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.     

Validation of a preoperative risk index as a predictor of perioperative morbidity and hospital costs in coronary artery bypass graft surgery

OBJECTIVE: To validate a previously developed model (CABDEAL) for predicting postoperative morbidity for coronary artery bypass graft (CABG) surgery patients using the New York State Statewide Planning and Research Cooperative System (SPARCS) database and to examine the effects of preoperative risk factors, postoperative complications, and death on costs of care for CABG surgery. DESIGN: Retrospective database review. SETTING: Governmental agency database of cardiac surgery. PARTICIPANTS: CABG surgery patients (n = 15,388). INTERVENTIONS: A previously developed preoperative risk model (CABDEAL) was applied to all patients. Predicted length of hospital stay and costs were compared with actual length of stay and costs, using a charge-to-cost conversion formula. MEASUREMENTS AND MAIN RESULTS: The CABDEAL model was moderately predictive of outcomes. The specificity was 64%, the sensitivity was 73.8%, and the receiver operating characteristic curve area was 0.728. Morbidity in the form of postoperative complications was recorded in 24.5% (3,770 patients), and the mortality rate was 3.4% (527 patients). The mean (+/- SD) total hospital cost was 28,408 US dollars +/-28,982, and the median cost was 21,644 US dollars. Based on the linear regression model, an equation was developed for predicting total costs: Cost (in US dollars) = 22,952 + (3,277. [CABDEAL score]). CONCLUSION: The previously developed CABDEAL model was predictive of increased morbidity in the SPARCS database. Total hospital costs increased nearly linearly with increasing CABDEAL score. These results encourage the development of models for preoperative estimation of costs related to perioperative morbidity.     

Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome

It has been suggested that coronary artery bypass grafting (CABG) performed in the setting of emergent failure of percutaneous transluminal coronary angioplasty causes minimal increased risk compared with routine CABG. We reviewed the records of 103 patients undergoing emergency CABG for failed percutaneous transluminal coronary angioplasty (group 1) and compared them with an identical number of consecutive CABG patients from 1987 (group 2). Group 1 had a lower risk profile evidenced by lower mean age (p less than 0.01), fewer diseased vessels (p less than 0.0001), better ventricular function (p less than 0.001), fewer left main lesions (p less than 0.0001), and fewer patients with acute ischemia requiring intravenous administration of nitroglycerin (p less than 0.01). Despite these differences, the group 1 patients had a higher mortality rate (11% versus 1%; p less than 0.01) and a higher rate of perioperative infarctions (new Q wave) (22% versus 6%; p less than 0.01). An analysis of risk factors was performed in the group 1 patients using 36 preoperative and operative variables. Multivariate analysis revealed that left ventricular score (p less than 0.0001), preoperative (after percutaneous transluminal coronary angioplasty) need for inotropic support (p less than 0.005), and age (p less than 0.025) were independent predictors of operative mortality. In conclusion, emergency CABG after failed percutaneous transluminal coronary angioplasty carries a significantly greater risk of operative death and perioperative infarction than elective CABG.     

Concomitant carotid endarterectomy and coronary artery bypass grafting versus staged carotid stenting followed by coronary artery bypass grafting

AIM: Significant carotid stenosis (>or=70%) in patients undergoing coronary artery bypass grafting (CABG) can increase the risk of perioperative cerebral vascular accident (CVA). In this study, we compared the results of two common operative strategies: concomitant carotid endarterectomy and CABG versus carotid stenting and CABG. METHODS: This cohort study was conducted from January 2001 to September 2006. Significant carotid artery stenosis was detected in patients who were candidates for CABG at the Tehran Heart Center. The stenosis was detected by carotid Doppler screening and was confirmed by magnetic resonance angiography. Reluctant patients or those with previous major CVA, significant bilateral carotid stenosis and intracranial lesions were excluded. Patients were divided into 2 groups. Group A underwent concomitant carotid endarterectomy and CABG (n=19), while carotid stenting and CABG were done in group B (n=28). RESULTS: The mean age in group A was 67.37+/-7.09 years and 65.57+/-8.13 years in group B. The mean hospital stay (days) was 18.68+/-7.95 in group A and 26.35+/-77.04 in group B (P=0.01). The median charge was dollars 252.79 in group A and dollars 2206.66 in group B (P <0.0001). There was a significant difference in frequency of hypotension and bradycardia between the 2 groups (P <0.05). There were 2 cases of in-hospital mortality in each group (10.5% and 7.1%, respectively). Two postoperative strokes occurred in group A and 3 in group B (10.5% and 10.7%, respectively). CONCLUSION: Concomitant carotid endarterectomy and CABG is as safe as carotid stenting and CABG, with fewer neurologic events and less hypotension, bradycardia, cost and shorter hospital stay.     

