Improved Health-related Quality of Life after Coronary Artery Bypass Grafting Is Unrelated to Use of Cardiopulmonary Bypass

Minimally invasive extracorporeal circulation improves quality of life after coronary artery bypass grafting

OBJECTIVES

The effect on postoperative health-related quality of life (HRQoL) after coronary artery bypass grafting (CABG) surgery with conventional cardiopulmonary bypass (cCPB) and off-pump surgery has been investigated extensively; however, there are no studies focusing on HRQoL after surgery with minimally invasive extracorporeal circulation (MiECC). Therefore, we sought to prospectively investigate the effect of MiECC on postoperative HRQoL when compared with cCPB in patients undergoing CABG over a short-term (3-month) follow-up period.

METHODS

Sixty patients scheduled for elective CABG surgery were randomly assigned into two groups: those who had surgery on MiECC system (n = 30) and those who underwent CABG using cCPB (n = 30). Quality-of-life assessment was performed preoperatively (baseline-T0), at first postoperative month (T1) and at 3-month follow-up (T3). The RAND SF-36 scale was used for data collection, which included both sociodemographic and clinical characteristics of patients. The primary outcome of the study was quantitative measurement of postoperative HRQoL at 3-month follow-up.

RESULTS

Both groups were balanced in terms of demographic, socio-economic and operative characteristics. At 3-month follow-up, mean SF-36 component and summary scores in each group were higher in absolute values than the respective mean baseline scores, apart from role-physical score in patients operated with cCPB. Patients operated on MiECC showed uniformly significantly higher values in all individual and summary domains, whereas patients operated on cCPB showed significant improvement in 6/8 individual domains. Patients operated on MiECC showed a more pronounced increase in SF-36 individual domain scores from the first to the third postoperative month when compared with cCPB, which was statistically significant regarding physical functioning (P = 0.001), role-physical (P < 0.001), vitality (P = 0.01) and role-emotional (P = 0.004). This resulted in a significant improvement in physical (P = 0.002) and mental (P = 0.01) summary scores.

CONCLUSIONS

The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with cCPB. This finding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECC as a dominant technique in coronary revascularization surgery.

The assessment of neural injury following open heart surgery by physiological tremor analysis

INTRODUCTION

The appearance of post-operative cognitive dysfunction as a result of open heart surgery has been proven by several studies. Focal and/or sporadic neuron damage emerging in the central nervous system may not only appear as cognitive dysfunction, but might strongly influence features of physiological tremor.

MATERIAL AND METHODS

We investigated 110 patients (age: 34-73 years; 76 male, 34 female; 51 coronary artery bypass grafting (CABG), 25 valve replacement, 25 combined open heart surgery, 9 off-pump CABG) before surgery and after open-heart surgery on the 3(rd) to 5(th) post-operative day. The assessment of the physiological tremor analysis was performed with our newly developed equipment based on the Analog Devices ADXL 320 JPC integrated accelerometer chip. Recordings were stored on a PC and spectral analysis was performed by fast Fourier transformation (FFT). We compared power integrals in the 1-4 Hz, 4-8 Hz and 8-12 Hz frequency ranges and these were statistically assessed by the Wilcoxon rank correlation test.

RESULTS

We found significant changes in the power spectrum of physiological tremor. The spectrum in the 8-12 Hz range (neuronal oscillation) decreased and a shift was recognised to the lower spectrum (p < 0.01). The magnitude of the shift was not significantly higher for females than for males (p < 0.157). We found no significant difference between the shift and the cross-clamp or perfusion time (p < 0.6450).

CONCLUSIONS

The assessment of physiological tremor by means of our novel, feasible method may provide a deeper insight into the mechanism of central nervous system damage associated with open heart surgery.

Neuropsychologic and quality-of-life outcomes after coronary artery bypass surgery with and without cardiopulmonary bypass: a prospective randomized trial

OBJECTIVES

The objective of this study was to compare neuropsychologic and quality-of-life outcomes of patients undergoing off-pump coronary artery bypass surgery to those undergoing coronary artery bypass graft surgery using conventional cardiopulmonary bypass.

DESIGN

A prospective randomized trial of coronary artery bypass graft surgery with and without the use of cardiopulmonary bypass.

SETTING

A cardiothoracic surgery unit at a tertiary hospital.

