The effect of race on coronary bypass operative mortality

OBJECTIVES: The study was done to determine whether race is an independent predictor of operative mortality after coronary artery bypass graft (CABG) surgery. BACKGROUND: Blacks are less frequently referred for cardiac catheterization and CABG than are whites. Few reports have investigated the relative fate of patients who undergo CABG as a function of race. METHODS: The Society of Thoracic Surgeons National Database was used to retrospectively review 25,850 black and 555,939 white patients who underwent CABG-alone from 1994 through 1997. A multivariate logistic regression model was developed to determine whether race affected risk-adjusted operative mortality. RESULTS: Operative mortality was 3.83% for blacks versus 3.14% for whites (unadjusted black/white odds ratio [OR] 1.23 [1.15-1.31]). Blacks were younger, more likely female, hypertensive, diabetic and in heart failure. Nonetheless, the influence of these and other preoperative risk factors on procedural mortality was quite similar in black and white patients. After controlling for all risk factors, race remained a significant independent predictor of mortality in the multivariate logistic model (adjusted black/white OR 1.29 [1.21, 1.38]). Proportionately, these differences were greatest among lower-risk patients. The race-by-gender interaction was significant (p<0.05). The unadjusted mortality for black men, 3.30% and white men, 2.64% differed significantly (p<0.05), whereas for women there was no difference (black, 4.49%; white 4.41%). CONCLUSIONS: Black race is an independent predictor of operative mortality after CABG except for very high-risk patients. The difference in mortality is greatest for male patients and, though statistically significant, is small in absolute terms. Therefore, patients should be referred for CABG based on clinical characteristics irrespective of race.     

Metabolic syndrome increases operative mortality in patients undergoing coronary artery bypass grafting surgery.

OBJECTIVES: The aim of this study was to determine the impact of the metabolic syndrome (MS) on operative mortality after a coronary artery bypass grafting surgery (CABG). BACKGROUND: Diabetes and obesity are highly prevalent among patients undergoing CABG. However, it remains unclear whether these factors have a significant impact on operative mortality after this procedure. We hypothesized that the metabolic abnormalities associated with MS could negatively influence the operative outcome of CABG surgery. METHODS: We retrospectively analyzed the data of 5,304 consecutive patients who underwent an isolated CABG procedure between 2000 and 2004. Of these 5,304 patients, 2,411 (46%) patients met the National Cholesterol Education Program-Adult Treatment Panel III criteria for MS. The primary end point was operative mortality. RESULTS: The operative mortality after CABG surgery was 2.4% in patients with MS and 0.9% in patients without MS (p < 0.0001). The MS was a strong independent predictor of operative mortality (relative risk 3.04 [95% confidence interval (CI) 1.73 to 5.32], p = 0.0001). After adjusting for other risk factors, the risk of mortality was increased 2.69-fold (95% CI 1.43 to 5.06; p = 0.002) in patients with MS and diabetes and 2.36-fold (95% CI 1.26 to 4.41; p = 0.007) in patients with MS and no diabetes, whereas it was not significantly increased in the patients with diabetes and no MS. CONCLUSIONS: This is the first study to report that MS is a highly prevalent and powerful risk factor for operative mortality in patients undergoing a CABG surgery. Thus, interventions that could contribute to reduce the prevalence of MS in patients with coronary artery disease or that could acutely modify the metabolic perturbations of MS at the time of CABG might substantially improve survival in these patients.     

Simultaneous coronary artery bypass grafting and carotid endarterectomy can be performed with low mortality rates

There is controversy over the best approach for patients with concomitant carotid and coronary artery disease.1 Therapeutic strategies include isolated coronary artery bypass grafting (CABG), staged carotid endarterectomy (CEA) and CABG, reversed staged CEA and CABG, and simultaneous procedures under single anaesthesia.2Although reported experiences over three decades are available, combining CEA with CABG remains to be elucidated.3 Furthermore, risk of cerebrovascular accident (CVA), which is one of the major predictors of prognosis of CABG, has been reported to increase up to 14% in patients with severe carotid artery stenosis (> 80%).4-9Peri-operative neurological events such as stroke after CABG are the major neurological complications, which increase with age.10 The incidence of peri-operative stroke has been well documented at approximately 2% of all cardiac surgeries.11 Despite reduced overall complication rates over the years after CABG, the incidence of stroke remains relatively unchanged.10The aetiology of peri-operative stroke is multi-factorial including hypotension or hypoperfusion-induced reduced brain flow, atherosclerosis due to micro- or macro-embolisation, and intra- or extra-cranial vascular diseases.5 In addition, carotid artery disease is a critical factor; however, it is considered unlikely to be the only culprit for peri-operative strokes.12Although no consensus on the optimal management of patients with concomitant carotid and coronary artery disease has been reached,13 simultaneous CEA and CABG surgery is often associated with low rates of mortality and morbidity.14-17 In this study, we report our experience with simultaneous CEA and CABG surgery in our clinic in the light of data in the literature.     

