Predictors of hospital readmission two years after coronary artery bypass grafting.

OBJECTIVE: To determine the clinical factors before, and in association with, coronary artery bypass grafting (CABG) that increase the risk of readmission to hospital in the first two years after surgery. PATIENTS: All patients in western Sweden who had CABG without simultaneous valve surgery between 1 June 1988 and 1 June 1991. METHODS: All patients who were readmitted to hospital were evaluated by postal inquiry and hospital records. RESULTS: A total of 2121 patients were operated on, of whom 2037 were discharged from hospital. Information regarding readmission was missing in four patients, leaving 2033 patients; 44% were readmitted to hospital. The most common reasons for readmission were angina pectoris and congestive heart failure. There were 12 independent significant predictors for readmission: clinical history (a previous history of either congestive heart failure or myocardial infarction, or CABG); acute operation; postoperative complications (time in intensive care unit greater than two days, neurological complications); clinical findings four to seven days after the operation (arrhythmia, systolic murmur equivalent to mitral regurgitation); medication four to seven days after the operation (antidiabetics, diuretics for heart failure, other antiarrhythmics (other than beta blockers, calcium antagonists, and digitalis), and lack of treatment with aspirin). CONCLUSION: 44% of patients were readmitted to hospital two years after CABG. The most common reasons for readmission were angina pectoris and congestive heart failure. Four clinical markers predicted readmission: clinical history; acute operation status; postoperative complications; and clinical findings and medication four to seven days after operation.     

不停跳与体外循环下冠状动脉旁路移植术对患者心肌和肾功能影响的对比研究

目的 探讨不停跳下行冠状动脉旁路移植术(CABG)与体外循环下行CABG对患者心肌和肾功能影响.方法 将2015年1月至2018年1月间陕西省汉中市中心医院收治的100例冠心病患者随机分为不停跳组(50例)和体外循环组(50例)分别在不停跳下行冠状动脉旁路移植术(OPCABG)与体外循环下冠状动脉旁路移植术(CCABG...     

冠状动脉旁路移植术后中期患者生命质量研究

目的 运用3个国外的生命质量(QOL)问卷对我院接受冠状动脉旁路移植术的患者进行QOL的研究,检验所使用问卷的信度和效度,并分析影响QOL的因素.方法 选择2001年1月至2002年1月于我院接受冠状动脉旁路移植术的患者,以书信的形式对287例患者发送QOL问卷,对问卷进行信度和效度的分析,并对影响QOL的因素进行分析.结果 共有273例患者寄回了问卷,3个QOL问卷的信度分析结果内部一致性系数分别为0.81、0.75、0.78.3个QOL问卷的结构效度分析结果显示存在不同程度的统计学相关性.对影响QOL的相关因素分析,3个问卷均提示术前加拿大心血管学会(CCS)心绞痛分级较严重患者的QOL低于术前CCS心绞痛分级较轻微患者的QOL.其中西雅图心绞痛问卷的"活动能力"、"疾病主观感受"亚组以及诺丁汉健康问卷的"社会孤独感"、"活动能力"亚组差异明显.结论 术前CCS心绞痛分级是影响冠状动脉旁路移植术后患者QOL的因素.     

冠状动脉搭桥围术期急性心肌梗死紧急再搭桥

目的：回顾性分析冠状动脉搭桥围术期急性心肌梗死急诊再搭桥的临床经验。方法：在510例冠状动脉搭桥患中，5例患在术后4h内因急性心肌梗死需急诊再搭桥，发生率0．98％。5例患中，男女比例为4：1，年龄56－77岁（平均63．6岁），均为冠状动脉三支血管病变（3例伴左主干病变），手术中搭桥3－5支（人均搭桥3．6支），左乳内动脉桥5根，其余为大隐静脉桥。2例在关胸后20min，3例在回重症监护病房后2－4h出现急性心肌缺血表现（明显心电图ST－T变化），伴室颤2例，5例血液动力学均不稳定，药物处理难以稳定血液动力学。全部患均立即送手术室（2例仍在手术室），急诊再次开胸。探查发现，2例患静脉桥（分别搭桥到回旋支第二钝缘支和右冠状动脉后降支）内急性血栓形成；另3例所有静脉桥良好，但左室前壁收缩运动明显减弱，结合心电图变化，诊断为左乳内动脉灌注不良。重新建立体外循环，清除桥内血栓重新搭桥2例（1例在非体外循环心脏跳动下进行）；另取一段静脉搭桥到左乳内动脉－左前降支吻合口远端的左前降支3例。结果：5例患顺利度过手术，均置入主动脉内球囊反搏，支持22－25h（平均42h）。手术后呼吸机支持4h－18d（平均7．3d）合并消化道出血4例，肾功能不全2例，肺部感染2例，切口感染1例。手术后住院时间12－35d，平均21d。全组均痊愈出院。结论：冠状动脉搭桥围术期急性心肌梗死应重在预防。如怀疑桥有问题，急诊再搭桥是良好选择，但手术后并发症发生率明显增加。     

Serial angiographic follow-up beyond 10 years after coronary artery bypass grafting.

