Octogenarians undergoing coronary artery bypass graft surgery: resource utilization, postoperative mortality, and morbidity

OBJECTIVE: The purpose of the present study was to examine resource utilization in octogenarians undergoing coronary artery bypass grafting (CABG) and compare it with usage in their younger cohorts at a tertiary care heart center. The resources examined were time to extubation, packed red blood cell transfusions, intensive care unit (ICU) length of stay (LOS), and preoperative and postoperative LOS. The study also examined differences in postoperative morbidity and mortality. DESIGN: Retrospective hospital follow-up study of consecutive patients undergoing CABG using a prospectively designed database. SETTING: University teaching tertiary care referral center for cardiac surgery. PARTICIPANTS: Seventeen hundred forty-six male and female patients undergoing CABG surgery, including 155 octogenarians and 1591 patients younger than 80 years. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, mortality, morbidity, and resource utilization data were collected from the records of patients undergoing CABG at the authors' institution over 3 years. There were 1746 patients: 155 octogenarians and 1591 nonoctogenarians. Octogenarians had a significantly higher incidence of preoperative stroke, peripheral vascular disease, chronic obstructive lung disease, congestive heart failure, and left main disease. They weighed significantly less, and had lower preoperative and postoperative hematocrit. There was a significantly higher percentage of women in the octogenarian group. Mean time from the end of surgery to endotracheal extubation was 9.3 hours for octogenarians and 6.3 hours for their younger cohorts (p < 0.001). Blood transfusion was required in 88.4% of octogenarians compared with 58.6% of nonoctogenarians (p < 0.001). Mean ICU LOS was 1.9 days for octogenarians and 1.4 days for nonoctogenarians (p < 0.001). Mean postoperative LOS was 8.7 days for octogenarians and 5.8 days for nonoctogenarians (p < 0.001). Clinical and demographic variables were correlated with age 80 years or older. Multivariate linear and logistic regression models were constructed to show the combined effects of age and comorbid conditions on outcomes. Octogenarians had a significantly higher incidence of postoperative renal failure and neurologic complications. The 30-day mortality rate was 9.0% for the octogenarian group v 1.2% for the younger group (p < 0.001). Age 80 years or older was significantly associated with outcome, and was an independent predictor of increased resource utilization and postoperative mortality and morbidity. CONCLUSIONS: The results demonstrated that octogenarians undergoing CABG required increased resource utilization and had significantly higher morbidity, with increased incidence of postoperative renal failure, neurologic complications, and 30- day mortality. Age 80 years or older was an independent predictor of increased resource utilization, postoperative morbidity, and mortality.     

A cost analysis of nonelective coronary artery bypass graft surgery

BACKGROUND: Previous studies suggest that nonelective coronary artery bypass graft surgery (CABG) is more costly than elective CABG. The goal of this study was to examine why cost differences exist between patients undergoing nonelective and elective CABG. METHODS: We compared the outcomes and costs of treating 1613 consecutive patients undergoing nonelective (N = 1071) and elective (N = 542) CABG at three U.S. hospitals. Participating centers each used the same cost accounting system to provide patient-level clinical and cost data. Total, direct, and overhead costs were examined as were department-level costs. RESULTS: Compared to elective patients, nonelective patients were of similar age (66.4 years vs 67.0 years, respectively, p = NS), but were more likely to be female (32.7% vs 24.0%, p = 0.0003). Nonelective patients had longer lengths of stay (LOS) than elective patients (9.7 +/- 0.2 days vs 6.6 +/- 0.3 days, p < 0.0001). The longer LOS among nonelective patients was primarily due to a longer preoperative LOS (2.6 +/- 0.08 days vs 0.4 +/- 0.05 days). Unadjusted in-hospital costs of treatment were 38% higher among nonelective patients ($25,111 +/-$550 vs $18,445 +/-$752, p < 0.0001). After controlling for baseline demographic and clinical differences, the increase in cost among nonelective patients was reduced to 33% (cost ratio = 1.33, 95% confidence interval = 1.27 to 1.39, p < 0.0001). The difference in cost among nonelective patients was further reduced to 16% after controlling for rates of preoperative angiography and percutaneous coronary intervention (PCI), 14% after adjusting for the use of a pacemaker or a balloon pump, and 7% after adjusting for preoperative LOS. CONCLUSIONS: Patients undergoing nonelective CABG have longer LOS and higher costs than patients undergoing elective CABG. The increased cost among nonelective patients is largely due to differences in rates of preoperative LOS, angiography, and PCI. This differential reflects increased nonsurgical costs among patients undergoing nonelective CABG rather than surgical costs.     