Relation of serum triglyceride levels to survival after coronary artery bypass grafting

We performed a prospective observational study on 6,602 subjects (94% for 5 years and 34% for 10 to 15 years) who underwent coronary artery bypass graft surgery (CABG) between 1982 and 1992. We examined whether triglyceride concentrations adjusted for other factors (total cholesterol, history of diabetes mellitus, systemic hypertension, left ventricular function, number of coronary arteries significantly narrowed, and use of the internal thoracic arteries) explained total and event-free survival. These analyses were duplicated within gender (1,354 women and 5,248 men). This approach allowed a determination of any gender-related disparities in lipid predictors. Triglycerides in the highest quartile were associated with an increased risk of mortality of 20% (confidence interval [CI] 1.0 to 1.4). Similar risk was seen for event-free survival. Although there was no evidence of gender differences in adjusted survival (p = 0.33), a gender by triglyceride interaction (p = 0.004) indicated that the response to high triglycerides as related to survival did differ by gender. Specifically, women had a dramatically higher risk (hazard ratio [HR] 1.5, CI 1.1 to 2.1) than men (HR 1.1, CI 0.9 to 1. 3). Both men and women did have triglyceride-associated risk with regard to event-free survival (HR in men 1.2, CI 1.1 to 1.4; HR in women 1.4, CI 1.1 to 1.8). Examination of high-density lipoprotein cholesterol in a subcohort did not eliminate the observed triglyceride effects. Thus, triglyceride baseline values are primary determinants (similar to baseline left ventricular function or extent of coronary disease) for long-term total and event-free mortality after CABG in women but not in men.     

Analysis of in-hospital mortality from coronary artery bypass grafting surgery

INTRODUCTION AND OBJECTIVES: Outcomes research and monitoring are of key importance in efforts to improve health care effectiveness and quality. The aim of this study was to describe in-hospital mortality from coronary artery bypass grafting in Spain. Data in an administrative database were used to estimate the statistical performance of two risk-adjustment methods, the Charlson and Ghali indexes. PATIENTS AND METHOD: From the Spanish Hospital Minimum Basic Data Set corresponding to 1997 and 1998 all records which included a code for coronary artery bypass grafting were selected. With in-hospital mortality as the outcome variable, two risk-adjusted logistic multiple regression models were constructed. RESULTS: The database included 13,203 cases, of which 80% were men; mean age was 64.5 years. In-hospital mortality was 7.3%. The figure was significantly higher for women and increased with age. A score of one on the Charlson and Ghali indexes was associated, respectively, with a 23 and 20% increase in the risk of mortality. Probability calculated with the Hosmer-Lemeshow goodness of fit test was 0.765 and 0.965, and the C index was 0.66 and 0.67. Values of Nagelkerke's R2 were 0.051 y 0.058. CONCLUSIONS: In-hospital mortality from coronary artery bypass grafting is much higher in Spain than in other countries. The Minimum Basic Data Set, a low-cost information system that is easy to access, yields interesting and useful information to measure health care quality.     

Determinants of hospital mortality after coronary artery bypass grafting.

OBJECTIVES: To examine causes of death and to find predictors of hospital mortality after elective coronary artery bypass graft (CABG) surgery. DESIGN: Case-control study. SETTING: Tertiary teaching hospital. METHODS: We prospectively collected various preoperative, operative, and immediate postoperative variables in a cohort of patients undergoing elective CABG surgery. RESULTS: Of the 2,014 consecutive patients (mean [+/- SD] age of 61.3+/-6.7 years old) undergoing elective CABG over a 2-year period, 27 patients (1.3%) died during their hospitalization. The main causes of death (either isolated or in combination) were cardiogenic shock (n = 13), brain death or stroke (n = 7), septic shock (n = 4), ARDS (n = 2), and pulmonary embolism (n = 1). A univariate statistical analysis revealed factors that significantly correlate with outcome: patient age, preoperative left ventricular ejection fraction, bypass time, aortic cross-clamp time, number of blood units transfused, number of inotropic agents administered in the operating room during the first postoperative day (POD), history of arterial hypertension, intra-aortic balloon pump usage, and perioperative development of shock. A logistic regression analysis showed that the combination of the number of inotropes and the number of blood units administered in the operating room during POD 1 was the most important determinant of outcome, with an overall positive predictive value of 91.7%. CONCLUSIONS: We conclude that the analysis of simple variables enhances our ability to accurately predict hospital mortality in patients undergoing elective CABG surgery. The number of inotropic agents and blood transfusions administered during the immediate postoperative period is the most important independent predictor of hospital mortality.     

Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting

Aim

The aims of this study were to determine the early mortality rate in low-risk coronary artery bypass graft (CABG) patients and examine the causes of death, to identify problems that could be avoided in future surgeries.

Methods

All low-risk patients (EuroSCORE ≤ 2) who died after CABG were included. Their peri-operative information was meticulously studied by internal and independent external reviewers to identify causes of death, which were classified as: cardiac or non-cardiac; and a further division as: (1) non-preventable, (2) preventable (technical error), and (3) preventable (system error).

Results

Early mortality was 0.93% (24/2 570). Eleven patients (45.8%) were classified as preventable deaths. In six of them the main problem was identified as graft thrombosis, which was secondary to a technical error of either the harvesting or anastomosis of the left internal mammarian artery. There were also five system errors identified as delays in the treatment of an identified and potentially reversible problem.

Conclusions

Correction of technical and system errors, such as harvesting of the left internal mammarian artery, haemostasis during surgery, and establishing standard protocols for the transfer of patients from ward to intensive care units will eventually lead to improvement in both the quality of care and patient outcomes, even in low-risk groups.     

Two- to eight-year survival rates in patients who refused coronary artery bypass grafting

One hundred and fifty patients with coronary artery disease (CAD) who refused bypass grafting were followed prospectively from 2 to 8 years. Mean age was 57 +/- 8 (standard deviation) years. Ejection fraction averaged 70 +/- 14%. Eight percent of patients had 1-vessel CAD and 92% had multiple-vessel CAD. Medical treatment included propranolol, nifedipine, isosorbide dinitrate, dipyridamole and aspirin. Annual mortality was 0% for 1- and 2-vessel CAD and 1.3% for left main equivalent disease, 3-vessel and left main CAD. Treatment significantly reduced the incidence of stable and unstable angina. Fifty-two patients (34%) had a second hemodynamic study 4.2 +/- 1.3 years after initial evaluation. Stenosis progression or new significant obstructions (greater than or equal to 70%) in previously normal coronary arteries occurred in 61% of 123 arteries studied, whereas new occlusions were observed in 12% of the arteries. Nonfatal acute myocardial infarction incidence was 8%. No significant changes occurred in ejection fraction. In conclusion, proper medical treatment in selected patients with advanced CAD but preserved ventricular function is associated with good long-term survival and remission of symptoms, although progression of coronary atherosclerosis does occur in some patients.     

小切口与胸骨正中切口在冠状动脉旁路移植手术中的比较

目的:比较左胸小切口冠状动脉旁路移植手术(MIDCAB)与常规正中切口冠状动脉旁路移植手术(CABG)的临床效果。方法:2012年10月至2015年12月,采用左胸小切口取左乳内动脉(LIMA)心脏不停跳CABG术45例和常规正中开胸CABG手术50例。比较术前基本情况、手术时间、出血量、术后疼痛评分、围术期心肌梗死、死亡等指标;所有患者均在术后1年时进行随访,比较术后1年的吻合口再狭窄、心绞痛、心肌梗死、脑卒中及死亡等重要终点事件发生率。结果:入选两组患者术前一般情况无显著差别。两组患者均成功施行不停跳CABG手术,围术期均无死亡。MIDCA组具有手术时间短,围术期出血少等优点。但MIDCAB组术后疼痛程度较常规正中切口CABG组大。两组在围术期心肌梗死发生、切口愈合不良发生率上差异无统计学意义。随访1年时,两组患者在心绞痛、心肌梗死、死亡、脑卒中、吻合口再狭窄等终点事件差异均无统计学意义。结论:MIDCAB术具有与传统正中切口手术一样的近中期效果,MIDCAB术安全可行,值得推广。     