BACKGROUND: The long-term prognosis and serial angiographic follow-up beyond 10 years in patients who underwent coronary artery bypass grafting (CABG) have not been fully studied in Japan. METHODS AND RESULTS: In the present study data from 71 patients who underwent CABG before 1992 were analyzed. Thirty patients had a saphenous vein graft (SVG) only group, and the remaining 41 had a left internal thoracic artery graft to the left anterior descending coronary artery (LITA) group; 6 patients died from malignancy, which was the most common cause of death after CABG. The major adverse cardiac events (MACE) were defined as cardiac death, Q-wave or nonQ-wave myocardial infarction, and congestive heart failure. The MACE-free rate was significantly higher in the LITA group than in the SVG group (p < 0.05). However, among the patients with an ejection fraction < 0.40, there was no significant difference in MACE-free rate between the 2 groups. The LITA patency rate was significantly higher than that for SVG (p < 0.05) and the SVG patency rate was lower in the patients with hyperlipidemia (p < 0.05); cholesterol-lowering therapy improved the SVG patency rate. CONCLUSION: The long-term outcome of CABG was favorable, particularly if using an arterial graft. Although the patency rate was lower for the SVG than LITA, the patient's lipid profile might be an important factor in the SVG patency rate.     

Long-term exercise performance after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

In our first 169 consecutive patients admitted to undergo percutaneous transluminal coronary angioplasty (PTCA) serial bicycle ergometric exercise sessions were scheduled to assess long-term-exercise performance. In 160 of these 169 patients (95%) an average of seven ergometric measurements were available during a mean follow-up period of 29 months (range 1 to 60 months). Two groups were formed. One consisted of 132 patients in whom PTCA was successful and the other consisted of 28 patients with failure of PTCA who subsequently underwent coronary artery bypass grafting (CABG) either on an emergency basis (12 patients) or as an elective procedure (16 patients). Exercise performance was expressed as work capacity in watts according to the highest completed exercise stage. In the successful PTCA group the actual work capacities increased from 74 +/- 42 W (mean +/- SD) before PTCA to 122 +/- 47 W at the most recent follow-up examination. In patients who underwent emergency or elective CABG the respective figures were 73 +/- 34 or 65 +/- 37 W before surgery and 120 +/- 41 or 119 +/- 41 W at the most recent follow-up examination (p less than .005 for all preprocedure to postprocedure comparisons). Successful PTCA and CABG after failed PTCA improve work capacity significantly. Comparison of our results with those of surgical studies indicates that a failed attempt at PTCA before CABG does not compromise the functional outcome of the operation, regardless whether it is done on an emergency or on an elective basis.     

Elevated temporal lability of myocardial repolarization after coronary artery bypass grafting

Introduction

Ventricular arrhythmias are uncommon after coronary artery bypass grafting (CABG), but the incidence and mortality are high in certain subsets of patients during the early recovery after surgery. Elevated temporal lability of myocardial repolarization has been associated with sudden cardiac death. The aim of the current study was to explore temporal variability of myocardial repolarization during both early and longtime follow-up after CABG.

Methods and Results

Patients (n = 61) who had undergone CABG and healthy subjects (HS, n = 33) were examined. Electrocardiogram and beat-to-beat blood pressure were recorded at 5 weeks and 5 months after surgery. The QT variability index (QTVI) was calculated as the log ratio between the temporal variabilities of the QT and RR intervals. The QTVI and QT variances were elevated by 40% and 44%, whereas RR variances were reduced by 40% among patients 5 weeks after CABG compared to HS (−0.90 ± 0.59, 29 ± 30, and 1223 ± 1895 ms² vs −1.50 ± 0.29, 15 ± 16, and 2200 ± 2877 ms² for HS; P < .01 for all). The QTVI and QT variances decreased by 38% and 31% between 5 weeks and 5 months after CABG, whereas the RR variances increased by 51% (P < .01 for all). The QTVI values remained elevated among patients compared to HS at 5 months after CABG (P < .01), whereas QT and RR variances did not differ.

Conclusion

Elevated temporal lability of myocardial repolarization prevails particularly during the early recovery phase after CABG and may reflect increased susceptibility to ventricular arrhythmia.     

Impact of perioperative myocardial injury on early and long-term outcome after coronary artery bypass grafting.