Intraaortic balloon pumping in patients undergoing coronary artery bypass grafting

Beneficial effect of preoperative intraaortic balloon pumping (IABP) treatment in high-risk patients who had open heart surgery have been demonstrated. The purpose of this study is to determine the impact of preoperative IABP use on survival in high-risk patients undergoing coronary artery bypass grafting (CABG). METHODS: Two hundred seventy-seven consecutive patients having CABG at our institution were reviewed. Patients having an IABP were identified retrospectively and grouped into one of 3 groups as follows. Group A (n = 14): preoperative IABP for high-risk urgent or elective cases. Group B (n = 26): preoperative IABP for emergency cases. Group C (n = 6): unplanned intraoperative or postoperative IABP. RESULTS: Forty-six patients had an IABP (16.6% of total). Parsonnet score in group B was significantly higher (p < 0.05). Length of operation for group C was significantly longer (p < 0.05). Overall hospital mortality in the total group of 277 cases was 4.2%. Hospital mortality was 7.1% in group A, 7.7% in group B, and 50% in group C. Hospital mortality in group C was significantly higher (p < 0.01). CONCLUSIONS: The beneficial effect of preoperative treatment with IABP in high-risk patients undergoing CABG was confirmed. This approach resulted in a significantly lower hospital mortality.     

Emergency off-pump coronary artery bypass grafting under a beating-heart.

BACKGROUND: Coronary artery bypass grafting (CABG) on a beating heart has been successfully performed for high risk patients, and is known to be less invasive than conventional CABG using cardiopulmonary bypass (CPB). We expanded the indication of beating-heart CABG in patients requiring emergency coronary revascularization. METHODS: A retrospective chart review was performed for patients who had undergone emergency CABG on a beating heart (EM-BH group), elective CABG on a beating heart (Elective-BH group) and emergency CABG under CPB (EM-CPB group), between January 1, 1997 and June 30, 1998. RESULTS: Four cases (1 male and 3 females with a mean age of 67.8 +/- 5.4) in the EM-BH group, 67 cases (48 males and 19 females with mean age of 67.3 +/- 7.8) in the Elective-BH group, and 41 cases (29 males and 12 females with mean age of 63.3 +/- 10.4) in the EM-CPB group were analyzed. The number of the grafts was 1.75 +/- 0.50 in EM-BH group, 1.37 +/- 0.55 in the Elective-BH group, and 2.95 +/- 1.07 in the EM-CPB group. The intubation period, ICU stay, and the postoperative hospital stay were significantly shorter in the EM-BH group (6.0 hours intubation, 1.5 days ICU stay, and 11.5 days postoperative hospital stay) and Elective-BH group (6.8 +/- 11.0 hours intubation, 1.6 +/- 1.5 days ICU stay, and 12.7 +/- 5.2 days postoperative hospital stay) than in the EM-CPB group (20.1 +/- 22.5 hours intubation, 3.6 +/- 2.4 days ICU stay, and 21.8 +/- 14.9 days postoperative hospital stay). CONCLUSION: The postoperative recovery period for EM-BH patients was almost the same as that for elective cases of beating-heart CABG, and was significantly shorter than that of conventional emergency CABG under CPB. Selected patients with coronary ischemia can be safely treated by beating-heart surgery.     

