Incidence and precipitating factors of delirium after coronary artery bypass grafting

Objective. To analyze large contemporary patient population, undergoing on-pump coronary artery bypass grafting at our institution, and identify the prevalence and precipitating factors of delirium development. Design. Baseline demographics, operative data and postoperative outcomes of 1367 consecutive patients were recorded prospectively and analysed using multivariate logistic regression analysis, to determine independent predictors of postoperative delirium development. Results. Delirium was detected in 42 (3.07%) patients. Eight factors: age more than 65 years, peripheral vascular disease, Euroscore≥5, preoperative IABP support, postoperative blood product usage and postoperative low cardiac output syndrome were independently predicting delirium development after coronary artery bypass procedures. Postoperative delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%, p=0.013), prolonged mechanical ventilation time (9.2±3.1 vs. 5.05±7.6, p=0.04) and increased length of intensive care unit stay (6.8±4.9 vs. 2.0±2.7 days, p=0.001). Conclusions. Delirium is a dangerous complication, prolonging intensive care unit stay and postoperative mortality. Factors associated with delirium development are advanced age, peripheral vascular disease, diminished cardiac function and blood product usage.     

The benefits and new predictors of early extubation following coronary artery bypass grafting.

OBJECTIVE: This study researched cardiorespiratory effects and cost-effectiveness of early extubation in patients following coronary artery bypass grafting. METHODS: We retrospectively examined the character of 86 (38 preoperative, 12 intraoperative, 36 postoperative) variables in 78 patients after coronary artery bypass grafting (CABG) at our hospital. The patients were classified into three groups according to the time of extubation: Group A (less than 8 hours), Group B (8 to 24 hours) and Group C (24 hours or more). RESULTS: There were 43 patients in Group A (55%), 27 patients in Group B (35%), and 8 patients in Group C (10%). Univariate preoperative analysis revealed several differences between Groups A and B: 15 variables were found to reach statistical significance. Stepwise logistic regression analysis implicated decreased forced expiratory volume rate in the first second (FEV1.0%), postoperative cardiac index (CI) after admission to the intensive care unit (ICU) and usage of postoperative temporary pace-makers as predictors of late extubation. Also, there was a statistical significance in usage of diuretics within the first day (15.8+/-11.6 vs 28.8+/-22.6 mg; p = 0.044) and in the ICU days (3.6+/-0.8 vs 4.2+/-1.0; p = 0.004) between early and late extubation groups. CONCLUSIONS: Early extubation within 8 hours into the ICU stay was accomplished in 55% of the patients in this study. We speculate that the benefits of early extubation contain improvement of cardiac function, reduction in respiratory infection and complications, and cost saving as the result of diminished ICU admission. Also, we have shown that decreased FEV1.0%, decreased CI and the usage of a postoperative temporary pacemaker were independent predictors of prolonged intubation in our study.     

Off-pump multivessel coronary artery surgery in high-risk patients

BACKGROUND: Coronary artery bypass surgery on cardiopulmonary bypass is associated with significant morbidity and mortality, which may be more marked in high-risk patients. We evaluated our results of off-pump coronary artery bypass (OPCAB) in high-risk patients with multivessel coronary artery disease and compared them with results in similar patients who underwent operation on cardiopulmonary bypass. METHODS: A total of 1,075 patients who underwent OPCAB between October 1996 and June 2001 and who had one or more of the following risk factors were included in the study: poor left ventricular function (EF < or = 30%), advanced age (> 70 years), left main stenosis, acute myocardial infarction, and redo coronary artery surgery. These patients were compared with 2,312 similar patients who underwent coronary artery bypass grafting on cardiopulmonary bypass during the same period. Preoperative risk factors, intraoperative variables, and postoperative results were analyzed and compared between two groups. RESULTS: The average number of grafts was 3.0 +/- 0.4 and 3.2 +/- 0.3 in the off-pump (OPCAB) and on-pump (CCAB) groups, respectively. Hospital mortality was 3.2% and 4.5% in OPCAB and CCAB groups respectively (p = 0.109). Perioperative myocardial infarction, requirement of inotropic agents, stroke, and renal dysfunction were comparable in two groups. Intubation time (19 +/- 5 vs 24 +/- 6 hours, p < 0.001), mean blood loss (362 +/- 53 vs 580 +/- 66 mL, p < 0.001), atrial fibrillation (14.3 vs 19.7%, p < 0.001), and prolonged ventilation (4.6 vs 7.6%, p = 0.002) were less in OPCAB group. Intensive care unit stay (20 +/- 8 hours) and hospital stay (6 +/- 3 days) were significantly less in the OPCAB group (p < 0.001). CONCLUSIONS: Off-pump coronary artery surgery can be safely performed in high-risk patients with multivessel coronary artery disease. Operative mortality is comparable to that associated with on-pump surgery, and avoidance of cardiopulmonary bypass is associated with reduced postoperative morbidity in these patients.     

