Off-pump coronary artery bypass grafting: initial experience at one community hospital

BACKGROUND: This study reports one cardiac surgical center's experience with off-pump coronary artery bypass (OPCAB) and compares clinical risk factors and outcomes with a group of patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass at the same institution. METHODS: Data on preoperative risk factors, intraoperative clinical markers, and postoperative outcomes were collected prospectively on all patients undergoing cardiac surgical procedures at our institution. From January 1, 1999, through October 7, 1999, 332 patients underwent OPCAB procedures at our institution. This group was compared with 445 consecutive patients undergoing CABG at the same institution during the period of January 1, 1998, through November 30, 1998. RESULTS: The two groups were similar with respect to preoperative clinical risk factors. Intraoperative data showed OPCAB patients tended to have fewer grafts performed and had a lower frequency of multiple grafts to obtuse marginal vessels. Outcomes showed no differences in the incidence of perioperative stroke, mediastinitis, reexploration for bleeding, pulmonary complications, new renal failure, postoperative atrial fibrillation, or transfusion of blood products. Patients in the OPCAB group had fewer perioperative myocardial infarctions and lower incidence of postoperative low cardiac output syndrome. A higher percentage of OPCAB patients had surgical lengths of stay of 5 days or less. The OPCAB group tended to have a lower in-hospital mortality rate but this difference did not reach statistical significance. CONCLUSIONS: Off-pump coronary artery bypass grafting with revascularization of all coronary artery segments is a safe and effective procedure that can be performed with equal or improved outcomes and shorter surgical lengths of stay compared with CABG with cardiopulmonary bypass.     

On- and off-pump coronary surgery and perioperative myocardial infarction: an issue between incomplete and extensive revascularization.

OBJECTIVE: Complete myocardial revascularization is the standard for coronary artery bypass grafting. It has been shown, however, that off-pump coronary bypass surgery (OPCAB) may reduce completeness of revascularization without affecting perioperative myocardial infarction rates. We evaluated the influence of OPCAB on major postoperative events in a large consecutive cohort of patients, with special emphasis on risk factors for perioperative myocardial infarction. METHODS: From 1995 to 2004, 5935 patients underwent isolated coronary bypass surgery; of these, 4623 (77.9%) and 1312 (22.1%) underwent on-pump coronary surgery (CABG) and OPCAB, respectively. Patients undergoing OPCAB were matched to patients undergoing CABG by propensity score; logistic regression analysis models were used to study predictors of perioperative myocardial infarction. RESULTS: In matched pairs, postoperative mortality, myocardial infarction, stroke, and atrial fibrillation were similar between groups, while reoperation for bleeding, time on ventilator and red blood cell use were lower in patients undergoing OPCAB. The number of distal anastomoses was lower in patients undergoing OPCAB (2.2+/-0.80 in OPCAB vs 2.9+/-0.86 in CABG, p<0.001), as well as complete revascularization rates (61.9% in OPCAB vs 90.0% in CABG, p<0.001). Multivariate analyses, performed on preoperative and intraoperative variables, showed that both incomplete revascularization and increasing numbers of distal anastomoses (even when controlling for completeness of revascularization) were significant predictors of perioperative myocardial infarction, while CABG/OPCAB strategy did not influence it. CONCLUSIONS: The choice of surgical technique did not influence the occurrence of major perioperative complications and of myocardial infarction, which is negatively affected by incomplete or too extensive revascularization strategies.     

Cerebral dysfunction after coronary artery bypass surgery

Cerebral dysfunction after cardiac surgery remains a devastating complication and is growing in importance with our aging populations. Neurological complications following cardiac surgery can be classified broadly as stroke, encephalopathy (including delirium), or postoperative cognitive dysfunction (POCD). These etiologies are caused primary by cerebral emboli, hypoperfusion, or inflammation that has largely been attributed to the use of cardiopulmonary bypass. Preventative operative strategies, such as off-pump coronary artery bypass grafting (CABG), can potentially reduce the incidence of postoperative neurological complications by avoiding manipulation of the ascending aorta. Although off-pump CABG is associated with reduced risk of stroke, there are no convincing differences in POCD between off-pump and on-pump CABG. Recently, the focus of postoperative neurological research has shifted from managing cardiopulmonary bypass to patient-related factors. Identifying changes in brains of aged individuals undergoing cardiac surgery may improve strategies for preventing cerebral dysfunction. Advanced age is associated with more undiagnosed cerebrovascular disease and is a major risk factor for stroke and POCD following cardiac surgery. Preoperative cerebrovascular evaluation and adaptation of surgical strategies will provide preventative approaches for cerebral dysfunction after CABG. This review focuses on recent findings of the relationship between perioperative stress and underlying fragility of the brain in cardiac surgical patients.     