Local versus general anesthesia for carotid endarterectomy: report of 329 cases

Since stroke is an important cause of morbidity and mortality, carotid endarterectomies are used frequently to reduce the risk of stroke and death. Unfortunately, an inherent risk of the carotid endarterectomy procedure is that surgery itself may result in stroke. At this point the question is which method of anesthesia, local or general, is better to protect and monitorize the brain function during cross-clamp period in carotid endarterectomies? In the authors' center, 365 carotid endarterectomies were applied to 329 patients between 1990 and 2001; 165 operations were done under general anesthesia and the other 200 operations were done under local anesthesia. These 2 groups, general (group I) and local anesthesia (group II), were studied retrospectively according to preoperative and postoperative data. In group I, the rate of major stroke was 7.3%, but this rate was 1% in group II (p < 0.05). Intraoperative shunts were used in 50 (30.3%) operations of group I, but the usage of shunt was 8% (16 operations) in group II (p < 0.0001). The hospitalization period was also much shorter in group II than in group I. The time of hospitalization was 4.1 +/-1.9 days in group I and 2.4 +/-1.1 days in group II (p < 0.0001). In terms of cost analysis, the mean costs were 1007.14 dollars +/-135.71 dollars in group I and 885.71 dollars +/-78.57 dollars in group II (p < 0.0001). In short, the local procedure was more cost-effective. As a result, in carotid endarterectomy procedures, the authors prefer local anesthesia to achieve better brain function monitoring and to reduce hospitalization time and cost.     

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.     

Mild or Moderate Chronic Obstructive Pulmonary Disease Risk in Elective Coronary Artery Bypass Grafting Surgery

A history of chronic obstructive pulmonary disease (COPD) is considered a risk factor in patients undergoing coronary artery bypass grafting (CABG) surgery. The objective of this study was to examine the impact of history of mild or moderate COPD on outcome in patients undergoing elective CABG surgery. In this prospective, case-controlled study, we compared two groups of adult patients undergoing elective CABG surgery. In this prospective, case-controlled study, we compared two groups of adult patients undergoing elective CABG surgery. There were no statistically significant differences regarding early postoperative complications between the groups (p > 0.05). The median duration of mechanical ventilation and ICU length of stay were 0.4 and 1 days, respectively, in the two groups. The mean (± SD) hospital stay was 7.8 ± 1.6 days in the COPD group and 7.5 ± 1.3 days in the control group (p = 0.1). The mortality rate was found 1.4% in COPD patients and 0.7% in the control group (p = 0.5). We concluded that patients with a history of mild or moderate COPD undergoing elective CABG had morbidity and mortality rates comparable with those of controls (p > 0.05).     

Effects of coronary artery bypass related conduction defects: a 10-year follow-up study

OBJECTIVES: The aim of this study is to determine the long-term prognostic significance of new permanent conduction defects (CDs) related to coronary artery bypass grafting (CABG), and to assess predisposing factors for increased mortality after CABG. DESIGN: One hundred and eighty patients who underwent an elective CABG without any evidence of preoperative CDs were followed on average for 9.6 years. Long-term outcome was observed in terms of Kaplan-Meier survival analysis, and several potential pre-, intra- and postoperative factors for increased mortality were analysed using the Cox regression model. RESULTS: Sixty-three (35.0%) of the patients developed a new CD (CD+ group) before hospital discharge. Early (<30 days) and long-term (>30 days) survival rates were 98.9 and 86.1%, respectively. The long-term survival in CD+ patients was significantly lower that in CD- patients (77.8% vs 90.4%, p = 0.02). However, cardiac survival in CD+ patients and CD- patients did not differ from each other (88.9% and 92.3%, respectively, p=NS). Five independent predictors for increased all cause mortality were identified: diabetes (relative risk ratio 5.99 [2.43-14.78]), number of distal anastomoses (3.20 [1.30-7.88]), a new intraoperative conduction defect (2.83 [95% CI 1.24-6.49]), preoperative ejection fraction <50% (2.60 [1.08-6.27]) and perfusion time (1.02 [1.01-1.03]). CONCLUSIONS: Excellent survival rates can be obtained 10 years after CABG. CDs were not related to increased cardiac mortality. The appearance of preoperative diabetes, intraoperative perfusion time, number of distal anastomoses performed, CABG derived permanent CDs and low preoperative ejection fraction are associated with higher all cause mortality during the long-term follow-up.     