The effect of peri-operative dexmedetomidine on the incidence of postoperative delirium in cardiac and non-cardiac surgical patients: a randomised,double-blind placebo-controlled trial

Delirium occurs commonly following major non-cardiac and cardiac surgery and is associated with: postoperative mortality; postoperative neurocognitive dysfunction; increased length of hospital stay; and major postoperative complications and morbidity. The aim of this study was to investigate the effect of peri-operative administration of dexmedetomidine on the incidence of postoperative delirium in non-cardiac and cardiac surgical patients. In this randomised, double-blind placebo-controlled trial we included 63 patients aged ≥ 60 years undergoing major open abdominal surgery or coronary artery bypass graft surgery with cardiopulmonary bypass. The primary outcome was the incidence of postoperative delirium, as screened for with the Confusion Assessment Method. Delirium assessment was performed twice daily until postoperative day 5, at the time of discharge from hospital or until postoperative day 14. We found that dexmedetomidine was associated with a reduced incidence of postoperative delirium within the first 5 postoperative days, 43.8% vs. 17.9%, p = 0.038. Severity of delirium, screened with the Intensive Care Delirium Screening Checklist, was comparable in both groups, with a mean maximum score of 1.54 vs. 1.68, p = 0.767. No patients in the dexmedetomidine group died while five (15.6%) patients in the placebo group died, p = 0.029. For patients aged ≥ 60 years undergoing major cardiac or non-cardiac surgery, we conclude that the peri-operative administration of dexmedetomidine is associated with a lower incidence of postoperative delirium.     

Coronary artery bypass combined with bilateral carotid endarterectomy

BACKGROUND: Surgical management of patients presenting for coronary artery bypass grafting with significant bilateral carotid artery stenosis has not been well defined. In this study, our preliminary results of coronary artery bypass grafting with concomitant bilateral carotid endarterectomy have been reviewed. METHODS: A retrospective nonrandomized chart review was performed in 33 patients with unstable angina and bilateral carotid artery stenosis, more than 70%, undergoing simultaneous coronary artery bypass grafting and bilateral carotid endarterectomy using an eversion technique. RESULTS: Concomitant coronary artery bypass grafting with bilateral carotid endarterectomy was performed urgently in 24 (73%) and electively in 9 (27%) patients. The average carotid artery cross-clamp and total perfusion times were 14.7 +/- 4.9 minutes and 123 +/- 29.2 minutes, respectively. The average length of stay in the cardiopulmonary intensive care unit was 4.2 +/- 14.2 days and total hospital stay was 16.2 +/- 20.5 days. Postoperative in-hospital stay was 14.9 +/- 20.3 days. There were no postoperative strokes. Twenty-one (64%) patients were discharged before the tenth postoperative day. Nonfatal postoperative complications occurred in 27% (9 of 33) of patients. The overall 30-day mortality was 6.1% (2 of 33) and that was unrelated to primary cardiac or cerebrovascular events. CONCLUSIONS: Favorable outcome supports the justification for performing concomitant coronary artery bypass grafting with bilateral carotid endarterectomies in selected patients.     