Outcome of Isolated Coronary Artery Bypass Surgery in Octogenarians

A bstract Background : Between 1989 and 1992 100 consecutive patients aged 80 or older underwent isolated coronary artery bypass grafting (CABG) in our institution. Eighty-six percent had angina grade III or IV symptoms. Methods : Emergency surgery was required in 31, urgent surgery in 30, and elective surgery in 39 patients. The average left ventricular ejection fractions (LVEF) in these groups were 36%, 43%, and 45% respectively. The operative mortality was 8% for these octogenarians compared to 2% in the younger cohort (p = 0.002). It was zero in elective cases and 13% (8/61) in urgent and emergency cases. It was increased by preoperative admission to coronary care unit (CCU) (p = 0.02), urgency of operation (p = 0.02), the use of intra-aortic balloon pump (IABP) (p = 0.0002), preoperative renal dysfunction (p < 0.03), and ± 3 grafts (p < 0.04). The late mortality was increased by LVEF ± 20% (p = 0.03) and operation from CCU (p < 0.05). On multivariate stepwise logistic regression analysis, the use of IABP (p < 0.0003) and preoperative renal dysfunction (p < 0.02) were independent predictors of operative mortality. LVEF ± 20% was the only independent predictor (p < 0.02) of late mortality. Results : Actuarial survival was noted to be 87%, 80%, 77%, and 73%, respectively, at 1, 2, 3, and 4 years, with two cardiac-related late deaths. Long-term follow-up revealed that 97% of patients had no or minimal anginal symptoms. Conclusions : Due to increasing use of nonsurgical options, the profile of elderly referred for CABG currently involves gravely ill patients with comorbidities. CABG under elective conditions, before deterioration of left ventricular function, can achieve normal life expectancy and good symptomatic relief in octogenarians.     

On-pump and off-pump coronary artery bypass grafting in the elderly: predictors of adverse outcome

OBJECTIVE: To establish the role that coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) may have in improving perioperative outcomes of patients 70 years of age and older. Background: Coronary revascularization in elderly patients is associated with morbidity and mortality rates higher than those observed in younger patients. The impact of CABG without CPB on perioperative outcomes has not been clearly established. METHODS: This retrospective, nonrandomized study consisted of 1,872 CABG patients. Of these, 1389 underwent CABG with CPB (CPB group) and 483 patients underwent CABG without CPB (off-pump group). Preoperative variables and outcomes were compared between the two groups. Multivariate logistic regression analysis was used to identify independent predictors of mortality, stroke, and adverse outcome. RESULTS: Demographics, Canadian Cardiovascular Society staging, operative priority, and other preoperative variables were comparable between the two groups. The prevalence of previous myocardial infarction was higher in the CPB group (62.6% vs 56.7%; p < 0.005), whereas the prevalence of calcified aorta and preoperative renal failure were higher in the off-pump group (5.4% vs 9.5%; p = 0.04 and 1.7% vs 3.3%; p = 0.04, respectively). Although the graft/patient ratio was higher in the CPB group (3.4 vs 1.9), these patients displayed more extensive coronary artery involvement. At univariate analysis, patients in the off-pump group had a higher rate of freedom from complications (88.2% vs 81.3%; p < 0.005) and a lower incidence of stroke (2.1% vs 4.2%; p = 0.034) than patients in the CPB group. Although there was a trend for a higher actual mortality in the off-pump group (4.8% vs 3.7%; p = ns), the risk adjusted mortality in this group was lower (1.9% vs 2.1%). Multivariate analysis showed that while the use of CPB correlated independently with an increased risk of overall complications, it was not associated with a higher probability of death or stroke. CONCLUSIONS: This investigation suggests that elderly patients undergoing CABG may benefit from off-pump revascularization, as the use of CPB correlated independently with an increased risk of overall complications. However, CPB did not emerge as an independent predictor of death or stroke at multivariate analysis.     

