Coronary Artery Bypass Surgery in Patients with Malignancy: A Single-Center Study with Comparison to Patients Without Malignancy

Abstract Background: There is debate on the timing and outcome of coronary artery bypass surgery in patients with coincident malignancy. In this study, we compared the outcome of coronary artery bypass graft (CABG) in such patients with those without malignancy. Methods: The patients were selected from those who had undergone coronary artery bypass surgery in the last decade. The study group (group I) included the patients with malignancy in remission. The control group comprised those patients who were selected randomly from those without any malignancy. The patients were retospectively examined with regard to preoperative, operative, and postoperative data from personal files, computerized recording system, and operation reports. Results: Group I included 48 patients (age 48 to 69; 29 male) while group II included 50 patients (age = 38 to 73; 35 male). In group I, comorbidity rates were: renal dysfunction in 12 (25%), obstructive lung disease 10 (21%), congestive failure in four (8%) patients. The malignancy rates were: lung in 15 (31%), breast in 10 (21%), stomach in five (10%), colon in four (8%), renal in one (2%), Hodgkin's lyphoma in three (6%), leukemia in two (4%), ovarian in three (6%), and prostate in five (10%) patients. In group II, the comorbidity rates were: diabetes mellitus 18 (36%), renal dysfunction in five (10%) and obstructive lung disease in 13 (26%) patients. In group I, chemotherapy and radiotherapy were performed in 38 and 34 patients, respectively. In groups I and II, the CABG was elective in 47 (98%) and in 45 patients (90%); the off‐pump surgery was performed in 27 (56%) and 12 (24%) patients, respectively. The total duration of bypass was 37 ± 6 minutes and 44 ± 5 minutes; the duration of aortic clamp was 26 ± 4 and 29 ± 7 minutes, respectively, in groups I and II. Posoperative complication rates were: infection in 12 (25%), bleeding in eight (17%), acute renal insufficiency in eight (17%), prolonged air escape in five (10%), and prolonged entubation in 17 (35%) patients in group I and atrial fibrillation in 11 (22%) patients in group II. Mortality rates in both groups were two (4%). Conclusion: CABG in patients with comorbid malignancy is as safe as the other patients. In patients with full remission of malignancy, the surgeons should be encouraged about the safety of CABG.     

Multivessel Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in ESRD

Thirty to sixty percent of patients with ESRD on dialysis have coronary heart disease, but the optimal strategy for coronary revascularization is unknown. We used data from the United States Renal Data System to define a cohort of 21,981 patients on maintenance dialysis who received initial coronary revascularization with either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) between 1997 and 2009 and had at least 6 months of prior Medicare coverage as their primary payer. The primary outcome was death from any cause, and the secondary outcome was a composite of death or myocardial infarction. Overall survival rates were consistently poor during the study period, with unadjusted 5-year survival rates of 22%–25% irrespective of revascularization strategy. Using multivariable-adjusted proportional hazards regression, we found that CABG compared with PCI associated with significantly lower risks for both death (HR=0.87, 95% CI=0.84–0.90) and the composite of death or myocardial infarction (HR=0.88, 95% CI=0.86–0.91). Results were similar in analyses using a propensity score-matched cohort. In the absence of data from randomized trials, these results suggest that CABG may be preferred over PCI for multivessel coronary revascularization in appropriately selected patients on maintenance dialysis.Cardiovascular disease is the leading cause of death in patients with ESRD.¹ Coronary heart disease affects 30%–60% of patients with ESRD, and it usually involves multiple vessels, proximal lesions, heavy calcifications, or diffuse disease.^2–4 Because of the high burden and poor prognosis of coronary disease in this patient population, optimal management of coronary heart disease—particularly the choice of revascularization modality—is a critical clinical issue.Although there have been several randomized trials comparing multivessel coronary artery bypass grafting (CABG) with multivessel percutaneous coronary intervention (PCI),^5,6 none of these trials included patients with ESRD. Evidence from previous observational studies is mixed; some studies indicate a long-term survival benefit associated with CABG versus PCI,^7–10 whereas other studies show no significant differences in survival.^11–15 These discrepant results may have stemmed, at least in part, from the heterogeneity of the studied populations (e.g., inclusion of patients with single- and multivessel coronary disease and small sample sizes from single institutions). Moreover, most of these studies were performed between the 1970s and early 2000s, and therefore, they do not reflect contemporary practice patterns, such as the use of drug-eluting stents.To address these issues, we used data from the US Renal Data System (USRDS), which collects extensive information for over 95% of patients with ESRD in the United States.¹ We examined the comparative effectiveness of CABG versus PCI between 1997 and 2009 in patients with ESRD on maintenance dialysis. We restricted our analysis to patients undergoing multivessel coronary revascularization to minimize indication bias, because they have the most similar likelihood of receiving either CABG or PCI. We hypothesized that an initial strategy of CABG would be associated with lower risks of mortality and cardiovascular morbidity compared with PCI.     