Can we identify risk factors for postoperative delirium in cardiac coronary patients? Our experience

Introduction: Delirium is a temporary mental disorder that frequently occurs among elderly hospitalized patients. Patients who undergo cardiac operations have an increased risk of postoperative delirium, which is associated with higher mortality and morbidity rates, a prolonged hospital stay, and reduced cognitive and functional recovery.Patients and Methods: In our prospective study, we included 370 consecutive adult patients who underwent on-pump coronary artery surgery between January 1, 2011, and July 1, 2011. We selected 21 potential risk factors and divided them into preoperative, intraoperative, and postoperative groups. Delirium was diagnosed with the Confusion Assessment Method.Results: Postoperative delirium was diagnosed in 74 patients (20%). Four predictive factors were associated with postoperative delirium: diabetes mellitus, cerebrovascular disease, peripheral vascular disease, and prolonged intubation (P < .05).Conclusion: Three of the four predictive factors significantly associated with delirium are preoperative. They are relatively easy to measure and can be used to identify patients at higher risk. Fast extubation of these patients and preventive interventions can be taken to prevent negative consequences of this postoperative complication.     

Off-pump surgery decreases postoperative complications and resource utilization in the elderly.

BACKGROUND: Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients. METHODS: Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65. RESULTS: Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency. CONCLUSIONS: OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.     

Off-pump coronary artery bypass surgery technique for total arterial myocardial revascularization: a prospective randomized study

BACKGROUND: We investigated whether off-pump coronary artery bypass (OPCAB) surgery should be the procedure of choice in total arterial myocardial revascularization with composite grafts. METHODS: We prospectively enrolled 176 patients undergoing total arterial myocardial revascularization and assigned them at random to one of two groups: group 1 was composed of 88 patients undergoing coronary surgery with cardiopulmonary bypass (CPB); group 2 consisted of 88 patients receiving the OPCAB procedure. We excluded from this study patients with significant risk factors for CPB-related morbidity. Composite arterial grafts in Y-T shape were realized in three different configurations according to patients' characteristics, coronary anatomy, and target stenosis. RESULTS: There were no significant differences between the two groups in terms of preoperative characteristics and risk factors (Euroscore: group 1 = 6.1 +/- 3.5, group 2 = 6.6 +/- 3.8). Mean number of anastomoses was similar in both groups (group 1 = 2.8 +/- 0.8, group 2 = 2.7 +/- 0.5) whereas mean mechanical ventilation time (group 1 = 23 +/- 9 hours, group 2 = 9 +/- 4 hours), intensive care unit stay (group 1 = 43 +/- 6 hours, group 2 = 22 +/- 8 hours), and postoperative stay (group 1 = 7 +/- 3 days, group 2 = 5 +/- 2 days) were significantly reduced in group 2. Early mortality was 2.3% in group 1 and 3.4% in group 2 (p = not significant). Major postoperative complications occurred similarly in the two groups (atrial fibrillation: group 1 = 35.2%, group 2 = 21.6%; myocardial infarction: group 1 = 2.2%, group 2 = 1.1%; stroke: group 1 = 2.2%, group 2 = 0%; abdominal infarction: group 1 = 3.4%, group 2 = 0%). At follow-up (mean, 15 +/- 12 months) no significant differences were observed in terms of survival free of any cardiac-related event (group 1 = 94.3%, group 2 = 96.5%; p = not significant). CONCLUSIONS: Off-pump coronary artery surgery could be successfully used for total arterial grafting without compromising the completeness of revascularization. Avoidance of CPB significantly decreased mechanical ventilation support and length of intensive care unit and postoperative stay; however in the absence of risk factors for cardiopulmonary bypass, off-pump coronary artery surgery did not improve early and midterm clinical outcome.     

Left internal thoracic artery-radial artery composite grafts as the technique of choice for myocardial revascularization in elderly patients: a prospective randomized evaluation