Simplified Parsonnet risk scale identifies limits to early patient discharge

BACKGROUND: Fast-track recovery after coronary artery bypass surgery has influenced patient care positively. Predicting patients who fall off track and require prolonged (> or =7 days) hospitalization remains uncertain. The Parsonnet risk assessment score is effective in predicting length of stay, but is limited by inaccurate subdivision of risk categories. We simplified the Parsonnet risk scale to better identify patients eligible for fast-track recovery. METHOD: The cases of 604 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) were reviewed retrospectively. A rapid recovery protocol emphasizing reduced CPB time, preoperative intra-aortic balloon pump (IABP) criteria, and atrial fibrillation prophylaxis was applied to all patients. The five original divisions of the Parsonnet risk scale were reduced to three risk categories: Low (0-10; Group A), Intermediate (11-20; Group B), High (> 20; Group C). Comparisons of progressive risk categories were analyzed to identify predictive factors associated with fast-track outcomes. RESULTS: The thirty-day operative mortality for the entire group was 3.6%. Three clinical features were identified that distinguished risk progression-female gender, reoperative CABG, and increased age. Additionally, the presence of diabetes (p < 0.05), congestive heart failure (p < 0.01), and peripheral vascular disease (p < 0.001) distinguished Groups A and B, while acute myocardial infarction (p < 0.05) influenced outcomes in Group C. Group A (48%) mean risk score 5.9+/-3.2 was compared to Group B (34%) 14.8+/-2.6, which was further compared to Group C (18%) 26.4+/-2.8. The mean length of stay for Group A (5.3+/-4.1 days) was notably less than Group B (6.1+/-4.7 days; p < 0.05); however, both groups responded favorably to fast-track techniques. Group C did not respond comparably (9.2+/-9.2 vs 6.1+/-4.7 days; p < 0.001) and experienced prolonged recovery. The simplified Parsonnet risk scale did not identify differences in operative mortality and revealed only pneumonia (p < 0.05) and atrial fibrillation (p < 0.01) to be greater in Group C. As risk increased, significantly less revascularization was performed (Group A 3.6+/-1.2 grafts/patient vs Group B 3.3+/-1.2 [p < 0.01]; Group B 3.3+/-1.2 vs Group C 2.5+/-1.0 [p < 0.001]). CONCLUSION: A simplified Parsonnet risk scale (three categories) is an effective tool in identifying factors limiting fast-track recovery. Low- and intermediate-risk patients represent the majority (82%) and respond well to fast-track methods. High-risk patients (18%) are limited by a greater percentage of female patients, reoperative CABG, and the very elderly, resulting in fast-track failure. Strategies to improve recovery in high-risk patients may include evolving off-pump techniques.     

Myocardial revascularization for acute myocardial infarction: benefits and drawbacks of avoiding cardiopulmonary bypass

BACKGROUND: Coronary artery bypass grafting (CABG) for acute myocardial infarction (AMI) is associated with increased mortality compared with CABG in non-AMI patients. Operating without cardiopulmonary bypass (CPB) might reduce this mortality. METHODS: Between January 1992 and December 1998, 225 patients underwent CABG within 7 days of AMI, 119 with CPB and 106 without. The two groups were similar regarding age, gender, left ventricular dysfunction, and incidence of cardiogenic shock. Mean number of grafts per patient was 3.1 in the CPB group, and 1.7 in the no-CPB group (p < 0.0001). RESULTS: Operative mortality in the CPB group was 12% compared with 3.8% without CPB (p = 0.027). Independent predictors of operative mortality were preoperative use of intraaortic balloon counterpulsation (IABP), nonuse of internal thoracic artery (ITA) to the left anerior descending artery, and the use of less than three grafts. Mortality of patients operated on with CPB within 48 hours of AMI was significantly higher (16.5% vs 4.3%, respectively; p = 0.044). However, patients operated on after 48 hours had similar mortality (5.8% vs 3.4%, respectively). Follow-up ranged from 6 to 84 months. Five-year survival (Kaplan-Meier) of both groups was similar (81%). Patients operated on with CPB had similar rates of recurrent angina; however, they had lower prevalence of reinterventions (0.8% vs 6.3%; p = 0.03). CONCLUSIONS: Our study suggests that CPB can be used safely for most patients referred for CABG within the first week of AMI. However, for emergency patients operated on within the first 48 hours of symptom onset, we advocate avoiding CPB because it is associated with lower operative mortality.     