Stroke after cardiac surgery: a risk factor analysis of 16,184 consecutive adult patients

BACKGROUND: Stroke remains a devastating complication after cardiac surgical procedures despite advances in perioperative monitoring and management. The purpose of this study was to determine the predictors of stroke in a large, contemporary cardiac surgery population. METHODS: Prospective data on 16,184 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting [CABG], n = 8,917; beating heart CABG, n = 1,842; aortic valve surgery, n = 1,830; mitral valve surgery, n = 708; double or triple valve surgery, n = 381; CABG and valve surgery, n = 2,506) between April 1996 and August 2001 were subjected to univariate and multivariate analysis. Stroke was defined as any new permanent (manifest stroke) or temporary neurologic deficit or deterioration (transient ischemic attack or prolonged reversible ischemic neurologic deficit) and was confirmed by computed tomography or magnetic resonance imaging whenever possible. RESULTS: Overall incidence of stroke was 4.6% and varied between surgical procedures (CABG 3.8%; beating-heart CABG 1.9%; aortic valve surgery 4.8%; mitral valve surgery 8.8%; double or triple valve surgery 9.7%; CABG and valve surgery 7.4%). Of 63 patient-specific and treatment variables, 54 were found to have a significant univariate association with postoperative stroke. Multivariable analysis revealed 10 variables that were independent predictors of stroke: history of cerebrovascular disease, peripheral vascular disease, diabetes, hypertension, previous cardiac surgery, preoperative infection, urgent operation, CPB time more than 2 hours, need for intraoperative hemofiltration, and high transfusion requirement. Beating heart CABG was associated with a lower incidence of stroke in this multivariable analysis. CONCLUSIONS: Identification of predictors for stroke is important for understanding the pathogenesis of this devastating complication as well as for developing preventative strategies. Although retrospective analyses can be subject to selection bias we believe beating heart CABG is associated with a lower incidence of stroke and may therefore improve patient outcomes.     

Thrombophilia in Cardiac Surgery—Patients with Symptomatic Factor V Leiden

Abstract   Background and aim of the study: Thrombophilia may cause severe complications in cardiac surgical patients. We analyzed our experience with symptomatic factor V Leiden patients. Methods: Over an eight-year period, 14 symptomatic patients previously diagnosed with activated protein C resistance, caused by factor V Leiden, underwent a cardiac surgical procedure. We retrospectively reviewed the clinical data, operative and postoperative courses, and the intermediate-term results of these patients. Results: Procedures performed were coronary artery bypass grafting (CABG, 10 patients), aortic valve replacement + CABG, pulmonary thromboendarterectomy, left ventricular thrombus removal, and aortic valve reconstruction (one patient each). Eleven patients survived; three patients died perioperatively, one from sepsis (25 days after surgery), one from recurrent stroke (28 days after surgery), and one from multiorgan failure following perioperative stroke (31 days after surgery). In one patient, all bypass grafts occluded intraoperatively. Three patients underwent cardiac surgery under continuous anticoagulation with phenprocoumon. In these three patients, no perioperative thromboembolic events occurred. At a mean follow-up of 32 months, three patients had suffered from cerebral stroke, two from graft occlusion, of which one was recurrent. Two more patients had died (one after cerebral stroke and one from cerebral metastases of a renal cell carcinoma). Conclusion: In 14 patients with symptomatic factor V Leiden who underwent cardiac surgery, we observed a considerable number of fatal and nonfatal thromboembolic events in the perioperative period and during a 32 months' follow-up. As conducted in three patients, continued anticoagulation with coumarin was safe and prevented perioperative thromboembolic events.     