AIMS: To establish the influence of perioperative myocardial injury on short- and long-term survival after coronary artery bypass grafting (CABG). METHODS AND RESULTS: The correlation of postoperative serum aspartate aminotransferase and creatine kinase MB to early cardiac-related death and to late survival was evaluated in 4911 patients who underwent CABG consecutively during a 6-year period. There were 93 early deaths (1.9%), 73 of them cardiac-related (1.5% of 4911). After a mean follow-up of 5 years, 409 additional deaths (8.5% of 4818) had occurred. Elevated enzyme levels on day 1 postoperatively highly increased the risk of early cardiac death (serum aspartate aminotransferase >or=2.35 microkat.l(-1): odds ratio 9.2; serum creatine kinase MB >or=61 microg.l(-1): odds ratio 6.0), and increased the risk of late death by approximately 50% (serum aspartate aminotransferase >or=2.35 microkat.l(-1): relative hazard 1.5; serum creatine kinase MB >or=61 microg.l(-1): relative hazard 1.4). This increased risk of death was independent of other risk factors and remained constant over time. CONCLUSIONS: Enzyme elevation after CABG implied an increased risk of both early and late death. The long-term effect persisted many years after surgery.     

Usefulness of a postoperative exercise test for predicting cardiac events after coronary artery bypass grafting.

The predictive value of a postoperative exercise test in terms of cardiac events after coronary artery bypass grafting (CABG) was prospectively studied in 231 consecutive patients. During a 5-year follow-up there were 28 cardiac events (12%), of which 15 were cardiac deaths (13 sudden), and 13 were nonfatal myocardial infarctions. There was no difference in the rate of graft patency between groups with and without cardiac events, but ejection fraction was lower in patients with than without events (51 +/- 16% vs 58 +/- 10%; p less than 0.05). Duration of the exercise test was shorter, and maximal work load was lower in patients with cardiac events (p less than 0.05 for both). The prevalence of greater than or equal to 1 mm ST-segment depression was 22% (symptomatic in 25%, and silent in 75%) and did not differ between groups with and without cardiac events. After adjustment for prognostic variables using the proportional hazards method, diuretic treatment (p = 0.007) and a low postoperative ejection fraction (p = 0.04) remained significant for predicting the risk of cardiac events within 5 years of CABG, but exercise duration and work load did not have any significant predictive value. Thus, the predictive value of a postoperative exercise test is limited, and signs of impaired left ventricular function are of greater significance for the 5-year prognosis after CABG than are those of myocardial ischemia.     

A comparison of the effects of strength and aerobic exercise training on exercise capacity and lipids after coronary artery bypass surgery

BACKGROUND: Coronary artery surgery improves symptoms and prognosis in patientswith angina. Aerobic exercise rehabilitation improves exercisecapacity and prognosis in cardiac patients. Strength exercisetraining has not been extensively studied. DESIGN: We studied the effects of 6 months aerobic and strength exercisetraining after coronary artery surgery in 81 men, mean age 57years. RESULT: Treadmill time(s) increased by l30·3 (95% confidenceinterval 467·4 to 214·2) in the aerobic group;by 83·1 (0·9 to l65·3) in the strengthgroup, and by 34·3 (–1 to 69·6 in the controlgroup (P=0·04 control versus aerobic) after 3 months;and by l96·4 (112·2 to 280·7) in the aerobicgroup, by 122·7 (37·7 to 207·6) in thestrength group and by 27 (– 40·4 to 94·4)in the control group (P=0·002, control versus aerobic,and P=0·03 control versus strength) after 6 months. Thelevel of fitness improved more in the strengthtrained group,and there was a minor reduction in body weight and degree offatness. There were no changes in lipoprotein levels. Aerobicexercise training causes early and sustained benefit in treadmillexercise capacity, while the effects of strength exercise trainingare later in onset. Exercise training alone did not influencelipid levels. CONCLUSION: Cardiac rehabilitation programmes should be comprehensive, includingadvice on diet and other risk factor modifications in additionto exercise sessions involving aerobic and strength trainingelements.     

The effects of aging after coronary arterial bypass grafting on the regulation of cardiac output during upright exercise

We examined the effects of age on cardiac performance and the mechanisms that regulate cardiac output during upright exercise in patients free of myocardial ischemia after coronary revascularization. There were 90 subjects, aged 36 to 75 years, of whom 27 were greater than or equal to 60 years. There were no age-related changes in resting heart rate, systolic blood pressure, left ventricular end-diastolic volume index, left ventricular end-systolic volume index, stroke volume index, cardiac index and left ventricular ejection fraction. There were, however, age-related changes in exercise capacity (y = 20 - 0.21x, r = -0.52, P less than 0.001); exercise heart rate (y = 185 - 1x, r = -0.42, P less than 0.001); exercise end-systolic volume index (y = 11 + 0.46x, r = 0.28, P less than 0.01) and exercise ejection fraction (y = 81 - 0.31x, r = -0.28, P less than 0.01). In a subgroup of 54 patients with comparable exercise workload (27 aged less than 60 and 27 greater than or equal to 60 years), the age-related differences in exercise end-systolic volume index, exercise ejection fraction and exercise cardiac index were not observed, but the exercise heart rate was still higher in the younger patients (y = 168 - 0.76x, r = -0.34, P less than 0.01). Thus, age modifies the compensatory mechanisms that regulate the cardiac output during exercise. Young and old patients alike show increases in end-diastolic volume and ejection fraction to maintain exercise cardiac output. The higher exercise heart rate in the younger subjects suggests a decrease in cardiac responsiveness to adrenergic stimulation associated with aging.     