Effect of off-pump and on-pump coronary artery bypass grafting on renal function

BACKGROUND: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) has the risk of renal dysfunction. The cause of renal dysfunction after CPB is multifactorial, such as nonpulsatile flow, renal hypoperfusion, hypothermia, and duration of CPB. This study compared off-pump technique with on-pump technique on renal function in patients who underwent CABG. METHODS: Sixty patients with normal preoperative renal functions undergoing CABG were randomly assigned to conventional revascularization with CPB (on-pump) or beating heart revascularization (off-pump). Renal functions were assessed up to 10 days postoperatively. RESULTS: Creatinine clearance was found to be significantly higher in the off-pump group than in the on-pump group (p<.05). The off-pump group had significantly less increase in creatinine levels when compared with the on-pump group (p<.05). The free water clearance values decreased similarly in both groups; however, the recovery was more prompt in the off-pump group (p<.05). No significant differences were found in the prevalence of postoperative hemodialysis. CONCLUSION: The off-pump technique may provide a positive contribution and sufficient protection on postoperative renal functions in patients undergoing CABG.     

Myocardial Revascularization of the Beating Heart in High-Risk Patients

OBJECTIVE: Myocardial revascularization without cardiopulmonary bypass (CPB) has been proposed as an alternative technique in patients at high risk for conventional coronary artery bypass grafting (CABG). The purpose of this article is to evaluate the potential benefit of such an approach. METHODS: We retrospectively evaluated the perioperative results of off-pump CABG (OPCAB) performed from January 1995 to December 1999. Patients were divided into three groups on the basis of their preoperative risk factors: age greater than 80 years, reoperative CABG, and left ventricular ejection fraction percentage (LVEF%) less than 40%. The three subgroups were compared with patients operated on-CPB (ONCAB) during the same period of time. A total of 172 octogenarians had ONCAB versus 97 OPCAB, 307 reoperations were ONCAB versus 274 OPCAB, and 514 patients with LVEF% less than 40% were operated ONCAB versus 220 OPCAB. RESULTS: Preoperative comorbidities were homogeneously distributed in the OPCAB and ONCAB groups. More extensive coronary artery disease was found in the ONCAB groups. A trend for a lower number of perioperative complications was reported in the OPCAB groups. Freedom from overall complications was significantly higher (p < 0.005) in the OPCAB group. Actual mortality rates in the OPCAB and ONCAB groups were comparable (p = NS). CONCLUSIONS: CABG can be performed safely without CPB in patients with a high preoperative risk profile. Freedom from perioperative complications is markedly higher when the OPCAB approach is utilized.     

Conventional coronary artery bypass grafting: why women take longer to recover

BACKGROUND: Recovery following successful coronary artery bypass grafting (CABG) has been dramatically improved with the use of fast-track methods. Although data exist that demonstrate a significant gender difference in survival following CABG, little is known about factors influencing gender-specific recovery. This report describes a series of consecutive patients undergoing isolated CABG to determine gender-associated factors that may impact outcomes and recovery. METHODS: Five hundred and seventeen consecutive patients underwent isolated CABG utilizing cardiopulmonary bypass and were retrospectively reviewed. The outcomes of 351 men in the study were compared to the group of 160 women. A rapid recovery protocol focused on reduced cardiopulmonary bypass time, aggressive preoperative intra-aortic balloon pump use, early extubation, perioperative administration of corticosteroids and thyroid hormone, aggressive diuresis and atrial fibrillation prevention was applied to all patients. RESULTS: The 30-day mortality rate for the women was 4.2% (Parsonnet risk 16.3+/-9.0) compared with 3.4% (Parsonnet risk 9.9+/-7.5) for the men. There were no statistically significant differences in the 30-day mortality rates or postoperative complication rates between the women and men. The women, however, were found to be older (71+/- years versus 65+/- years, p<0.001), and to have a higher incidence of acute myocardial infarction (31% versus 20%, p<0.05), obesity (23% versus 10%, p <0.05), diabetes (31% versus 22%, p<0.05), hypertension (65% versus 48%, p<0.001), and symptomatic vascular disease (20% versus 12%, p<0.05). The women required fewer bypass grafts (2.9 versus 3.5 grafts, p<0.001), and consequently, had shorter cross and cardiopulmonary bypass times. Rapid recovery with discharge before the fifth postoperative day was achieved in 30% of the women, in comparison to 44% of the men (p<0.01). The postoperative hospital length of stay was longer for the women in comparison to the men (7.2+/-7.1 versus 5.8+/-5.2 days, p<0.05). CONCLUSIONS: Women had similar operative mortality and postoperative complication rates to men under a rapid recovery protocol. However, women have a longer recovery interval compared to men, which may be a reflection of their higher preoperative risk profile.     