Risk factors and outcomes after coronary reoperation in 739 elderly patients

BACKGROUND: As second coronary artery bypass graft (CABG) operations are becoming more common in elderly patients, we conducted a retrospective analysis of risk factors for in-hospital and late outcome in patients aged 70 and over. METHODS: We reviewed records of 739 patients who underwent second CABG at age 70 or older at our institution between 1983 and 1993. Preoperative, operative, and postoperative variables were analyzed to identify predictors of in-hospital and long-term mortality. RESULTS: The mean age (+/- standard deviation) at reoperation was 74 +/- 3 years and the mean interval after primary operation was 130 +/- 55 months. In-hospital mortality was 7.6% (n = 56). Preoperative factors associated with increased in-hospital mortality were preoperative creatinine greater than 1.6 mg/dL (p < 0.001), emergency operation (p < 0.001), female sex (p = 0.012), moderate or severe left ventricular dysfunction (p = 0.049), and left main coronary disease (p = 0.045). In-hospital, actuarial survival was 75% at 5 years and 49% at 10 years. Cardiac event-free survival was 60% at 5 years and 27% at 10 years. The factors independently associated with increased late death were hematocrit (p = 0.046), diabetes (p = 0.011), peripheral vascular disease (p < 0.001), left ventricular function (p < 0.001), history of cancer (p = 0.016), preoperative nonsinus rhythm (p = 0.003), anticoagulation or antiplatelet therapy (p = 0.018), postoperative encephalopathy (p = 0.001), and postoperative stroke (p = 0.014). CONCLUSIONS: CABG reoperation can have excellent results for many elderly patients, but mortality is markedly higher when elderly patients have certain risk factors and comorbidities, alone or in combination. This information should be helpful in educating patients before they decide whether to choose reoperation.     

Rapid Recovery of Octogenarians Following Coronary Artery Bypass Grafting

A bstract Background : Rapid recovery protocols for coronary artery bypass grafting (CABG) have resulted in major decreases in postoperative hospital length of stay (LOS) when applied to younger patients undergoing elective procedures. However, the effectiveness of rapid recovery protocols when applied to octogenarians has not been thoroughly studied. Methods : Thirty-seven consecutive octogenarians underwent isolated CABG utilizing cardiopulmonary bypass (CPB). A protocol emphasizing preoperative placement of the intra-aortic balloon pump, reduced CPB time, early extubation, perioperative steroids, thyroid hormone, and aggressive postoperative diuresis was used. Results : The 30-day operative mortality for the entire series was 5.4%. Twenty-five patients (71%, group I) were discharged in < 10 days postoperatively (average LOS of 6.3 ± 1.6 days), while ten patients (29%, group II) were discharged at 10 or more days postoperatively (average LOS of 20.3 ± 8.0, p < 0.001). Patients in group II were found to have a higher incidence of obesity (50% vs 4%, p < 0.01), symptomatic peripheral vascular disease (60% vs 8%, p < 0.01), and preoperative ambulatory difficulties (50% vs 0%, p < 0.01). The incidence of complications was 31% for the entire series, with no differences between the groups. Conclusion : Octogenarians performed well under a rapid recovery protocol, with 71% being discharged in < 10 days postoperatively, while patients with obesity, symptomatic peripheral vascular disease, and ambulatory difficulties rehabilitated more slowly.     

Leukodepletion reduces renal injury in coronary revascularization: a prospective randomized study