体外循环与非体外循环冠状动脉旁路移植术早期疗效分析

目的:探讨体外循环冠状动脉旁路移植术(CCABG)和非体外循环冠状动脉旁路移植术（OPCABG）早期疗效的差异。方法: 采集自2003年10月~2008年1月我院单纯冠状动脉旁路移植术5325例临床资料,分为CCABG组（343例）与OPCABG组（4 982例）。对两组患者各项术前因素、术中因素、手术死亡率及并发症进行比较。结果: OPCABG组实际手术死亡率（1.7％）明显低于CCABG组（6.7％）,P<0.01;术后二次开胸止血、肾功能不全等并发症的发生率及ICU停留时间、呼吸机辅助时间、术后住院时间都低于CCABG组（P<0.05,P<0.01）。风险调整后CCABG组手术死亡率仍高于OPCABG组6个百分点,术后并发症的发生率均略高于OPCABG组（P<0.05）。结论: CCABG与OPCABG早期临床疗效均令人满意,后者更好一些。     

Predictors of perioperative mortality after coronary artery bypass grafting in the elderly

BACKGROUND: Coronary artery bypass grafting (CABG) is associated with higher operative risk in the elderly compared to younger patients. The aim of this study was to evaluate risk factors for perioperative mortality after CABG in the elderly. METHODS: We investigated 325 consecutive patients aged 75 or over undergoing isolated CABG at our institution. We analyzed the patients' characteristics and perioperative outcome. Patients were divided into survivors and non-survivors; risk factors and complications were compared. Based on this, we performed a multivariate logistic regression analysis to determine independent risk factors for perioperative mortality. RESULTS: Non-survivors of CABG more often suffered from concomitant extracardiac atherosclerosis (non-survivors, 62.2 %; survivors, 40.6 %; p = 0.013) as well as from renal insufficiency preoperatively (non-survivors, 35.1 %; survivors 8.0 %; p < 0.0001). A trend towards higher incidences of impaired left ventricular function (non-survivors, 37.8 %; survivors, 29.9 %; p = 0.105) and a history of recent myocardial infarction (non-survivors, 29.7 %; survivors, 17.0 %; p = 0.061) were found in non-survivors compared to survivors. Furthermore, non-survivors more often underwent CABG with cardiopulmonary bypass (CPB non-survivors, 96.1 %; survivors 70.6 %; p = 0.0005). Multivariate logistic regression analysis revealed that preoperatively impaired renal function (OR: 2.857, p < 0.0001), use of CPB (OR: 5.952, p = 0.0175), extracardiac atherosclerosis (OR: 1.581, p = 0.0228), and recent myocardial infarction (OR: 1.574, p = 0.0405) were independent risk factors for perioperative mortality. Comparison of patients undergoing CABG with or without CPB reveals that patients operated without CPB had a higher preoperative risk than patients undergoing CABG with CPB. CONCLUSION: These results show that besides impaired renal function, extracardiac atherosclerosis, and history of recent myocardial infarction, the use of CPB is a major risk factor for CABG in the elderly. Perioperative mortality and morbidity can be significantly reduced if CPB is avoided.     

Perioperative monitoring of primary and secondary hemostasis in coronary artery bypass grafting