Coronary artery bypass in patients 80 years and older: comparison with a younger age group.

Octogenarians are at increased risk for perioperative morbidity and mortality following coronary artery bypass grafting (CABG). We compared the perioperative outcome after CABG from March 1997 to June 2003, between patients 80 years and older (n=15), and those aged 70 to 79 years (n=64). In comparison with younger patients, more octogenarians had congestive heart failure (40% vs. 9% in patients aged 70 to 79 years, p=0.003) and underwent off-pump CABG more frequently (80% vs. 42%, p=0.008). There were no significant differences in the incidence of emergent surgery (27% vs. 28%) and number of bypass grafts (2.3+/-0.7 vs. 2.5+/-0.9) between the two groups. Octogenarians had less complete revascularization compared to the younger group (67% vs. 81%, not significant). There was no mediastinitis, and no stroke in either groups. Octogenarians had more minor wound complications (20% vs. 3%, p=0.01). There were no operative deaths in octogenarians, while the mortality rate of the younger group was high (6%). Surgical myocardial revascularization in octogenarians can be performed with acceptable mortality and morbidity using off-pump CABG.     

Avoidance of Cardiopulmonary Bypass Improves Early Survival in Multivessel Coronary Artery Bypass Patients with Poor Ventricular Function

Abstract Background: Patients with diminished ventricular function represent an increasing percentage of candidates for coronary artery bypass grafting (CABG). We have reviewed our recent experience in CABG in patients with ejection fractions (EF) 相似文献   

Inflammatory response after coronary revascularization with or without cardiopulmonary bypass

BACKGROUND: We sought to investigate the effect of multiple coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (CPB) on the perioperative inflammatory response. METHODS: Sixty patients undergoing CABG were randomly assigned to one of two groups: (A) on pump with conventional CPB and cardioplegic arrest, and (B) off pump on the beating heart. Serum samples were collected for estimation of neutrophil elastase, interleukin 8 (IL-8), C3a, and C5a preoperatively and at 1, 4, 12, and 24 hours postoperatively. Furthermore, white blood cell (WBC), neutrophil, and monocyte counts were carried out preoperatively and at 1, 12, 36 and 60 hours postoperatively. Overall incidence of infection and perioperative clinical outcome were also recorded. RESULTS: The groups were similar in terms of age, weight, gender ratio, extent of coronary disease, left ventricular function, and number of grafts per patient. Neutrophil elastase concentration peaked early after CPB in the on-pump group, with a decline with time. Repeated-measures analysis of variance between groups and comparisons at each time point (modified Bonferroni) showed elastase concentrations were significantly higher in the on-pump than the off-pump group (both p < 0.0001). IL-8 increased significantly after surgery in the on-pump group, with no decline during the observation period (p = 0.01 vs off pump). C3a and C5a rose early after surgery in both groups when compared with baseline values. Postoperative WBC, neutrophil, and monocyte counts were significantly higher in the on-pump than the off-pump group (p < 0.01). Finally, the incidence of postoperative overall infections was significantly higher in the on-pump group (p < 0.0001 vs off pump). CONCLUSIONS: CABG on the beating heart is associated with a significant reduction in inflammatory response and postoperative infection when compared with conventional revascularization with CPB and cardioplegic arrest.     