Predictors of atrial fibrillation in patients undergoing surgery for ischemic heart disease

OBJECTIVES: Atrial fibrillation (AF) remains a common problem after cardiac surgery. AF increases the risk for stroke and is associated with increased length of hospitalization. The aim of this study was to analyze risk factors for postoperative AF in a uniformly managed cohort of patients. DESIGN: The records of 775 consecutive patients undergoing coronary artery bypass grafting (CABG) or CABG + valve procedures were examined. Forward stepwise multiple logistic regression analysis was used for statistical evaluation. RESULTS: Mean age was 64.6 +/- 8.7 years. The incidence of AF was 29.1% in patients undergoing isolated CABG and 48.6% after CABG + valve procedures. Multivariate analysis identified advanced age (p = 0.000003), low postoperative mixed venous oxygen saturation (p = 0.0018), hypertension (p = 0.0059), preoperative history of AF (p = 0.023) and the need for mechanical circulatory support (p = 0.030) as predictors for postoperative AF. CONCLUSIONS: In agreement with previous studies, advanced age was the most important predictor of AF. Hypertension, history of AF and signs of circulatory failure were also predictive of AF. Preventive measures against AF should preferably be tested in high-risk populations, such as elderly patients.     

Applications of statins in cardiothoracic surgery: more than just lipid-lowering.

Statins exert several actions in cardiothoracic surgical procedures besides lipid-lowering. In patients undergoing coronary artery bypass grafting (CABG), statins improve bypass graft patency, perioperative as well as long-term mortality rates. In addition, statins reduce the number of postoperative complications and clinical events, revascularization rates and postoperative hospital stay (as well as associated costs). Furthermore, they are protective against de novo atrial fibrillation and renal dysfunction following CABG. In cardiac transplantation, statins decrease cardiac allograft vasculopathy and cardiac rejection rates. They are also associated with a significant reduction in mortality rates in cardiac transplant patients. According to the results of a meta-analysis, statins are associated with one life saved for every 8.5 heart transplant recipients treated for 1 year. Alternatively, routine statin treatment in cardiac transplant patients might have the potential to save 471 lives each year among the 4000 heart transplantation operations performed worldwide. The results from several studies suggest that statins may also play a role in heart valve surgery, lung transplantation, pulmonary resection and thoracic aortic aneurysm repair. Statin use is safe and cost-effective. Despite the multiple beneficial effects of statin therapy, there is evidence suggesting that a large percentage of cardiothoracic surgical patients are suboptimally treated with respect to statins. Risk management in these patients should be improved to reduce cardiovascular morbidity and mortality rates.     

七氟醚和异丙酚对冠状动脉旁路移植术患者心肌保护作用比较的Meta分析

目的 采用Meta分析法比较七氟醚和异丙酚对冠状动脉旁路移植术患者心肌的保护作用.方法 通过电子数据库检索比较冠状动脉旁路移植术患者七氟醚和异丙酚心肌保护作用的临床随机对照研究,文献检索至2008年9月.由两位作者分别对研究质量进行评估,并提取有关资料,主要包括患者术前情况、术中情况、体外循环后心脏指数、术后心肌肌钙蛋白Ⅰ水平、机械通气时间、正性肌力药物使用情况、ICU停留时间、住院时间、术后死亡、心肌梗死、心肌缺血和房颤的发生情况,采用RevMan 5.0软件进行Meta分析.结果 共纳入13项前瞻性临床随机对照研究,包括696例患者,其中七氟醚组402例,异丙酚组294例.两组患者术后机械通气时间、正性肌力药物使用率、术后病死率、心肌梗死和房颤的发生率差异无统计学意义(P>0.05).与异丙酚组相比,七氟醚组患者体外循环后心脏指数升高,术后心肌肌钙蛋白Ⅰ水平和心肌缺血发生率降低,ICU停留时间和住院时间缩短(P<0.05).结论 冠状动脉旁路移植术患者七氟醚的心肌保护作用优于异丙酚.     