PARTICIPANTS

Sixty-six patients undergoing coronary artery bypass graft surgery and a control group of 50 participants not undergoing cardiac surgery.

INTERVENTIONS

Patients were randomized to receive coronary artery bypass graft surgery with cardiopulmonary bypass or randomized to coronary artery bypass graft surgery without the use of cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

The proportions of neuropsychologic deficits and improvement in quality-of-life were comparable regardless of whether patients were randomized to receive off-pump coronary artery bypass graft surgery or conventional coronary artery graft surgery with cardiopulmonary bypass.

CONCLUSIONS

Patients receiving coronary artery bypass grafts without cardiopulmonary bypass did not show fewer cognitive deficits or greater improvement in quality of life.

Coronary Artery Bypass Grafting: Patients' and Health Professionals' Views of Recovery After Hospital Discharge

Background: Coronary artery bypass grafting (CABG) is effective in relieving symptoms and reducing mortality but some patients report no improvement or a decline in quality of life and hence do not experience a good recovery after surgery. Little published research has explored patients' and particularly health professionals' views on barriers and facilitators to recovery or the processes by which these factors affect recovery.

Aims: To identify post-discharge facilitators and barriers to recovery after CABG.

Methods: Semi-structured interviews were conducted with 11 patients who had previously undergone elective, isolated, first-time CABG and with 10 health professionals experienced in caring for these patients.

Results: Thematic analysis identified the following themes: person characteristics, including the impact on recovery of anxiety, depression, optimism and determination; rehabilitation classes; social support; and the effect of surgery. Findings indicate a complex relationship between the various barriers and facilitators to recovery and explore possible processes by which these influences on recovery operate.

Conclusions: Findings have indicated areas where health professionals can intervene to aid patients' long-term recovery, and thereby maximise the benefits of CABG, by providing information, support and reassurance particularly to patients who appear anxious and/or depressed.

Coronary artery bypass

Coronary artery bypass grafting as a means of myocardial revascularisation is a remarkably successful operation. Over 25,000 procedures are carried out each year in the UK with an operative mortality of the order of 2% achieved despite an ageing surgical population. Over the last decade, a remarkable increase in the number of patients treated percutaneously by angioplasty and stenting has lead to a levelling off, or even a decline, in the number of patients treated surgically. In an attempt to reduce further the operative morbidity and mortality by excluding that attributable to the extracorporeal circulation, several surgical groups have pioneered performing the procedure without the heart-lung machine (off-pump or OPCAB). Although not a new concept there has been a dramatic increase in its use, lead by the development of sophisticated and disposable devices for stabilising the heart to enable the demanding anastomotic technique required to suture vessels of 1-2 mm often containing degenerative plaque. Concerns remain about the completeness of revascularisation and about the quality of the anastomoses obtained, particularly in the right and circumflex territories which are less accessible than the anterior descending artery. Although some reduction in morbidity has been demonstrated, this has not been as marked as had been hoped. Davies and Wallwork from Papworth argue persuasively and colourfully in favour of the conventional operation and point out the difficulties in designing an appropriate, prospective, randomised,controlled clinical trial because of the apparently small differences in outcome between the two techniques. Amrani and colleagues from Harefield, leading proponents of off-pump surgery using it in virtually 100% of patients undergoing revascularisation, extensively review the comparative literature to date.

Assessment of Health-Related Quality of Life after Coronary Revascularization

The use of patient-oriented outcomes, in particular health-related quality if life (HRQOL), to evaluate coronary revascularization is continuously increasing. Current data underline that patients undergoing conventional CABG show a tremendous improvement of HRQOL status as early as 3 months postoperatively. There seems to be no clear benefit concerning HRQOL for off-pump coronary surgery versus conventional CABG. The benefits of minimal invasive CABG via mini-thoracotomy are compromised by increased incidence of pain during the immediate postoperative period. Totally endoscopic approaches seem to be more effective with regard to pain reduction and resume of every day activities. Compared to catheter-based interventions there is evidence that conventional CABG offers significant advantages over PCI. The influence of drug-eluting stents and newer surgical techniques on HRQOL remains to be determined. Inclusion of HRQOL data in CABG and PCI databases can play a central role in order to identify patient groups who benefit the most from each revascularization strategy.