Changes in health-related quality of life following coronary artery bypass graft surgery

Background. There are limited data to help clinicians identify patients likely to have an improvement in quality of life following CABG surgery. We evaluated the relationship between preoperative health status and changes in quality of life following CABG surgery.

Methods. We evaluated 1,744 patients enrolled in the VA Cooperative Processes, Structures, and Outcomes in Cardiac Surgery study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) surveys. The primary outcome was change in the Mental Component Summary (MCS) and Physical Component Summary (PCS) scores from the SF-36.

Results. On average, physical and mental health status improved following the operation. Preoperative health status was the major determinant of change in quality of life following surgery, independent of anginal burden and other clinical characteristics. Patients with MCS scores less than 44 or PCS scores less than 38 were most likely to have an improvement in quality of life. Patients with higher preoperative scores were unlikely to have an improvement in quality of life.

Conclusions. Patients with preoperative health status deficits are likely to have an improvement in their quality of life following CABG surgery. Alternatively, patients with relatively good preoperative health status are unlikely to have a quality of life benefit from surgery and the operation should primarily be performed to improve survival.     

Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery.

OBJECTIVE: Improvement in survival and quality of life are the primary indications for coronary artery bypass graft (CABG) operations. Among elderly patients the main goal of surgery is not necessarily to prolong life, but to improve the health-related quality of life. Factors associated with mortality and morbidity following CABG surgery have been well defined, but the quality of life and functional capacity in elderly patients undergoing CABG are poorly documented. The aim here was to investigate changes in health-related quality of life, overall performance status and symptomatic status during 1 year after CABG surgery. METHODS: Comprehensive data on 508 CABG patients were prospectively collected, including preoperative risk factors and postoperative morbidity in a surgical center and in all eighteen secondary referral hospitals up to discharge. The RAND-36 Health Survey (RAND-36) was used as indicator of quality of life. The primary outcome was change in the physical component summary, mental component summary and General Health summary scores from the RAND-36. Karnofsky dependency category was used to assess overall performance status, and symptomatic status was estimated according to New York Heart Association (NYHA) class. All assessments were made preoperatively and repeated 12 months later. Analysis was based on three age groups: 64 years or less (282 patients), 65-74 years (175 patients), and 75 or more years (51 patients). RESULTS: Thirty-day and 1-year survival rates were 98.2 and 96.7%, respectively. A great majority (86.4%) of the patients recovered without major complication. In all, the present data showed significant improvement in all eight domains of QOL as well as in functional capacity and NYHA class during the 1st year after CABG. However, the mean change in RAND-36 Mental Component Summary scores among patients aged 75 years or more did not reach a statistically significant level (P=0.097) and they had significantly minor improvement as compared to younger patients (P<0.05). Moreover, their General Health score improvement was poorer and statistically insignificant (P=0.817). CONCLUSIONS: Elderly patients not only have higher mortality and morbidity but also derive less benefit from CABG regarding certain aspects of QOL.     

Experience of perioperative myocardial infarction with graft patency following coronary artery bypass graft surgery

Coronary artery bypass graft surgery, with current operative mortality rates of one to three percent, is now an accepted treatment for coronary artery disease. However, perioperative myocardial infarction (PMI) is not a rare complication of this procedure, and the precise mechanism of its occurrence is not well elucidated. We experienced a case of 70-year-old man who had transmural hemorrhagic PMI in the distribution of the grafted vessel and died due to low output syndrome in spite of vigorous treatment. All five grafts were found to be well patent at autopsy. In this case, the cause of PMI was supposed to be inadequate intraoperative myocardial protection and reperfusion injury.     