How to avoid problems in redo coronary artery bypass

BACKGROUND: Redo cardiac surgery still carries higher mortality and increased morbidity as compared with primary coronary revascularizations. Various steps can be taken to decrease the incidences of adverse outcomes. From our experience, we have accumulated safe steps to be taken during the surgical procedure to reach a positive outcome. METHODS: We reviewed our own experience of redo coronary artery bypass surgery (CABG) at two institutions during the last 4 years. Though the surgeons were the same at both institutions, because of institutional variability of patient referrals, operative equipment, anesthesia management, and preoperative care, we kept the data separate. Five surgeons performed CABG with almost similar myocardial preservation techniques; however, the surgical skill varied slightly depending on the seniority and clinical experience. We performed 433 redo coronary artery revascularizations at one institution and 201 in the second institution. Fifteen percent of these patients also had additional procedures, such as valve repair, valve replacement, or aneurysm resection. In this patient group, 160 patients underwent either urgent or emergent CABG. Urgent surgery was defined as patient revascularization during the same admission as cardiac catheterization, and emergency surgery was defined as a patient undergoing surgery on the same day as the catheterization, especially when hemodynamic instability was present. The total mortality was 7%, while the elective redo CABG mortality was 3%. The length of stay ranged from 8.5 to 12.6 days. The morbidity included perioperative stroke in 18 patients and nonfatal perioperative myocardial infarction (MI) in 19 patients. Major factors contributing to the mortality were stroke, perioperative bleeding and exploration, renal failure, respiratory failure, and malnutrition. CONCLUSION: We outlined the precautions and safe surgical approaches to be undertaken during redo CABG for a successful outcome.     

How to Avoid Problems in Redo Coronary Artery Bypass

ABSTRACT Background: Redo cardiac surgery still carries higher mortality and increased morbidity as compared with primary coronary revascularizations. Various steps can be taken to decrease the incidences of adverse outcomes. From our experience, we have accumulated safe steps to be taken during the surgical procedure to reach a positive outcome. Methods: We reviewed our own experience of redo coronary artery bypass surgery (CABG) at two institutions during the last 4 years. Though the surgeons were the same at both institutions, because of institutional variability of patient referrals, operative equipment, anesthesia management, and preoperative care, we kept the data separate. Five surgeons performed CABG with almost similar myocardial preservation techniques; however, the surgical skill varied slightly depending on the seniority and clinical experience. We performed 433 redo coronary artery revascularizations at one institution and 201 in the second institution. Fifteen percent of these patients also had additional procedures, such as valve repair, valve replacement, or aneurysm resection. In this patient group, 160 patients underwent either urgent or emergent CABG. Urgent surgery was defined as patient revascularization during the same admission as cardiac catheterization, and emergency surgery was defined as a patient undergoing surgery on the same day as the catheterization, especially when hemodynamic instability was present. The total mortality was 7%, while the elective redo CABG mortality was 3%. The length of stay ranged from 8.5 to 12.6 days. The morbidity included perioperative stroke in 18 patients and nonfatal perioperative myocardial infarction (MI) in 19 patients. Major factors contributing to the mortality were stroke, perioperative bleeding and exploration, renal failure, respiratory failure, and malnutrition. Conclusion: We outlined the precautions and safe surgical approaches to be undertaken during redo CABG for a successful outcome.     

Effects of Aprotinin During Cardiopulmonary Bypass in Patients Treated with Acetylsalicylic Acid

Abstract

Objectives. To assess preoperative depression in middle-aged men undergoing coronary artery bypass graft surgery (CABG) and to determine if depression is related to perioperative outcomes. Design. One hundred and nine middle-aged male patients were randomly selected and assessed for depression one day before CABG using the Symptom Checklist-90 Revised (SCL-90R). Perioperative outcomes were: (1) postoperative length of hospital stay, (2) the presence of any early complications (at intensive care unit), and (3) the presence of any late complications (at cardiac surgery unit). Results. Twenty-five (23%) patients had a high level of depression. Preoperative depression scores significantly predicted postoperative length of hospital stay (p<0.001) and the incidence of late perioperative complications (p<0.05) independently from biomedical and sociodemographic factors. Each increase in depression T score increased the odds of occurrence of late complications by 10% (p=0.018, CI 95% 1.02–1.19). Conclusions. Depression is common in middle-aged men undergoing CABG and is an independent predictor of postoperative length of hospital stay and late perioperative complications.     

Anesthetic and surgical factors affecting open heart surgery patients leading to cerebrovascular accident--retrospective study at King Khalid University Hospital.