OBJECTIVES: The technique of choice for myocardial revascularization in elderly patients remains a debated issue. We evaluated the potential advantages of the use of left internal thoracic artery-radial artery composite grafts compared with conventional coronary artery bypass grafts in elderly patients. METHODS: We prospectively enrolled 160 patients aged more than 70 years scheduled to undergo isolated myocardial revascularization. Patients were assigned at random to group 1, 80 patients undergoing total arterial revascularization (left internal thoracic artery on left anterior descending coronary artery plus radial artery), or group 2, 80 patients undergoing standard coronary artery bypass graft surgery (left internal thoracic artery on left anterior descending coronary artery plus saphenous veins). The radial artery was used in all cases as a composite Y-graft. RESULTS: Preoperative characteristics and risk factors (EuroSCORE: group 1 = 7.9 vs group 2 = 8.1), number of grafted coronary vessels (group 1 = 2.4 vs group 2 = 2.5), aortic crossclamping time (group 1 = 37 +/- 7 minutes vs group 2 = 38 +/- 7 minutes), ventilation time (group 1 = 22 +/- 12 hours vs group 2 = 23 +/- 11 hours), intensive care unit stay (group 1 = 39 +/- 10 hours vs group 2 = 40 +/- 9 hours), and hospital mortality (group 1 = 3.8% vs group 2 = 5%) were comparable between the groups. Comparison between the 2 groups in terms of early postoperative complications showed a higher incidence of cerebrovascular accidents in group 2 (group 1 = 0 patients vs group 2 = 4 patients, 5%). At a mean follow-up of 16 +/- 3 months, patients in group 1 showed superior clinical results with a lower incidence of graft occlusion (group 1 = 2 vs group 2 = 11; P =.06) and angina recurrence (group 1 = 2 patients vs group 2 = 12 patients; P =.03). Multivariate analysis identified saphenous vein grafts as independent predictors for graft occlusion and angina recurrence. CONCLUSIONS: Left internal thoracic artery-radial artery composite grafts proved to be a safe procedure in elderly patients. It improved the clinical outcome, providing a significantly higher graft patency rate and a lower incidence of late cardiac events.     

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass

BACKGROUND: An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. METHODS: Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001). CONCLUSIONS: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.     

Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery

This randomised, double-blinded, placebo-controlled study was primarily aimed to evaluate the potential of risperidone to prevent postoperative delirium following cardiac surgery with cardiopulmonary bypass and the secondary objective was to explore clinical factors associated with postoperative delirium. One-hundred-and-twenty-six adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomly assigned to receive either 1 mg of risperidone or placebo sublingually when they regained consciousness. Delirium and other outcomes were assessed. The confusion assessment method for intensive care unit was used to assess postoperative delirium. The incidence of postoperative delirium in the risperidone group was lower than the placebo group (11.1% vs. 31.7% respectively, P=0.009, relative risk = 0.35, 95% confidence interval [CI] = 0.16-0.77). Other postoperative outcomes were not statistically different between the groups. In exploring the factors associated with delirium, univariate analysis showed many factors were associated with postoperative delirium. However multiple logistic regression analysis showed a lapse of 70 minutes from the time of opening eyes to following commands and postoperative respiratory failure were independent risk factors (P=0.003, odds ratio [OR] = 4.57, 95% CI = 1.66-12.59 and P=0.038, OR = 13.78, 95% CI = 1.15-165.18 respectively). A single dose of risperidone administered soon after cardiac surgery with cardiopulmonary bypass reduces the incidence of postoperative delirium. Multiple factors tended to be associated with postoperative delirium, but only the time from opening eyes to following commands and postoperative respiratory failure were independent risk factors in this study.     

Temporal synthesis and release of endothelin within the systemic and myocardial circulation during and after cardiopulmonary bypass: relation to postoperative recovery

OBJECTIVE: To determine endothelin levels in arterial, pulmonary, and myocardial vascular compartments in patients undergoing coronary artery bypass graft surgery and to examine the influence of endothelin on postoperative recovery. DESIGN: Prospective, clinical study. SETTING: University hospital. PARTICIPANTS: Fifty patients undergoing elective coronary artery bypass graft surgery. INTERVENTIONS: Endothelin plasma content (fmol/mL) was measured in 50 patients undergoing coronary revascularization from various vascular compartments before surgery and at specific intervals up to 24 hours postoperatively. MEASUREMENTS AND MAIN RESULTS: Myocardial endothelin gradient (coronary sinus - aorta) was calculated before cardiopulmonary bypass (CPB), at release of the aortic cross-clamp, immediately after CPB, and 0.5 hour after CPB. The requirement for inotropic therapy and duration of patient stay in the intensive care unit were determined. Systemic and pulmonary endothelin levels were increased by >80% immediately after CPB when compared with preoperative values and increased again by approximately 60% during the first 24 hours postoperatively (p < 0.05). The myocardial endothelin gradient was reversed after CPB, indicating myocardial production of endothelin (pre-CPB, -0.72+/-0.39 fmol/mL v 0.5 hour post-CPB, 0.60+/-0.49 fmol/mL; p < 0.05). Longer intensive care unit times (>28 hours) were associated with higher systemic endothelin levels when compared with shorter times (<18 hours) (16.30+/-1.33 fmol/mL v 9.81+/-1.67 fmol/mL; p < 0.05). Patients with higher endothelin levels 6 hours postoperatively had greater inotropic requirements during the intensive care unit period. CONCLUSION: Endothelin levels after CPB remained persistently increased for at least 24 hours after surgery and were associated with increased myocardial production of endothelin. These results suggest that the increased endothelin observed in the early postoperative period may contribute to a complex recovery from coronary artery bypass graft surgery.     

