography before chest closure. Among the 112 1-stop hybrid CABG/PCI patients, 67 (60%) underwent a planned hybrid procedure based on pre-operative assessment, whereas 45 (40%) underwent open-chest PCI (unplanned hybrid) based on intraoperative findings. Among the 796 CABG grafts (345 left internal mammary artery, 12 right internal mammary artery/radial, and 439 veins), 97 (12%) angiographic defects were identified. Defects were repaired with either a minor adjustment of the graft (n = 22, 2.8%), with intraoperative open-chest PCI (unplanned hybrid, n = 48, 6%) or with traditional surgical revision (n = 27, 3.4%). Hybrid patients had clinical outcomes similar to standard CABG patients. Routine completion angiography detected 12% of grafts with important angiographic defects. One-stop hybrid coronary revascularization is reasonable, safe, and feasible. Combining the tools of the catheterization laboratory and operating room greatly enhances the options available to the surgeon and cardiologist for patients with complex coronary artery disease.

The Shelhigh No-React® bovine internal mammary artery: a questionable alternative conduit in coronary bypass surgery?☆

Increasing age and comorbidities among patients undergoing coronary artery bypass surgery (CABG) stimulates the exhaustive research for alternative grafts. No-React treatment should render the tissue resistant against degeneration and reduce early inflammatory response. The aim of the present study was an invasive assessment of the patency of No-React bovine internal mammary artery (NRIMA grafts) used as bypass conduit in CABG surgery. Nineteen NRIMA grafts were used in 17 patients (2.9%) out of a total of 572 patients undergoing CABG surgery within a 12-month period. All intraoperative data were assessed and in-hospital outcome was analysed. Follow-up examination was performed 7.0+/-4.0 months after initial surgery, including clinical status and coronary angiography to assess patency of the NRIMA grafts. Average perioperative flow of all NRIMA grafts was 71+/-60 ml/min. One patient died in hospital due to a multi-organ failure. Four patients refused invasive assessment. Follow-up was complete in 12 patients with overall 13 NRIMA grafts. Nine NRIMA grafts (69.2%) were used for the right coronary system, two NRIMA grafts (15.4%) on the LAD and two on the circumflex artery. Graft patency was 23.1% and was independent of the intraoperative flow measurement. NRIMA grafts show a very low patency and cannot be recommended as coronary bypass graft conduits. Patency was independent of the perioperative flow, assessed by Doppler ultrasound. Because of this unsatisfying observation, this type of graft should be utilised as a last resource conduit and used only to revascularise less important target vessels, such as the end branches of the right coronary artery.

The Role of Angina Pectoris in Chronic Pain After Coronary Artery Bypass Graft Surgery

Visceral nociception readily sensitizes the central nervous system, causing referred somatic pain and hyperalgesia via somato-visceral convergence. Hyperalgesia in the perioperative period may increase vulnerability to subsequent development of chronic pain. The study aim is to investigate the role of angina pectoris, an ischemic visceral pain, in long-term pain after coronary artery bypass surgery (CABG). We sent questionnaires to 369 patients who underwent CABG surgery in 2003. Questions were asked about angina pectoris and other pain in the period before surgery, the first week postoperatively (= acute pain), and the period after 3 months after surgery (= chronic pain). We obtained results from 256 patients (response rate = 69%). The point prevalence of chronic pain after CABG was 27% after a mean follow-up of 16 months (SD +/- 3 months). Patients with chronic pain after CABG had more angina pectoris than those without chronic pain: Before surgery (P = .07), early on postoperatively (P = .004), and more than 3 months after surgery (P = .000004). We found cumulative prevalences of chronic pain after CABG at 3 months of 39%, and of 32% after 6 months. Other predictive factors for chronic pain after CABG were acute postoperative pain (P = .00002) and younger age (P = .002). Angina pectoris is associated with chronic pain after CABG surgery. Other predictive factors include acute postoperative pain and younger age. The influence of postoperative angina pectoris for chronic pain after CABG surgery has not been described in the literature to date. Visceral nociception may play an important role in the development of chronic pain after surgery and should be taken into account in future studies.