BACKGROUND: Cardiopulmonary bypass (CPB) is an important contributor to renal failure, which is a well-recognized complication after coronary artery bypass grafting (CABG). Leukodepletion reduces CPB-associated inflammation and resultant end-organ injuries. However, its effectiveness in renal protection has not been evaluated in a prospective randomized clinical setting. METHODS: Forty low-risk patients awaiting elective CABG with normal preoperative cardiac and renal function were prospectively randomized into those undergoing nonpulsatile CPB without (group A: n = 20) and with leukodepletion (group B: n = 20). Renal glomerular and tubular injury were assessed by urinary excretion of microalbumin and retinol binding protein (RBP) indexed to creatinine (Cr), respectively. Daily measurements were taken from admission to postoperative day 5. Fluid balance, serum creatinine, and blood urea were also monitored. RESULTS: No mortality or renal complication occurred. Both groups had similar demographic makeups, Parsonnet scores, extents of coronary revascularization and, durations of CPB and aortic cross-clamping. Daily fluid balance, serum creatinine, and blood urea remained comparable in both groups throughout the study period. From equal preoperative values, a significantly higher release of urinary RBP:Cr (7,807 +/- 2,227 vs 3,942 +/- 2,528; p < 0.001) and urinary microalbumin:Cr (59.4 +/- 38.0 vs 4.7 +/- 6.7; p < 0.0001) occurred in group A, peaking on day 1 before returning to approximate baseline levels. CONCLUSIONS: Although clinically overt renal complications were absent, sensitive indicators revealed significantly more injury to both renal tubules and glomeruli after nonpulsatile CPB without leukodepletion. These data suggest that leukocytes play an important role in post-CPB renal dysfunction, and leukodepletion may offer some renal protection in low-risk patients during CABG.     

Different CABG methods in patients with chronic obstructive pulmonary disease

BACKGROUND: Pulmonary dysfunction is still a major problem in coronary artery bypass grafting (CABG). The purpose of this randomized study was to determine the effect of different CABG techniques on pulmonary function. METHODS: Fifty eight patients with severe obstructive pulmonary disease had elective isolated coronary surgery. The surgical methods for the patients with chronic obstructive pulmonary disease (COPD) were standard CABG in 18 patients (group 1), beating heart surgery in 19 patients (group 2), and minimally invasive direct coronary artery bypass grafting (MIDCABG) in 21 patients (group 3). RESULTS: The earliest extubation time was from group 3 (p < 0.001). The average stay in the intensive care unit was significantly longer in group 1 (2.6 +/- 1.5 days) than in groups 2 (1.4 +/- 0.8 days) and 3 (1.1 +/- 0.8 days) (p < 0.05). The most prevalent respiratory morbidity was atelectasis that developed in 6 patients from group 1, in 2 patients from group 2, and in 3 patients from group 3. Forced expiratory volumes in 1 second (FEV1) obtained in the second postoperative month were significantly lower than preoperative values only in group 1 (p < 0.05). Forced vital capacity (FVC) values were significantly lower than the preoperative values in all three groups (p < 0.05). CONCLUSIONS: Off-pump bypass surgical procedures are more advantageous than on-pump methods for patients with COPD. These patients can be operated on using the beating heart technique or by using MIDCABG to prevent side effects of CPB on pulmonary function and effects of sternotomy.     

Off-pump coronary artery bypass

OBJECTIVES: Off-pump coronary artery bypass grafting (CABG) on the beating heart has become popular procedure in cardiac surgery and its initial results appeared favorable. We report our early and mid-term results of off-pump CABG performed at Shin-Tokyo Hospital. METHODS: Medical records of patients undergoing off-pump or conventional on-pump CABG from September 1, 1996, to August 31, 1999 were retrospectively reviewed. Patients underwent off-pump CABG were further classified into 2 groups; MIDCAB (Off-pump CABG for single vessel revascularization via a small skin incision) and OPCAB (off-pump CABG mainly approached via midline sternotomy) group. Their preoperative, perioperative, and follow-up data were collected and analyzed. RESULTS: Among a total of 995 cases of CABG, 194 cases were off-pump CABG (male/female 142/52, mean age 66.9). The mean number of distal anastomoses in off-pump CABG was 1.9 +/- 0.9 (1.0 +/- 0.0 in MIDCAB and 2.3 +/- 0.7 in OPCAB), which was significantly fewer than in on-pump CABG (3.6 +/- 1.1), with p < 0.0001. Intubation time (5.3 +/- 5.7 hours in off-pump CABG vs 13.1 +/- 24.2 hours in on-pump CABG), ICU stay (1.7 +/- 1.1 vs 3.2 +/- 3.0 days), and postoperative hospital stay (14.0 +/- 7.9 vs 18.1 +/- 12.1 days) in off-pump CABG were significantly shorter than in on-pump CABG (p < 0.0001). In the off-pump CABG group, there were no in-hospital deaths and 14 major complications, fewer than in on-pump CABG (8 hospital deaths and 114 major complications). Postoperative angiography before hospital discharge was conducted in 80 patients (41.2%) and showed 2 occlusions, giving a graft patency rate of 98.6% in the off-pump group. During follow-up (0.9 +/- 0.6 year) period, there were 5 non-cardiac deaths and 20 cardiac events in the off-pump group. The actuarial survival rate at 36 months was 94.6% for off-pump CABG, showing no significant difference from the rate for conventional CABG patients (95.2% at 36 month, p = NS) The event-free rate was 84.0% at 36 months in off-pump CABG patients; however, which was less favorable than on-pump CABG patients (88.0% at 36 months, p < 0.05). CONCLUSIONS: Both in-hospital and mid-term results for off-pump CABG patients were acceptable. Isolated CABG can thus be safely performed without cardiopulmonary bypass. Advances in coronary stabilization have contributed to these improved results. The observed long-term cardiac events may be related to incomplete revascularization.     