Coronary artery bypass grafting with and without cardiopulmonary bypass: a comparison analysis

Coronary artery bypass grafting (CABG) using stabilization devices in place of the heart-lung machine is being performed on a wide range of patients. This study retrospectively compared the performance of off-pump coronary artery grafting bypass (OPCAB) with conventional bypass patients over the same 6-month period at The Medical University of South Carolina. Data were collected and compared from the National Cardiac Database of the Society of Thoracic Surgeons (STS). Parameters studied included age, gender, left ventricular ejection fraction (LVEF), previous myocardial infarction (MI), disease severity, number of grafts, complications, blood usage, ventilation times, operating room (OR) time, and hospital length of stay (LOS). There were no significant difference between the patient groups with regard to age, gender, LVEF, previous MI, predicted mortality, and LOS. Operative mortality was also similar in the two groups: conventional bypass 4/117 (3%) and OPCAB 2/86 (2%). The conventional bypass patients (CPB) had significantly (p < 0.05) more diseased vessels (2.9 vs. 2.6) and distal grafts (4.1 vs. 2.7), as compared to the OPCAB group. OPCAB procedures resulted in significantly (p < 0.05) lower mean OR time (365 min vs. 406 min) and reduced mean postoperative ventilation hours (3.4 vs. 8.3 hours), as compared to conventional bypass. There were significantly (p < 0.05) fewer blood transfusions in the OPCAB group (1.1 units vs. 2.4 units), and the percentage of patients transfused blood was significantly less (34.9% vs. 57.3%). Nine out of 95 (9.5%) of patients who presented for OPCAB were converted to conventional bypass. Although there may be potential benefits to OPCAB, further studies must be directed at determining those patients who would benefit most from CABG using the off-pump technique.     

Impact of a phosphorylcholine-coated cardiac bypass circuit on blood loss and platelet function: a prospective, randomized study

Platelet dysfunction due to cardiopulmonary bypass (CPB) surgery increases the risk of bleeding. This study analyzed the effect of a phosphorylcholine (PC)-coated CPB circuit on blood loss, transfusion needs, and platelet function. We performed a prospective, randomized study at Strasbourg University Hospital, which included 40 adults undergoing coronary artery bypass graft surgery (CABG) (n = 20) or mitral valve repair (n = 20) using CPB. Patients were randomized either to PC-coated CPB or uncoated CPB (10 CABG patients and 10 mitral valve repair patients in each group). Blood loss and transfusion needs were evaluated intra- and postoperatively. Markers of platelet activation and thrombin generation were measured at anesthesia induction, at the beginning and end of CPB, on skin closure, and on days 0, 1, and 5. Comparisons were made by Student's t test or covariance analysis (significance threshold p < or = .05). Blood loss was significantly lower in the PC group during the first 6 postoperative hours (171 +/- 102 vs. 285 +/- 193 mL, p = .024), at the threshold of significance from 6-24 hours (p = .052), and similar in both groups after 24 hours. During CPB, platelet count decreased by 48% in both groups. There was no difference in markers of platelet activation, thrombin generation, or transfusion needs between the two groups. Norepinephrine use was more frequent in the control group (63% vs. 33%) but not significantly. PC-coating of the CPB surface reduced early postoperative bleeding, especially in CABG patients, but had no significant effect on platelet function because of large interindividual variations that prevented the establishment of a causal relationship.     

Predictors of prolonged mechanical ventilation following aorta no-touch off-pump coronary artery bypass surgery.

OBJECTIVE: To identify parameters associated with prolonged mechanical ventilation (PMV) (>48 h) after off-pump coronary artery bypass (OPCAB) in our patient population. MATERIALS AND METHODS: From February 2001 to November 2005, we operated on 1359 patients for isolated coronary revascularization with the pi-circuit technique, consisting of: (1) beating heart, (2) OPCAB, (3) aorta no-touch, (4) use of composite grafts, and (5) arterial revascularization. RESULTS: From the total number of our patients, 1320 patients had been extubated within 48 h postoperatively (Group A) and 39 patients needed PMV (Group B). In our study we have found that PMV were associated with advanced age (64.74+/-9.85 Group A vs 68.43+/-10.03 Group B, p<0.02) as well as higher incidence with octogenarians (4.4% Group A vs 10.2% Group B, p=0.09). Patients with preoperative history of transient ischemic attacks (TIAs) or stroke were more likely to belong to Group B (1.5% Group A vs 7.7% Group B, p<0.02; 2.8% Group A vs 10.3% Group B, p<0.02, respectively). Preoperative intra-aortic balloon pump (IABP) insertion was associated with PMV (1.6% Group A vs 15.4% Group B, p<0.0005). Unexpectedly, neither COPD nor obesity was associated with PMV (4.9% Group A vs 7.7% Group B, p=NS, 21.7% Group A vs 23.1% Group B, p=NS, respectively). CONCLUSION: In this study, PMV following aorta no-touch OPCAB was related to preoperative variables: age, octogenarians, preoperative IABP, TIA, and stroke. There was no relation between PMV and any of the operative data.     