On-pump cardiac surgery is accompanied by complex alterations of hemostasis. The excessive postoperative bleeding has been attributed to acquired platelet dysfunction, impaired plasmatic coagulation, and increased fibrinolysis. The characterization of the hemostatic defects responsible for bleeding is crucial for specific treatment and optimal clinical management of the patient. For rapid determination of platelet-dependent primary hemostatic capacity (PHC), the Platelet Function Analyzer PFA-100 system is available. To evaluate the PFA performance in perioperative monitoring, a study was performed in 49 patients selected for low bleeding risk undergoing selective primary coronary artery bypass grafting (CABG). We compared PHC with Simplate bleeding time (BT) and platelet aggregometry. Furthermore, we analyzed global hemostasis by thromboelastography (TEG) and plasmatic coagulation by standard clotting tests prothrombin time (PT, Quick), activated partial thromboplastin time (aPTT), thrombin time (TT) and clotting factors and fibrinolysis by batroxobin (reptilase) time (RT). In all patients BT was postoperatively increased by 1.5- to 2-fold irrespective of perioperative complications and decreased to mildly prolonged values on the first postoperative day (1st day). In patients without complications, PHC in both collagen-adenosine diphosphate closure time (CADP-CT: 83 seconds preop, 78 seconds postop, and 74 seconds 1st day) and collagen-epinephrine closure time (CEPI-CT: 98 seconds preop, 95 seconds postop, 85 seconds 1st day) remained nearly stable. Apart from a patient with postoperative moderate thrombocytopenia, in bleeding patients no other significant defect of postoperative platelet hemostatic capacity was observed. However, on 1st day, the PHC of those patients was significantly reduced compared with non-bleeding patients. In patients with postoperative myocardial ischemia, increased PHC was identified by significantly shorter postoperative CADP-CT (66 seconds vs. 83 seconds) than in uncomplicated patients. By aggregometry, partial platelet dysfunction was observed in some patients without correlation to bleeding complications. In seven of 9 patients the postoperative bleeding complication was attributed to prolonged heparin anticoagulation and/or mildly enhanced fibrinogenolysis/fibrinolysis by TEG and standard plasmatic coagulation tests (TEG: k time 18 minutes vs. 8 minutes; aPTT: 47 seconds vs. 32 seconds; TT: 18.0 seconds vs. 12.3 seconds) and (RT: 19.5 seconds vs. 17.7 seconds). The impairment of PHC, platelet aggregation, and clotting factors observed on the 1st day in bleeding and in intra-aortic balloon pump (IABP) patients are most likely secondary effects, for example, loss of active platelets and clotting factors, to the primary postoperative bleeding or implantation of the IABP. In conclusion, our data indicate that in standard CABG procedures highly variable alterations of the hemostatic system occur after cardiopulmonary bypass (CPB) even in patients with assumed low operative risks. For identification of post-CPB bleeding complications, thromboelastography, aPTT, and TT and heparin and batroxobin (reptilase) time as fibrinolysis-sensitive assays are useful. Platelet function appears to be rapidly restored in uncomplicated CABG. PHC determination by PFA-100 demonstrates a high specificity for adequate platelet function and, therefore, could be beneficial in improved transfusion of platelet concentrates. PHC testing by PFA-100 may help identify postoperative platelet hyper-reactivity associated with myocardial lesion.     

Concomitant aortoaxillary bypass and coronary artery bypass grafting

The optimal revascularization strategy for patients with subclavian and coronary artery disease has not been established. This study assessed the mid-term clinical outcome of concomitant aortoaxillary bypass and coronary artery bypass grafting in 5 patients. A ring-reinforced polytetrafluoroethylene graft was attached to the ascending aorta and led to the proximal segment of the axillary artery via the pleural cavity. Patients were followed up for 2-10 years (mean, 5.4 +/- 3.4 years). Postoperative aortography and angiography demonstrated patent aortoaxillary and coronary bypass grafts in the short-term follow-up of all patients. Two patients with Takayasu aortitis needed re-operations for recurrent angina and annuloaortic dilatation. Another patient required removal of the aortoaxillary bypass graft because of infection, and subsequently underwent a left femoroaxillary bypass one year after the original procedure. Subclavian steal phenomenon did not occur. Aortoaxillary bypass with coronary artery bypass may be an effective option for patients with co-existing subclavian and coronary artery disease.     

186例老年冠心病患者是、否体外循环下冠脉旁路移植术的比较

目的:比较老年冠心病患者体外循环与非体外循环下冠状动脉旁路移植术的疗效。方法:A组选择87例65岁以上的老年患者在体外循环下行冠状动脉旁路移植术(CCABG);B组选择79例65岁以上的老年患者在非体外循环下行冠状动脉旁路移植术(OPCABG)。结果:B组死亡率低于A组(P<0.05),术后胸腔引流量明显少于A组(P<0.05)。结论:老年冠心病患者行冠状动脉旁路移植术是安全的。     

心脏瓣膜手术同期冠状动脉旁路移植术的临床探讨

目的 探讨心脏瓣膜手术同期冠状动脉旁路移植术的治疗效果.方法 回顾性分析2010年1月至2013年8月新疆医科大学第一附属医院心脏外科心脏瓣膜手术同期行冠状动脉旁路移植术45例患者的临床病例资料,对其进行整理统计分析,评价治疗效果.结果 患者术后左心室舒张末径较前明显减小,差异均有统计学意义（P＜0.01）;左心室射血分数较术前明显升高,差异均有统计学意义（P＜0.05）.术后早期（住院期间）死亡3例,其中2例发生低心排综合征、1例室颤均抢救无效死亡.通过电话及门诊复查,随访3～24个月,2例失访,失访率4.44％,无一例死亡.结论 心脏瓣膜手术同期行冠状动脉旁路移植术的治疗效果满意.充分的术前准备、合理的手术方案、有效的心肌保护措施、熟练的手术技术及术后的重症监护治疗是手术成功的关键.