Stroke after coronary bypass grafting (CABG) is often disabling. The incidence of ischemic stroke may approach 3% to 5%. Several risk factors have been identified including previous history of stroke, prolonged cardiopulmonary bypass time, and postoperative atrial fibrillation. Retrospective study during the period 1992-1995 was undertaken to determine the incidence, risk factors of neurological deficit after open-heart surgery at King Khalid University Hospital, Riyadh, Saudi Arabia. There were 350 patients who were subjected to CABG, 10 patients (2.8%) were found to suffer from cerebrovascular accidents (CVA) following open-heart surgery. In 18 patients, the complaint lasted more than 24 hours (stroke), while 2 patients developed transient ischemic attacks (TIA). Five factors were found to be associated with increased risk of post cardiac surgery CVA. These factors are postoperative atrial fibrillation, carotid bruit, past history of heart failure, past history of CVA and smoking. The authors concluded that it is necessary to start a prospective study to verify the area of improvement with regards to technique, selection of patients and mode of perfusion during cardiopulmonary bypass (CPB).     

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.     

Does intensive perioperative dialysis improve the results of coronary artery bypass grafting in haemodialysed patients?

BACKGROUND: Between January 1996 and April 1998, 17 chronic haemodialysed patients underwent coronary artery bypass grafting (CABG). Two of them simultaneously had valve replacement. METHODS: Except for two cases in which CABG was performed in an emergency, 15 patients (CRF group) received 3 consecutive days of haemodialysis in the preoperative period, intraoperative haemodialysis connected to cardiac pulmonary bypass (CPB) and continuous hemodiafiltration in the early postoperative period. The perioperative clinical parameters of the CRF group were compared with those of 17 age-matched patients with normal renal function undergoing CABG as the control (NRF group). RESULTS: When the perioperative variables were compared, no significant differences were seen in total operation time and CPB time, but we noted significant increases in the mean volume of transfused blood in the 6 perioperative days, postoperative intubation time, postoperative fasting time, and time spent in the intensive care unit. Levels of central venous pressure, systolic blood pressure, respiratory index (PaO2/FiO2) and daily fluid balance of the CRF group were the same as the control group in the early postoperative period. In addition, the levels of serum creatinine, urea nitrogen, potassium and hematocrit of CRF group remained almost constant in the early postoperative period. After all, the hospital morbidity of the CRF group was not more serious than that of the NRF group, and hospital mortality of the CRF and NRF groups was 0%. CONCLUSIONS: Our intensive perioperative dialysis programme could successfully manage the perioperative clinical course of haemodialysed patients undergoing CABG.     

Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery

BACKGROUND: Patients undergoing vascular surgical procedures are at high risk for perioperative myocardial infarction (PMI). This study was undertaken to identify predictors of PMI and in-hospital death in major vascular surgical patients. METHODS: From the Vascular Surgery Registry (6,948 operations from January 1989 through June 1997) the authors identified 107 patients in whom PMI developed during the same hospital stay. Case-control patients (patients without PMI) were matched at a 1x:x1 ratio with index cases according to the type of surgery, gender, patient age, and year of surgery. The authors analyzed data regarding preoperative cardiac disease and surgical and anesthetic factors to study association with PMI and cardiac death. RESULTS: By using univariable analysis the authors identified the following predictors of PMI: valvular disease (P = 0.007), previous congestive heart failure (P = 0.04), emergency surgery (P = 0.02), general anesthesia (P = 0.03), preoperative history of coronary artery disease (P = 0.001), preoperative treatment with beta-blockers (P = 0.003), lower preoperative (P = 0.03) and postoperative (P = 0.002) hemoglobin concentrations, increased bleeding rate (as assessed from increased cell salvage; P = 0.025), and lower ejection fraction (P = 0.02). Of the 107 patients with PMI, 20.6% died of cardiac cause during the same hospital stay. The following factors increased the odds ratios for cardiac death: age (P = 0.001), recent congestive heart failure (P = 0.01), type of surgery (P = 0.04), emergency surgery (P = 0.02), lower intraoperative diastolic blood pressure (P = 0.001), new intraoperative ST-T changes (P = 0.01), and increased intraoperative use of blood (P = 0.005). Patients who underwent coronary artery bypass grafting, even more than 12 months before index surgery, had a 79% reduction in risk of death if they had PMI (P = 0.01). Multivariable analysis revealed preoperative definitive diagnosis of coronary artery disease (P = 0.001) and significant valvular disease (P = 0.03) were associated with increased risk of PMI. Congestive heart failure less than 1 yr before index vascular surgery (P = 0. 0002) and increased intraoperative use of blood (P = 0.007) were associated with cardiac death. The history of coronary artery bypass grafting reduced the risk of cardiac death (P = 0.04) in patients with PMI. CONCLUSIONS: The in-hospital cardiac mortality rate is high for patients who undergo vascular surgery and experience clinically significant PMI. Stress of surgery (increased intraoperative bleeding and aortic, peripheral vascular, and emergency surgery), poor preoperative cardiac functional status (congestive heart failure, lower ejection fraction, diagnosis of coronary artery disease), and preoperative history of coronary artery bypass grafting are the factors that determine perioperative cardiac morbidity and mortality rates.     