Normothermic cardiopulmonary bypass: effect on the incidence of persistent postoperative neurological dysfunction following coronary artery bypass graft surgery

We retrospectively reviewed the records of 250 consecutive patients undergoing coronary artery bypass graft surgery (CABG) from January 1994 through January 1996 to determine the incidence of persistent postoperative neurological dysfunction after CABG and to compare normothermic and moderate hypothermic cardiopulmonary bypass (CPB). Normothermic CPB was used in 128 patients (36°–37°C) and hypothermic CPB (27°–28°C) in 122 patients. Postoperative neurological dysfunction included focal motor deficits, delayed recovery of consciousness (>24h) after surgery, and seizures within 1 week postoperatively. Persistent neurological dysfunction was diagnosed if complete resolution had not occurred within 10 days of surgery. The incidence of persistent postoperative neurological dysfunction was 4.1% in the hypothermic CPB group and 2.3% in the normothermic CPB group. There were no statistically significant differences between the two groups (P=NS). These results suggest that normothermic CPB did not increase the incidence of persistent postoperative neurological dysfunction compared to hypothermic CPB.     

Platelet function after coronary artery bypass grafting: is there a procoagulant activity after off-pump compared with on-pump surgery?

OBJECTIVE: After off-pump coronary artery bypass (OPCAB) haemostasis might be better preserved compared with on-pump coronary artery bypass grafting (CABG). The aim of this study was to investigate whether this possibly better preserved haemostasis results in a procoagulant activity of the platelets. DESIGN: Thirty patients were studied prospectively, 15 undergoing on-pump CABG and 15 undergoing OPCAB. Platelet function was evaluated four times within the first 24 h: preoperatively, postoperatively, 4 h and 1 day after surgery with a bedside whole blood clotting test. RESULTS: A significant increase of platelet-activating-factor-induced platelet aggregation was observed postoperatively after OPCAB (p < 0.01). Only two patients did not reach preoperative values within 1 day postoperatively and four patients had a more than twofold increase. Platelet aggregation immediately after on-pump CABG was reduced to near half of preoperative values, but within 1 day postoperatively normal platelet aggregation was regained in half of the patients. CONCLUSION: This study has mainly indicated that platelets after OPCAB were more easily activated in the early postoperative period. After CABG with cardiopulmonary bypass we found a temporary platelet dysfunction which seemed to be overcome within the first postoperative day.     

Initial experience with beating heart surgery: comparison with fast-track methods.

Cardiopulmonary bypass (CPB) in coronary artery bypass grafting (CABG) may increase postoperative complications in high-risk patients. The goal of this study is to retrospectively review a series of consecutive patients undergoing conventional CABG using a fast-track recovery method and to compare this series with the initial series of patients undergoing beating heart surgery using either the single-vessel minimally invasive approach or the off-pump multivessel bypass technique with a median sternotomy. One hundred fifty-eight consecutive patients underwent CABG. One hundred four patients underwent conventional CABG using CPB with a short-pump fast-track recovery method (Group A). Twenty-nine patients underwent a single-vessel bypass via a left anterior thoracotomy off pump [Group B, minimally invasive direct coronary artery bypass (MIDCAB)]. Twenty-five patients underwent multivessel CABG with a median sternotomy off pump (Group C). Short-pump fast-track (Group A) patients exhibited minimal complications and expedient recovery and received extensive revascularization. Off-pump multivessel patients (Group C) received fewer bypass grafts, had more preoperative comorbidity, and recovered as quickly as lower-risk fast-track short-pump patients (Group A). Single-vessel off-pump patients (Group B, MIDCAB) were younger elective patients and demonstrated no recovery advantage. The overall mortality was 1.8 per cent. The conversion rates from beating heart surgery to CPB for groups B and C were 10.3 and 16 per cent, respectively. The postoperative hospital length of stay for groups A, B, and C were 4.8+/-2.4, 3.9+/-1.8, and 5.2+/-2.3 days, respectively. Eliminating CPB is not as important as reducing exposure for minimizing operative risk. Beating heart surgery is an adjunct to conventional CABG with CPB. The off-pump multivessel bypass technique is best suited for high-risk patients requiring three grafts or fewer, whereas MIDCAB is best suited for single-vessel bypass that cannot be managed using interventional percutaneous techniques; however, the recovery advantage with MIDCAB is not apparent. Patients requiring more than three bypass grafts should undergo conventional CABG with CPB.     