Enhanced Recovery After Cardiac Surgery: A Propensity-Matched Analysis

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Coronary Artery Bypass Grafting vs Percutaneous Coronary Intervention in Patients With Diabetes

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Percutaneous Coronary Intervention With Drug Eluting Stents Versus Coronary Artery Bypass Graft Surgery in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

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Perioperative Stroke in Coronary Artery Bypass Surgery: Analysis of Risk Factors

Objective - To investigate relations between chest pain after coronary artery bypass grafting (CABG), quality of life (QoL), and coping capacity. Design - Two groups were included, Group I ( n = 111) was evaluated before and 1 year postoperatively, and Group II ( n = 102) once, at 3 years. The questionnaire included parts of the Seattle angina questionnaire, one question concerning chest pain, coping capacity (sense of coherence), emotional state, the Psychological general well-being index, and a global QoL question. Results - Chest pain was significantly related to lower coping capacity (at 1 year) and lower QoL scores (at 1 and 3 years). Changes of coping capacity and emotional state from before to 1 year after the CABG did not reach statistical significance in the chest pain group while the no chest pain patients had significantly better emotional state. The relation between chest pain and worse QoL was significantly reduced by high coping capacity. Conclusion - Independent of the direction of causality, the patient's coping capacity and experienced chest pain is highly related.     

Chronological Improvement in Survival Following Rectal Cancer Surgery: A Large-Scale, Single-Center Study

Background

Total mesorectal excision (TME) and preoperative chemoradiation therapy (PCRT) for rectal cancer are used sequentially in our center. The aim of this study was to evaluate survival of patients with stage II/III rectal cancer chronologically and to determine whether therapeutic advances associated with TME and PCRT have improved patient survival.

Methods

A retrospective review of 2,197 patients from July 1989 to December 2006 was conducted. The time period (P) for this study was divided into three groups: P1 (1989–1995), P2 (1996–2001) for TME, P3 (2002–2006) for PCRT. Cancer-specific survival (CSS), disease-free survival (DFS), and recurrences among the three periods were investigated.

Results

A total of 293 patients in P1, 836 patients in P2, and 1,068 patients in P3 were enrolled. The 5-year CSS in stages II and III was statistically different between P1/P2 and P3 (stage II, p = 0.008; stage III, p < 0.001). The 5-year DFS was significantly different between P1/P2 and P3 for stage III (p = 0.001). The local recurrence and systemic recurrence rates decreased during P3, but there was no significant difference between the three periods for stage II. For stage III, local recurrence was significantly different between the three periods (P1 vs. P2, p = 0.002; P1 vs. P3, p < 0.001; P2 vs. P3, p = 0.008).

Conclusions

We identified an improvement in survival for stage II/III rectal cancer and a decrease in local recurrence for stage III rectal cancer during P3, the most recent period. This may be due to frequent application of PCRT based on the TME.