Predictors and Outcomes of Extended Intensive Care Unit Length of Stay in Patients Undergoing Coronary Artery Bypass Graft Surgery

To assess risk predictors of increased intensive care unit (ICU) length of stay in patients undergoing isolated coronary artery bypass surgery (CABG) and assess outcomes associated with increased ICU length of stay. We conducted a nested case-control study from a 9-year hospitalization cohort with prospective data collection (N = 9869). Cases were CABG patients with ICU greater than or equal to 168 hours (N = 236) and controls were CABG patients with an ICU stay of less than 168 hours (N = 708). We examined 15 risk factors and 11 outcomes. Nine risk factors proved significant in predicting an increased ICU length of stay. Cases were more likely to be older, with an increased pump time, and a lower body surface area. Cases tended to be female, with COPD, hypertension, and undergoing an urgent surgical procedure. Controls tended to have hypercholesterolemia and abnormal left ventricular hypertrophy. There was no significant difference between the cases and controls for the remaining six risk factors. Five of the nine significant predictors correlated with four predictors: age, urgent surgical procedure, pump time, and chronic obstructive pulmonary disorder (COPD). Using logistic regression analysis, we found that patients undergoing CABG had an increased ICU length of stay if they were older than 70 years (OR 2.59, 95% CI 1.86 to 3.62), with longer pump time (OR 2.45, 95% CI 1.75 to 3.44), had COPD (OR 2.04, 95% CI 1.36 to 3.05), and had an urgent surgical procedure (OR 1.59, 95% CI 1.12 to 2.26). Patients with an extended ICU length of stay were also found to experience 11 additional negative outcomes. In patients undergoing CABG surgery an increased age, increased pump time, COPD, and urgent surgical procedure significantly increased the risk of an increased ICU length of stay. Patients with an increased ICU length of stay also experienced more negative outcomes.

Predictors and outcomes of gastrointestinal complications in patients undergoing coronary artery bypass graft surgery: a prospective, nested case-control study.

The aim of this study was to assess risk factors and outcomes of gastrointestinal (GI) complications in patients undergoing coronary artery bypass surgery (CABG). We conducted a nested case-control study from a 9-year hospitalization cohort (n = 7,345) in which data were collected prospectively. Patients developed GI complications (n = 66) and controls did not (n = 330). Cases were matched to controls 1:5 on type of surgery. We examined 16 risk factors and 14 outcomes. Five risk factors proved significant in predicting GI complications. Patients were more likely to be older than age 70, to be on dialysis, to have left ventricular hypertrophy, and to be on anticoagulants; the procedure was also more likely to be urgent. There was no significant difference between the cases and controls for the remaining 11 risk factors. We also computed correlation coefficients among the significant variables; using regression analysis, we found that patients undergoing CABG had a threefold increase in the risk of GI complications if they were older than age 70 (odds ratio [OR] 1.06, 95% CI 1.03 to 0.97), if they were on dialysis (OR 1.87, 95% CI 1.98 to 1.22), and if their procedure was urgent (OR 1.91, 95% CI 1.07 to 3.4). Eleven outcomes proved significant. Patients with GI complications ran a greater risk of mortality; required more additional procedures; suffered arrhythmia that required treatment; and were more likely to have neurologic, pulmonary, renal, and sternal wound complications. They also had greater length of hospitalization, intensive care unit length of hospitalization, ventilator time, and postoperative creatine phosphokinase levels. In patients undergoing CABG surgery, urgency of the procedure, age greater than 70 years, and dialysis all significantly increased the risk of a GI complication. Patients with GI complications also experienced more negative outcomes.

ICU readmission after cardiac surgery.

The increasing cost of intensive care unit (ICU) care and limited resources lead us to evaluate predictors of ICU readmission in a large group of patients undergoing coronary artery bypass surgery (CABG) at one institution. Two thousand one hundred and seventeen consecutive patients undergoing CABG surgery between January 1999 and August 2001 were reviewed retrospectively. The reasons for readmission were determined by reviewing the physician's progress notes, the nurse's progress notes and the discharge summary. A total of 75 patients were readmitted to ICU during the study period for a readmission rate of 3.6%. Eight of these were readmitted a second time, and three a third time, for a total of 86 readmissions. Forty-seven patients died, for a mortality of 2% among patients that were not readmitted to the ICU, compared to 17% among those who were readmitted (P<0.0001). Median hospital length of stay was 6 days for patients not readmitted and 23 days for those readmitted (P<0.0001). The most common reason for readmission was respiratory failure, accounting for 47% of readmissions (n=40). Multivariate analysis using a stepwise logistic regression analysis revealed that preoperative renal failure (odds ratio 2.13; CI 1.03-4.41) and prolonged mechanical ventilation of >24 h (odds ratio 10.52; CI 6.18-17.91) were the only independent predictors for readmission to the ICU after CABG. Identification of patients that have preoperative renal failure or that required initial ventilation for more than 24 h after CABG may help to identify patients at risk of ICU readmission. Preemptive strategies designed to optimize these high-risk patients may improve outcomes.