Predictors of health-related quality of life after coronary artery bypass surgery

BACKGROUND: Little is known about the determinants of health-related quality of life after coronary artery bypass surgery. We determined the predictors of overall physical and mental health status 6 months after the operation. METHODS: We evaluated 1,973 patients enrolled in a multicenter Veterans Affairs prospective cohort study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) health status surveys. Multiple linear regression was used to identify the significant independent predictors of 6-month physical and mental component summary scores from the SF-36. RESULTS: In multivariable analyses adjusting for baseline health status, significant predictors of postoperative physical health status were a history of neurologic disease, peripheral vascular disease, chronic obstructive pulmonary disease, hypertension, current smoking, forced expiratory volume, left ventricular ejection fraction, and serum creatinine. Significant predictors of postoperative mental health status were a history of psychiatric disease, chronic obstructive pulmonary disease, current smoking, age, and New York Heart Association functional class. CONCLUSIONS: These predictors of health-related quality of life after coronary artery bypass surgery may be useful for preoperative risk assessment and counseling of patients with regard to anticipated health status outcomes. Factors such as current smoking and psychiatric disease may be targets for interventions to improve health-related quality of life outcomes.     

Perioperative myocardial infarction and changes in left ventricular performance related to coronary artery bypass graft surgery

Recent advances in perioperative management and surgical technique have been associated with low operative mortality and a high incidence of symptomatic relief in patients undergoing coronary artery bypass graft (CABG) operations. The frequency and importance of perioperative myocardial infarction (MI) and immediate as well as long-term changes in left ventricular (LV) performance are factors of considerable current interest in any critical analysis of the effectiveness of CABG surgery. The present review describes the effects of patient selection, anesthetic techniques, and newer methods of myocardial protection as they relate to perioperative MI and LV performance. In addition, newer tests useful in the diagnosis of perioperative MI are discussed. The application of noninvasive techniques for the serial determination of LV performance and myocardial perfusion in CABG operations is also described.     

The impact of coronary artery bypass on late myocardial infarction.

Two hundred consecutive patients undergoing coronary artery bypass for stable and unstable angina pectoris were followed clinically 3 to 53 months (mean 27) and with serial electrocardiograms (ECG's) 3 to 43 months (mean 18.5) postoperatively. Complete (twelve lead) resting ECG data including preoperative, early postoperative (in hospital), and late (post hospital) studies were available in 98 per cent (196/199) of hospital survivors. A total of 2,304 ECG's were examined by two cardiologists for a total follow-up of 3,629 patient months. Myocardial infarction was defined as the appearance of a new, significant (Minnesota Code) Q wave. Fifty-four per cent (108/200) had triple vessel disease and 24 per cent (47/200) preinfarction angina pectoris by strict criteria. There was one hospital death for an operative mortality of 0.5 per cent (1/200). There was one late fatal and three late nonfatal myocardial infarctions. Seventeen patients developed new Q waves in the early postoperative period, a perioperative infarction rate of 8.5 per cent (17/200). The 43 month cumulative myocardial infarction rate, including all early and late postoperative new Q waves and three late deaths from cardiac disease, was 14 per cent. Twenty-two per cent (20/91) showed disappearance of Q waves present at the time of hospital discharge. These data suggest that the late myocardial infarction rate is low in surgically managed patients.     

Emergency coronary artery bypass graft surgery for threatened acute myocardial infarction related to coronary artery catheterization

In 20 patients undergoing cardiac catheterization, usually involving balloon-catheter dilation or streptokinase infusion, catheter-induced coronary artery intimal damage resulted in severe chest pain, electrocardiographic evidence of obstruction or dissection of a major coronary artery. These patients were surgically revascularized within 8 hours after the onset of the acute chest pain syndrome. Our experience with pharmacological and catheter-related manipulations to improve coronary blood flow after the ischemic episode but before operation suggested that the additional time spent in the catheterization laboratory was worthwhile. The injured coronary artery was the left anterior descending in 10 patients, the right in 8, the left main in 1 patient, and an obtuse marginal branch of the circumflex in 1. The average number of grafts per patient was 2.5; only 6 patients had single bypass grafts. In 5 patients, intraaortic balloon pumping was used either preoperatively or postoperatively. Inotropic support was used postoperatively in 5 patients, and 7 patients received lidocaine for ventricular irritability. Abnormal elevation of the serum isoenzyme of creatine kinase (CK-MB) was seen in 8 patients, and new Q waves were noted in 4 patients; 3 of these 4 patients with new Q waves also had abnormal serum CK-MB levels. Global ejection fraction obtained by the equilibrium-gated blood pool scan postoperatively was 60 +/- 3%, which was similar to the 62 +/- 3% obtained from the contrast-determined ventriculogram done preoperatively prior to the catheter-related injury. There were no early or late deaths, but morbidity was much higher in the group who had emergency coronary artery bypass grafting (CABG) compared with those who had elective CABG.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of training on outcomes following coronary artery bypass graft surgery.