Postoperative effects of low-dose intrathecal morphine in coronary artery bypass surgery

BACKGROUND: Intrathecal morphine has been used in hopes of providing long-lasting postoperative analgesia in patients after cardiac surgery. The aim of this study was to evaluate the effects of 7 micro/kg intrathecal morphine administration in coronary bypass surgery in the postoperative period. METHODS: We conducted a prospective, randomized, blinded, and controlled study. Twenty-three patients, who underwent primary elective coronary bypass surgery, were randomly allocated to receive morphine 7 micro/kg intrathecally, before the induction of general anesthesia (Group M, n = 12) or no intrathecal injection (Group C, n = 11). Pain scores, determined by visual analogue scale (VAS), were recorded immediately after extubation upon admission to the intensive care unit (ICU), at the 2nd, 4th, 6th, and 18th hour after extubation. Pethidine was administered if the patient's VAS > or = 4 and consumption was recorded. Extubation time and ICU length of stay were also recorded. RESULTS: VAS scores were lower in the Group M at each measured time than the control group (p = 0.016, 0.023, 0.004, 0.0001, and 0.001, respectively). According to the VAS scores, pethidine requirement was lower in the Group M than the control (p = 0.001). Extubation time (3.58 +/- 1.57 vs. 4.86 +/- 1.38 hours, p = 0.045) and ICU length of stay (16.25 +/- 2.70 vs. 19.30 +/- 2.45 hours, p = 0.014) were also significantly shorter in the Group M than the control group. No significant complications were seen in this group of patients. CONCLUSIONS: Intrathecal morphine provided effective analgesia, earlier tracheal extubation and less ICU length stay after on-pump coronary bypass surgery. The influence on ICU length of stay requires further evaluations.     

Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off-pump) surgery

BACKGROUND: Despite improved outcomes after cardiac operations, postoperative delirium remains a common complication that is associated with increased morbidity and prolonged hospital stay. METHODS: Univariate and multivariate predictors of postoperative delirium were determined from prospectively gathered data on 16,184 patients undergoing cardiac operations with cardiopulmonary bypass (conventional, n = 14,342) and without cardiopulmonary bypass (beating-heart surgery, n = 1847) between April 1996 and August 2001. Delirium was defined as a transient mental syndrome of acute onset characterized by global impairment of cognitive functions, a reduced level of consciousness, attentional abnormalities, increased or decreased psychomotor activity, and a disordered sleep-wake cycle. RESULTS: The overall prevalence of postoperative delirium was 8.4%. Of 49 selected patient-related risk factors and treatment variables, 35 were highly associated with postoperative delirium by univariate analysis. Stepwise logistic regression revealed the following variables as independent predictors of delirium: history of cerebrovascular disease, peripheral vascular disease, atrial fibrillation, diabetes mellitus, left ventricular ejection fraction of 30% or less, preoperative cardiogenic shock, urgent operation, intraoperative hemofiltration, operation time of 3 hours or more, and a high perioperative transfusion requirement. Two variables were identified as having a significant protective effect against postoperative delirium: beating-heart surgery and younger patient age. CONCLUSIONS: Postoperative delirium is a common complication in cardiac operations. The increased use of beating-heart surgery without cardiopulmonary bypass may lead to a lower prevalence of this complication and thus improve patient outcomes.     