Beating heart versus conventional single-vessel reoperative coronary artery bypass

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG. METHODS: We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 +/- 9 for on-pump versus 24 +/- 8 for off-pump patients (p = nonsignificant). RESULTS: On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 +/- 4 days on-pump versus 5 +/- 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03). CONCLUSIONS: Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.     

Circadian rhythm has no effect on mortality in coronary artery bypass surgery

BACKGROUND: The circadian variation that affects atherosclerosis has not been studied in the surgical patient. The circadian variation in mortality dependent on the time of surgery was examined in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: A 4-year retrospective review of all CABG patients (n = 3140) from 1999 to 2002 was undertaken. The patients were divided into elective, urgent, and emergency cases. The cases were subdivided according to the start time of the operation as morning (7 AM to 2 PM = AM), afternoon (2 PM to 8 PM = AF), and night (8 PM to 7 AM = NT). The outcome was mortality within 30 days and compared for three different time frames: (1) AM versus AF (2) AM versus NT (3) AF versus NT for each prioritized group. Risk factors and number of anastamoses were compared for each group. Sigma Statistical package and Z-test for two group comparison were used for analysis. t-Test was used to compare age and ejection fraction. RESULTS: No statistically significant difference in mortality was observed for the elective and urgent groups for each of the time periods compared. The emergency cases had significantly increased deaths in the AM and NT compared to the AF (p < 0.01 and p < 0.05, respectively). There was no statistically significant difference with respect to age, gender, number of anastamoses performed, ejection fraction, and preoperative risk factors between groups. CONCLUSIONS: The mortality for nonemergent CABG is independent of the timing of surgery. Circadian variation does not influence the outcome in cardiac surgical patients.     

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.     

Off-pump surgery decreases postoperative complications and resource utilization in the elderly.

BACKGROUND: Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients. METHODS: Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65. RESULTS: Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency. CONCLUSIONS: OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.     

Peroperative factors influencing the outcome of elective abdominal aorta aneurysm repair.

PURPOSE: To identify perioperative variables which may influence mortality of elective abdominal aneurysm repair (AAA). METHOD: prospective study of patients undergoing elective AAA repair between 1986 and 1997. RESULTS: Four hundred and seventy patients (438 men, 32 females) with a mean age of 69.4+/-13 years and aneurysms with a diameter of 60+/-3 mm were operated on with a 1-month mortality rate of 5.3%. Multivariate analysis identified the following independent risk factors for mortality: age >70 (p<0.0001), a past history of myocardial infarction (p<0.0001), preoperative renal insufficiency (p<0.0001), reoperation (p<0.0001), colonic necrosis (p<0.0001), and severe postoperative medical complications (p<0.0001). CONCLUSION: Intra- and postoperative events affect the outcome of AAA repair, independently of preoperative factors, and should be described when presenting the results of AAA repair.