Risk factors of stroke and delirium after off-pump coronary artery bypass surgery

Off-pump coronary artery bypass surgery (CABG) has not abolished the risk of postoperative stroke and delirium seen for on-pump CABG. Advanced arteriosclerotic changes are common in both on-pump and off-pump CABG. We sought to analyze if advanced arteriosclerotic changes are risk factors of stroke or transient ischemic attack (TIA), and delirium after off-pump CABG. Patients undergoing off-pump CABG between 2001 and 2005 were reviewed using medical records (n=685). Potential risk factors of postoperative stroke and delirium were identified from previous studies. Further, variables retrieved from carotid artery duplex scanning as indices of advanced arteriosclerosis, were examined. The incidences of postoperative stroke/TIA and delirium after off-pump CABG were 2.6% (n=18) and 16.4% (n=112), respectively. Carotid artery stenosis >50% was a significant risk factor of stroke or TIA (P=0.02) as well as delirium (P=0.04) after off-pump CABG. A history of atrial fibrillation (AF) (P=0.037) or diabetes mellitus (P=0.041) was a risk factors of postoperative stroke or TIA. In contrast, age over 75 years (P=0.006), creatinine >1.3 mg/dl (99 μmol/l) (P=0.011), a history of hypertension (P=0.001), past history of AF (P=0.024), and smoking (P=0.048) were significant risk factors of postoperative delirium.     

Contemporary incidence and risk factors for carotid artery disease in patients referred for coronary artery bypass surgery

ABSTRACT: BACKGROUND: In the past decade, there has been an increase in the amount of patients with medical co-morbidities referred for coronary artery bypass surgery (CABG). Significant carotid artery disease in patients undergoing CABG procedures increases the risk of neurological complications. We review the results of routine carotid screening in patients undergoing CABG to determine the contemporary incidence and risk factors for carotid artery disease. METHODS: Between 2008 through 2010, 673 patients were referred for isolated coronary artery bypass surgery at a single institution. Patients were identified through a systematic review of The Department of Cardiothoracic Surgery Society of Thoracic Surgery Outcomes Database. A retrospective analysis of prospectively collected demographic, clinical data and outcomes were performed. All patients with screening preoperative carotid duplex were reviewed. We defined the degree of carotid disease as: none to mild stenosis (<50%), moderate stenosis (50-69%), severe stenosis (70-99%). Multivariate analysis was performed to identify risk factors. RESULTS: 559 (83%) patients underwent screening preoperative carotid ultrasonography prior to CABG. The incidence of carotid artery disease (>50% stenosis) was 36% with 18% unilateral moderate disease, 10% bilateral moderate and 8% severe disease. Risk factors associated with carotid artery disease included: advanced age, renal failure, previous stroke, peripheral vascular disease, left main coronary artery disease, and previous myocardial infarction. CONCLUSIONS: There is a significant incidence of carotid artery stenosis in patients referred for CABG. Routine screening will identify patients with carotid artery disease and may reduce the risk of postoperative stroke.     

Predictors of stroke in the modern era of coronary artery bypass grafting: a case control study