OBJECTIVE: We examined our coronary artery bypass surgery (CABG) experience to assess the effect of training on mortality and morbidity outcomes. METHODS: Between April 1997 and September 2002, 5678 consecutive patients underwent isolated CABG. Five hundred and fifty-five (9.9%) were performed by trainee surgeons. Multivariate logistic regression was used to assess the effect of training on adverse outcomes, while adjusting for patient and disease characteristics (treatment selection bias). Cox proportional hazards analysis was used to adjust Kaplan-Meier survival curves. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics including the additive EuroSCORE. The propensity score was the probability of CABG performed by trainee, with a C-statistic of 0.79, and was included along with the comparison variable (trainee vs Consultant) in a multivariable analysis of outcome. The propensity score is used as the sole variable for adjustment due to the low number of events, providing a more complete risk adjustment. RESULTS: CABG procedures performed by trainee surgeons were less likely to be female, hypertensive, obese, triple-vessel disease, redo and emergency cases. Also, trainee surgeons were less likely to operate on patients with cerebrovascular disease, renal dysfunction, and previous myocardial infarctions, prior gastrointestinal surgery, and poor left ventricular ejection fraction. The additive EuroSCORE was 2.9 in trainee cases compared to 3.5 in Consultant led cases (P<0.001) Crude outcomes were significantly better in trainee CABGs due to selection bias. In-hospital results were no longer significantly different between both groups after adjusting for the propensity score. The adjusted freedom from death in the trainee cases at 30 days, 1, 2, 3, and 4 years was 98.1, 96.2, 94.7, 93.2 and 91.8%, respectively, compared to 97.9, 95.7, 94.1, 92.3 and 90.8% for the Consultant led cases (P=0.53). CONCLUSIONS: After adjusting for case-mix, with careful case selection, training does not adversely affect the early and mid-term outcomes of CABG.     

Prevention of urethral strictures following coronary artery bypass graft surgery.

A total of 62 patients undergoing coronary artery bypass graft surgery were randomized into three groups using one of three methods for bladder drainage: 12F Foley catheter introduced after anesthesia prior to surgery (21 patients); 12F Foley catheter introduced after termination of cardiopulmonary bypass period (17 patients); or a suprapubic catheter, introduced after termination of the bypass period (24 patients). Later we also studied 39 consecutive patients undergoing coronary artery bypass graft surgery with a 12F Foley catheter introduced after anesthesia to assess the risk of urethral stricture in a larger group of patients. The patients' records were reviewed and a postal questionnaire was sent to all patients six months after surgery. The response rate was 84 percent, with 36 percent having complaints about micturition; of these 79 percent were evaluated by cystourethrography, and 2 cases of urethral stricture were found. The incidence of major postoperative complications was low, with no differences in rate among the various groups. Our results indicate that the use of small caliber Foley catheters is associated with a low incidence of urethral strictures following coronary artery bypass graft surgery; and when indicated, this type of surgery can be performed with other methods of bladder drainage without increased morbidity.     

EuroSCORE predicts health-related quality of life after coronary artery bypass grafting