Frequency and prognosis of emergency coronary artery bypass grafting after percutaneous coronary intervention for acute myocardial infarction

We evaluated the frequency and prognosis of emergency coronary artery bypass grafting (CABG) after percutaneous coronary intervention (PCI) for acute myocardial infarction in a large, multicenter registry of contemporary PCI. In this study, emergency CABG occurred in 2% of cases, and was associated with high in-hospital mortality (20%) and with a high incidence of stroke (8%), renal failure requiring dialysis (8.3%), and bleeding (63.3%).     

Onset of blood lactate accumulation exercise capacity, skeletal muscle fibers and metabolism before and after coronary artery bypass grafting

Male patients with effort angina were studied before (n = 7), 1 week, and 1 and 6 months (n = 6) after coronary artery bypass grafting (CABG) with 2 to 7 grafts. The test battery included graded exercise, which was performed until unbearable leg exertion or chest pain, or both, was present. Onsets of blood lactate accumulation, anginal pain, leg exertion and dyspnea were interpolated for either the lactate concentration 2 mmol X 1-1 or the ratings 2 on the Borg subjective intensity scale. Onsets of blood lactate accumulation and symptom-limited exercise capacity before surgery amounted to 58 and 100 W, respectively. The corresponding figures 6 months later were the same for onset of blood lactate accumulation, whereas symptom-limited exercise capacity had increased by 58%. Blood lactate was the same at rest and mild exercise (congruent to onset of blood lactate accumulation) but more than doubled at symptom-limited exercise capacity (peak blood lactate concentration). Muscle fiber typing showed a low figure for the slow twitch fiber proportion (35%), which was unchanged after 6 months. Fast twitch subtype C was elevated before (7%) but disappeared after surgery, and fast twitch subtype A percent increased correspondingly. The major muscle biochemical changes were in the glycogenolytic pathway and the lactate dehydrogenase enzyme system, which appeared to increase in a quantitative manner, but with an unchanged relative lactate dehydrogenase isozyme pattern. The increased symptom-limited exercise capacity was related to the increased glycogenolytic activity and peak blood lactate (i.e., increased "anaerobic power"). Whether the causative explanation was the relief from chest pain, i.e., a psychophysiologic feature or the biochemical changes that took place in the muscle could only be speculated on.     

Effects of five years of cardiac rehabilitation after coronary artery bypass grafting on coronary risk factors

In conclusion, the long-term impact of a standard cardiac rehabilitation program on serum lipids, blood pressures, exercise habits, and smoking is modest in unselected patients undergoing elective CABG.     

Effects of curcuminoids on frequency of acute myocardial infarction after coronary artery bypass grafting

It is well established that myocardial infarction (MI) associated with coronary artery bypass grafting (CABG) predicts a poor outcome. Nevertheless, cardioprotective therapies to limit myocardial injury after CABG are lacking. Previous studies have shown that curcuminoids decrease proinflammatory cytokines during cardiopulmonary bypass surgery and decrease the occurrence of cardiomyocytic apoptosis after cardiac ischemia/reperfusion injury in animal models. We aimed to evaluate whether curcuminoids prevent MI after CABG compared to placebo. The 121 consecutive patients undergoing CABG were randomly allocated to receive placebo or curcuminoids 4 g/day beginning 3 days before the scheduled surgery and continued until 5 days after surgery. The primary end point was incidence of in-hospital MI. The secondary end point was the effect of curcuminoids on C-reactive protein, plasma malondialdehyde, and N-terminal pro-B-type natriuretic peptide levels. Baseline characteristics were comparable between the curcuminoid and placebo groups. Mean age was 61 ± 9 years. On-pump CABG procedures were performed in 51.2% of patients. Incidence of in-hospital MI was decreased from 30.0% in the placebo group to 13.1% in the curcuminoid group (adjusted hazard ratio 0.35, 0.13 to 0.95, p = 0.038). Postoperative C-reactive protein, malondialdehyde, and N-terminal pro-B-type natriuretic peptide levels were also lower in the curcuminoid than in the placebo group. In conclusion, we demonstrated that curcuminoids significantly decreased MI associated with CABG. The antioxidant and anti-inflammatory effects of curcuminoids may account for their cardioprotective effects shown in this study.