The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study

BACKGROUND: Although use of the internal thoracic artery has been shown to improve outcomes after coronary artery bypass grafting, the same cannot be said of alternative arterial conduits. To determine the benefit of radial artery (RA) grafting, a case-matched review was undertaken. METHODS: Between March 1994 and March 1999, 2,847 patients underwent isolated coronary artery bypass grafting with a left internal thoracic artery graft, plus saphenous vein grafts (SVGs). Of these patients, 478 also received an RA graft (RA group). The RA patients were matched at a ratio of 1:2 with patients receiving only SVGs and a left internal thoracic artery graft (SVG group; n = 956) using six prognostic risk factors: age, sex, Canadian Cardiovascular Society class, left ventricular grade, number of diseased vessels, and timing of operation. Target vessels were graded according to quality and graftability and were similar between groups. Outcomes were evaluated by univariate and multivariate analyses. RESULTS: There was a significantly higher prevalence of diabetes, hypertension, and peripheral vascular disease in the RA group (p < 0.05). Although stay in the intensive care unit was shorter in the RA group (RA, 30 +/- 2 hours, and SVG, 37 +/- 2 hours; p = 0.0002), total hospital stay was similar between groups. The incidence of perioperative myocardial infarction was higher in the SVG group (SVG, 31 of 956 or 3.2%, and RA, 6 of 478 or 1.3%; p = 0.02). Multivariate analysis revealed RA grafting to be protective against early mortality and morbidity (odds ratio = 0.58; 95% confidence interval, 0.37 to 0.90; p = 0.015) and late mortality and morbidity including late reintervention (risk ratio = 0.60; 95% confidence interval, 0.37 to 0.93; p = 0.02). Actuarial freedom from events at 36 months postoperatively was greater in the RA group (RA, 95% +/- 2%, and SVG, 86% +/- 4%; p = 0.01). CONCLUSIONS: Despite a higher prevalence of preoperative comorbidity, patients in the RA group demonstrated improved outcomes after coronary artery bypass grafting. The RA is a viable and beneficial conduit for this operation.     

Alfentanil and sufentanil in fast-track anesthesia for coronary artery bypass graft surgery

OBJECTIVE: To evaluate alfentanil, sufentanil, and the combination of both opioids in patients undergoing cardiac surgery. DESIGN: Prospective, randomized study. SETTING: University hospital. PARTICIPANTS: Patients undergoing coronary artery bypass graft (CABG) surgery (n = 195), randomly assigned to 3 groups of 65 each. INTERVENTIONS: Patients in group A received alfentanil, induction (15 microg/kg) and maintenance (15 microg/kg/hr); patients in group S received sufentanil, induction (1 microg/kg) and maintenance (1 microg/kg/h); and patients in group AS received alfentanil and sufentanil, induction with alfentanil (15 microg/kg) and maintenance with sufentanil (1 microg/kg/hr). MEASUREMENTS AND MAIN RESULTS: Hemodynamic data showed a reduction of all parameters at induction in the 3 groups (p < 0.05). Cardiac index decreased at induction in all groups (p < 0.05) but increased in groups S and AS toward baseline values at the end of surgery. The intubation time and length of stay in the intensive care unit were less in group AS (2.3 +/- 1.2 hours; p < 0.001 and 20 +/- 8 hours; p < 0.05), than in groups A (4.2 +/- 1.7 hours and 28 +/- 13 hours) and S (3.1 +/- 1.1 hours; p < 0.05 and 26 +/- 12 hours). Length of hospital stay and patients' outcome were similar in the 3 groups. CONCLUSION: Although the differences among groups regarding extubation time, intensive care unit length of stay, and some hemodynamic data were statistically significant, the differences were clinically small. All 3 anesthetic protocols were shown to be safe and appropriate for patients undergoing elective coronary artery bypass graft surgery and early postoperative tracheal extubation.     

Factors influencing intensive care unit length of stay after surgery for acute aortic dissection type A