BACKGROUND: Stroke is a rare but devastating complication after coronary artery bypass grafting (CABG) and its prevention remains elusive. We used a case control design to investigate the extent to which preoperative and perioperative factors were associated with occurrence of stroke in a cohort of consecutive patients undergoing myocardial revascularization. METHODS: From April 1996 to March 2001, data from 4,077 patients undergoing CABG were prospectively entered into a database. The association of preoperative and perioperative factors with stroke was investigated by univariate analyses. Factors observed to be significantly associated with stroke in these analyses were further investigated using multiple logistic regression to estimate the strength of the associations with the occurrence of stroke, after taking account of the other factors. RESULTS: During the study period, 4,077 patients underwent CABG and of these 923 (22.6%) had off-pump surgery. Forty-five patients suffered a perioperative stroke (1.1%). Overall there were 46 in-hospital deaths (1.1%), of whom 6 also suffered a stroke. Brain imaging of the stroke patients showed embolic lesions in 58%, watershed in 28%, and mixed in 14%. Multivariate regression analysis identified several preoperative factors as independent predictors of stroke, ie, age, unstable angina, serum creatinine greater than 150 mcg/ml, previous cerebrovascular accident (CVA), peripheral vascular disease (PVD), and salvage operation. When operative risk factors were added to the adjusted model, off-pump surgery was associated with a substantial, but not significant, protective effect against stroke (odds ratio = 0.56, 95% confidence interval 0.20 to 1.55). Survival for stroke patients was 93% and 78% at 1 and 5 years, respectively. CONCLUSIONS: Overall incidence of stroke is relatively low in our series. Age, unstable angina, previous CVA, PVD, serum creatinine greater than 150 mcg/ml, and salvage operation are independent predictors of stroke. These factors should be taken into account when informing each individual patient on the possible risk of stroke and in the decision-making process on the surgical strategy.     

Risk factors for late stroke after coronary artery bypass grafting

BACKGROUND: Postoperative stroke is a severe complication immediately after coronary artery bypass grafting, and it significantly deteriorates the postoperative quality of life if it occurs in the long term. It was the aim of our study to determine factors associated with the occurrence of new strokes during long-term follow-up after coronary artery bypass grafting. METHODS: From 387 of 500 patients undergoing coronary artery bypass grafting (age, 67 years [33-84 years]; 76% male) who had intraoperative epiaortic ultrasonography for assessment of ascending aortic wall thickness, a complete follow-up regarding postoperative stroke was achieved. The median follow-up time was 52 months (9-74 months). RESULTS: A stroke occurred in 26 (7%) of 387 patients, and the cumulative freedom from stroke was 99%, 95%, and 89% after 1, 3, and 5 years, respectively. A significantly lower freedom from stroke was present in patients with an age of 70 years or more (P = .007), preoperative unstable angina (P = .031), chronic obstructive pulmonary disease (P = .009), carotid artery disease (P < .001), preoperative history of neurologic events (P < .001), and a maximum ascending aortic wall thickness of 4 mm or more (P = .010). Multivariate analysis revealed preoperative history of neurologic events (P = .021) to be an independent risk factor. CONCLUSION: Patients with ascending aortic atherosclerosis, older age (> or =70 years), preoperative unstable angina, chronic obstructive pulmonary disease, and carotid artery disease are at risk for late postoperative stroke after coronary artery bypass grafting. A history of neurologic events is of special predictive importance.     

Effective surgical management of high-risk coronary patients using preoperative intra-aortic balloon counterpulsation therapy.

The proportion of high-risk coronary patients submitted to surgical myocardial revascularization (CABG) is steadily increasing. High-risk patients utilize more hospital resources and have a higher procedural cost than low-moderate risk CABG patients. An efficient management is essential to improve outcome and reduce costs. This report entails three study periods. In an initial retrospective study coronary high-risk criteria were established. At least two of the following factors were required: redo CABG, unstable angina, left main stem stenosis greater than 70%, preoperative left ventricular ejection fraction < 0.30 and diffuse coronary artery disease. Poor preoperative cardiac performance was the major contributing factor for poor outcome. Intra-aortic balloon counterpulsation therapy (IABP) was introduced as preoperative therapy. During a second study period prospective randomized studies found preoperative IABP-therapy efficient, significantly improving both preoperative cardiac index (P < 0.0001), decreasing postoperative mortality (P < 0.0001) and morbidity, shorten intensive care unit stay as well as total hospital stay (P < 0.0001). Drug consumption was significantly reduced (P < 0.0001). Optimal timing was found to be 2 h prior to aortic cross-clamping and the therapy was found highly cost-beneficial with an average 36% reduction of the total procedural cost. During a third study period, well beyond any study protocol period, preoperative IABP therapy was again found highly effective with a close to 100% utilization rate in high-risk patients and continuous efficacy with excellent outcome, despite acceptance of sicker patients. During this post-study evaluation period 1/3 of the high-risk patients presented with 4 of the established risk factors.The use of preoperative IABP therapy is therefore highly recommended for high-risk coronary patients undergoing CABG.