Release of cardiac biochemical and inflammatory markers in patients on cardiopulmonary bypass undergoing coronary artery bypass grafting

Abstract Background: Determination of cardiac markers can assess cardiac injury induced by cardiopulmonary bypass (CPB) during coronary artery bypass grafting (CABG). However, the markers and their release pattern are not well defined. This study was aimed at assessing the release and timing of cardiac biochemical and inflammatory markers in patients undergoing elective CABG with CPB. Methods: Forty patients undergoing elective CABG were included in this study. Blood samples were collected for biochemical measurements at the following time points: immediately prior to the induction of anesthesia, one, six, 12, and 24 hours after initiation of CPB. Results: Increased release of cardiac troponin I was observed one hour after initiation of CPB (p < 0.05) and reached the maximum at 12 hours after CPB (p < 0.01). Serum CK‐MB enzyme activity and CK‐MB mass both were highly elevated starting at one hour after initiation of CPB, peaked at six hours, and remained elevated until 24 hours after CPB. Both lactate and lactate dehydrogenase were highly elevated six hours after CPB and peaked at 12 hours after CPB (p < 0.01). Serum levels of interleukin‐6 and tumor necrosis factor‐α increased significantly one hour after initiation of CPB and peaked at six hours (p < 0.01), while serum high sensitivity C‐reactive protein levels started to elevate 12 hours after CPB (p < 0.01). Conclusion: Monitoring of these markers could help to determine implementation of protective interventions during CABG with CPB to prevent myocardial deterioration and to predict the risk and prognosis.     

Coronary artery bypass grafting: an off-pump versus on-pump review

There has been a proliferation in the number of coronary artery bypass grafts (CABG) being performed without the use of cardiopulmonary bypass (CPB). However, the benefits of off-pump coronary artery grafting (OPCAB) are still being determined. The aim of this retrospective review was to compare the perioperative outcomes of CPB patients with OPCAB patients and to identify the patients most likely to benefit from the off-pump procedure. We reviewed the perioperative data of all isolated CABG patients at two metropolitan hospitals for the period of August 2000 to September 2001. The two groups (OPCAB vs. CPB) were further divided into subgroups identifying patients by their predicted mortality (higher-risk and lower-risk) and the number of distal graft anastomoses received (1, 2, 3, 4, or 5). A p value less than .05 was considered significant. Out of the total of 882 patients, 46.2% were OPCAB cases. Both CPB and OPCAB groups were similar in terms of demographics and predicted risk of mortality. Intraoperatively, OPCAB patients had fewer distal graft anastomoses (2.4 +/- 1.0 vs. 3.2 +/- 1.0, p < .001). Postoperatively, patients in the OPCAB group had less chest drainage (889 +/- 588 vs. 989 +/- 662 mls, p < .001), sustained fewer strokes (0.2 vs. 1.9%, p < .05), were transfused less (15.4 vs. 32.5%, p < .001) and were discharged earlier (7.3 +/- 5.6 vs. 8.5 +/- 9.1 days, p < .05). For higher-risk patients, OPCAB was associated with fewer reoperations for bleeding (1.3 vs. 6.4%, p < .05), a lower stroke rate (0 vs. 3.2%, p < .05), and a trend toward lower mortality (7.1 vs. 15.1%, p = .08). However, lower-risk OPCAB patients' stroke incidences (0.5% OPCAB group vs. 1.4% CPB group), and mortality rates (0.5 vs. 0.5%) were similar. Comparisons by number of grafts performed revealed that only the single-grafted OPCAB patients had statistically fewer postoperative complications, reduced chest drainage, and a shorter intensive care stay. Differences between either operation groups in transfusion rates were only statistically significant for the one to three grafted patients, while postoperative stays were similar for patients having four grafts. These results suggest that OPCAB is associated with a reduction in mortality and morbidity, particularly within the higher-risk patients. However, the benefits of OPCAB diminished with an increasing number of distal anastomoses performed.