Three hundred and two patients were evaluated for the EuroSCORE risk and health-related quality of life (HRQoL) during three years after CABG as assessed by the 15D instrument. Both additive and logistic EuroSCORE correlated significantly with the 15D score at 6, 18 and 36 months. A clinically important increase > or =0.03 in the 15D score was achieved by 50.6% of patients at 6 months, 40.0% at 18 months and 35.9% at 36 months. The rates were similar among patients with increasing EuroSCORE at 6 and 18 months, but tended to decrease at 36 months in the highest EuroSCORE group (EuroSCORE 0-2: 46.8%; 3-5: 34.8%; and 6-14: 33.3%, respectively, P=0.13). Both additive (area under the receiver operating characteristic curve, AUC: 0.582, P=0.024) and logistic EuroSCORE (AUC: 0.575, P=0.039) were predictors of a significant increase of the 15D score. The best cut-off value of the additive EuroSCORE for prediction of a clinically important improvement of the 15D score during 3-year follow-up was 3, as 46.7% of patients with EuroSCORE 0-3 and 30.1% of patients with a score >3 (P=0.006) improved clinically. The present study showed that the EuroSCORE also predicts long-term HRQoL after CABG.     

Perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Two patients in whom myocardial infarction in the inferior wall occurred after off-pump coronary artery bypass grafing (OPCAB) are described. In both patients, the right coronary artery had no critical lesion and was not grafted. There was no ischemic episode during operation. Coronary artery spasms and/or intracoronary thrombus formation may have been causes of these events. To our knowledge, this is the first report on perioperative myocardial infarction in OPCAB.     

Predictors of cognitive decline following coronary artery bypass graft surgery

BACKGROUND: A significant number of patients develop cognitive impairment that persists for months following coronary artery bypass grafting (CABG) surgery. Our objectives were to identify patient-related risk factors, processes of care, and the occurrence of any perioperative complications associated with cognitive decline. METHODS: Nine hundred thirty-nine patients enrolled in the Processes, Structures, and Outcomes of Care in Cardiac Surgery study undergoing CABG-only surgery at 14 Veterans Administration medical centers between 1992 and 1996 completed a short battery of cognitive tests at baseline and 6-months post-CABG. The composite cognitive score was based on the sum of errors for each individual item in the battery. Multiple linear regression analyses were used to identify independent predictors of the 6-month composite cognitive score. RESULTS: In multivariable analyses, patient characteristics associated with cognitive decline included cerebrovascular disease (p = 0.009), peripheral vascular disease (p = 0.007), history of chronic disabling neurologic illness (p = 0.016), and living alone (p = 0.049), while the number of years of education (p = 0.001) was inversely related to cognitive decline. After adjustment for baseline patient risk factors, the presence of any postoperative complication(s) (p = 0.001) was also associated with cognitive decline while cardiopulmonary bypass time (p = 0.008) was inversely related to cognitive decline. CONCLUSIONS: Patients with noncoronary manifestations of atherosclerosis, chronic disabling neurologic illness, or limited social support are at risk for cognitive decline after CABG surgery. In contrast, more years of education were associated with less cognitive decline. Preoperative assessment of risk factors identified in this study may be useful when counseling patients about the risk for cognitive decline following CABG surgery.     

Epsilon-aminocaproic acid administration and stroke following coronary artery bypass graft surgery.

BACKGROUND: Epsilon-aminocaproic acid is routinely used to reduce bleeding during cardiac surgery. Anecdotal reports of thrombotic complications have led to speculation regarding this drug's safety. We investigated the association between epsilon-aminocaproic acid administration and postoperative stroke. METHODS: Six thousand two hundred ninety-eight patients undergoing isolated coronary artery bypass graft surgery between 1989 and 1995 were studied. Data was obtained from the Duke Cardiovascular Database as well as from an automated intraoperative anesthesia record keeper. Patients identified as having postoperative stroke were reviewed and confirmed by a board certified neurologist blinded to epsilon-aminocaproic acid administration. RESULTS: Postoperative stroke occurred in 97 patients (1.5%). Three thousand one hundred thirty-five (49.8%) patients received epsilon-aminocaproic acid. Increased age was associated with a higher incidence of postoperative stroke (p = 0.0001). In contrast, there was no significant difference (p = 0.7370) in the incidence of stroke between use of epsilon-aminocaproic acid (1.3%) and nonuse (1.7%). Multivariable logistic regression found no significant effect of epsilon-aminocaproic acid use on stroke after accounting for age, date of surgery, and history of diabetes. CONCLUSIONS: This series suggests that epsilon-aminocaproic acid administration does not increase the risk of postoperative stroke.