BACKGROUND: Operative mortality after acute aortic dissection type A is still high, and prolonged stay at the intensive care unit is common. Little has been documented about factors influencing the intensive care unit length of stay. The aim of this study was to determine such variables. METHODS: During a 10-year period, 67 patients (47 male, 20 female) were operated on for acute aortic dissection type A. In 42 patients (63%), an ascending aortic replacement was performed, 23 patients (34%) underwent a Bentall procedure, and 2 patients (3%) received a valve-sparing David type of operation. In 14 of these cases (20%), an additional partial or total arch replacement was performed. RESULTS: Hospital mortality was 9 of 67 (14%). Median postoperative intensive care unit length of stay was 5 days (range, 1 to 72 days). Intensive care unit stay was in univariate analysis significantly influenced by the following factors: age (p = 0.008), body mass index (p = 0.039), cardiopulmonary bypass time (p = 0.018), aortic cross-clamp time (p = 0.031), postoperative low cardiac output syndrome (p < 0.001), and postoperative lactate levels (p = 0.01). By multivariate analysis, age (p = 0.012), cardiopulmonary bypass time (p = 0.037), and the presence of a postoperative low cardiac output syndrome (p < 0.001) significantly influenced intensive care unit stay. CONCLUSIONS: Stay in the intensive care unit after operation for acute aortic dissection type A seems to be determined by age, cardiopulmonary bypass time, and the postoperative presence of a low cardiac output syndrome.     

Fast track recovery of high risk coronary bypass surgery patients.

OBJECTIVE: Fast track recovery protocols on younger, low risk patients result in shorter hospital stays and decreased costs. However, data is lacking on the impact of these protocols on high risk patients based on an objective scoring system. METHODS: In this study, a high risk cohort of patients (EuroSCORE >or=6, n=158) was compared with a low risk cohort of patients (EuroSCORE <6, n=1004) to define the safety and efficacy of fast track recovery among high risk patients. A standard perioperative data is collected prospectively for every patient. RESULTS: Time to extubation was longer in the high risk group (299+/-253 vs. 232+/-256min; P=0.003), but intensive care unit (ICU) stay (25.6+/-28.7 vs. 21.5+/-9.4h; P=ns), and postoperative length of stay (5.8+/-2.4 vs. 5.6+/-2.7 days; P=ns) was similar when compared with the low risk group. Of the high risk patients 81% were extubated within 6h, 87% were discharged from the intensive care unit within 24h, and 67% were discharged from the hospital within 5 days. Multiple regression analysis showed that any red blood cell transfusion (P=0.02), and cross clamp time >60min (P=0.03) were the predictors of delayed extubation (>or=6h) in the high risk group. The predictors of extended ICU stay were any red blood cell transfusion (P=0.0001), and peripheral vascular disease (P=0.05). Any red blood cell transfusion was the only predictor for mortality (P=0.02) and readmission to the hospital within the first 30 days (P=0.02) in this cohort of patients. CONCLUSIONS: This study confirms the safety and efficacy of fast track recovery protocol among high risk patients undergoing coronary artery bypass surgery. All patients are basically suitable for fast track recovery and the preoperative risk factors are poor predictors of prolonged ventilation, increased ICU and hospital stay. Red blood cell transfusion is associated with delayed extubation and discharge from the ICU, and increased mortality and hospital readmission rate.     

Cardiac protection by volatile anaesthetics: a multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass

BACKGROUND AND OBJECTIVES: To evaluate the effects of total intravenous anaesthesia vs. volatile anaesthesia on cardiac troponin release in coronary artery bypass grafting with cardiopulmonary bypass, we performed a multicentre randomized controlled study to compare postoperative cardiac troponin release in patients receiving two different anaesthesia plans. METHODS: We randomly assigned 75 patients to propofol (intravenous anaesthetic) and 75 patients to desflurane (volatile anaesthetic) in addition to an opiate-based anaesthesia for coronary artery bypass grafting. Peak postoperative troponin I release was measured as a marker of myocardial necrosis. RESULTS: There was a significant (P < 0.001) difference in the postoperative median (25th-75th percentiles) peak of troponin I in patients receiving propofol 5,5 (2,3-9,5) ng dL(-1) when compared to patients receiving desflurane 2,5 (1,1-5,3) ng dL(-1). The median (interquartile) troponin I area under the curve analysis confirmed the results: 68 (30.5-104.8) vs. 36.3 (17.9-86.6) h ng dL(-1) (P = 0.002). Patients receiving volatile anaesthetics had reduced need for postoperative inotropic support (24/75, 32.0% vs. 31/75, 41.3%, P = 0.04), and tends toward a reduction in number of Q-wave myocardial infarction, time on mechanical ventilation, intensive care unit and overall hospital stay. CONCLUSIONS: Myocardial damage measured by cardiac troponin release could be reduced by volatile anaesthetics in coronary artery bypass surgery.