Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project

Gait speed assessment as a prognostic tool for morbidity and mortality in vulnerable older adult patients following vascular surgery

INTRODUCTION

Predicting the risk associated with vascular surgery in older adult patients has become increasingly challenging, primarily due to limitations in existing risk assessment tools. This study aimed to evaluate the utility of gait speed, a clinical indicator of frailty, in enhancing the prediction of mortality and morbidity in older adult patients undergoing vascular surgery.

METHODS

A single-center prospective cohort study was conducted, involving older adult patients undergoing vascular surgery at four tertiary care hospitals between 2021 and 2022. Eligible patients were aged 80 years or older and scheduled for surgical treatment of peripheral arterial disease of the lower limbs (IIb Leriche-Le Fontaine). The primary factor of interest was gait speed, defined as taking more than 6 s to walk 5 meters. The primary outcomes were in-hospital postoperative mortality and major morbidity.

RESULTS

The cohort comprised 131 patients with a mean age of 82.8 ± 1.4 years, with 34 % being female. Before vascular surgery, 60 patients (46 %) were categorized as slow walkers. Slow walkers were more likely to be female (43 % vs. 25 %, p < 0.03) and diabetic (50 % vs. 28 %, p < 0.01). Among the patients, 30 (23 %) experienced the primary composite outcome of mortality or major morbidity following vascular surgery. After adjusting for the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) Surgical Risk Calculator, slow gait speed independently predicted the composite outcome (odds ratio: 3.05; 95 % confidence interval: 1.23 to 7.54).

CONCLUSIONS

Gait speed is a straightforward and effective test that can help identify a subgroup of frail older adult patients at an elevated and incremental risk of mortality and major morbidity after vascular surgery. While gait speed remains a valuable clinical indicator of frailty, it is important to recognize that the broader context of mobility plays a pivotal role in postoperative outcomes.

Functional capacity in smoking patients after coronary artery bypass grafting surgery: a quasi-experimental study

Coronary artery bypass grafting surgery (CABG) is an important approach to treating coronary heart disease. However, patients undergoing open heart surgery are at risk of postoperative complications. Cigarette smoking is one of the preoperative risk factors that may increase postoperative complications. Studies show that early mobilization intervention may reduce these complications and improve functional capacity, but the impact of smoking on early outcomes after CABG has been controversial for the past two decades. This quasi-experimental study explored the effects of early mobilization on functional capacity among patients with different smoking histories undergoing CABG. The study involved 51 participants who underwent CABG surgery, divided into three groups: current smokers, former smokers, and non-smokers (n=17 each). A day before surgery, all groups underwent a six-minute walking test (6MWT). Every participant received the same intervention after surgery, including deep breathing exercises, an upper limb range of motion assessment, an incentive spirometer, and walking with and without assistance. Five days postoperatively, all outcomes - including the 6MWT, length of stay (LOS) in the ICU, and postoperative pulmonary complications - were assessed, and the 6MWT was repeated. There was a reduced functional capacity after CABG in ex-smokers (215.8±102 m) and current smokers (272.7±97m) compared to non-smokers (298.5±97.1m) in terms of 6MWT (p<0.05). Current smokers were more likely to have atelectasis after CABG than ex-smokers (76.5% vs. 52.9%), with non-smokers being the least likely to have atelectasis among the three groups (29.4%, p<0.05). Additionally, current smokers required longer ventilator support post-CABG (11.9±7.3 hours) compared to ex-smokers (8.3±4.3 hours) and non-smokers (7±2.5 hours, p<0.01). Smoking status significantly impacts functional capacity reduction after CABG, with current smokers being more susceptible to prolonged ventilator use and atelectasis.

Hemodynamic Monitoring Using a Pulmonary Artery Catheter Versus the Vigileo/FloTrac System during Elective Cardiac Surgery Based on Real-world Data in Japan

BACKGROUND

The controversy concerning the benefits of pulmonary artery catheter (PAC)-based hemodynamic monitoring in cardiac surgeries has not been adequately addressed. This study aims to compare the all-cause mortality between the PAC with venous oxygen saturation monitoring and the Vigileo/FloTrac (FloTrac) system with central venous oxygen saturation monitoring in cardiac surgeries.

METHODS

This nationwide retrospective study includes adult patients who underwent elective cardiac surgeries between April 2010 and October 2014, based on the Japanese health insurance claims database. The main outcome was 30-day all-cause mortality. Propensity scores (PS) were used to adjust for the confounding factors. Treatment effects were estimated using multivariable logistic regression analysis, including PS.

RESULTS

A total of 5,838 patients were included in this study. The crude 30-day mortality rates were 2.4% (8/334) and 1.7% (96/5,504) in the FloTrac and PAC groups, respectively. After PS matching, the ORs for 30-day all-cause mortality, in-hospital mortality after PAC placement (vs. FloTrac) were 0.36 (95% CI: 0.05-2.37; p = 0.28) and 0.59 (95% CI: 0.16-2.20; p = 0.43), respectively. The amount of dobutamine was larger in the PAC group (281 ± 31 mg vs 155 ± 19 mg; p < 0.001). There were no significant differences in the amounts of other inotropes, the volume of fluids, or blood transfusions.

CONCLUSIONS

The association between PAC (with venous oxygen saturation monitoring) and mortality in patients who underwent elective cardiac surgeries was unclear compared to FloTrac (with central venous oxygen saturation monitoring). Additional investigation is needed to evaluate the benefits of PAC-specific hemodynamic parameters in this population.

Prognostic Value of GDF-15 in Predicting Prolonged Intensive Care Stay following Cardiac Surgery: A Pilot Study

INTRODUCTION

Predicting intensive care unit length of stay and outcome following cardiac surgery is currently based on clinical parameters. Novel biomarkers could be employed to improve the prediction models.

MATERIALS AND METHODS

We performed a qualitative cytokine screening array to identify highly expressed biomarkers in preoperative blood samples of cardiac surgery patients. After identification of one highly expressed biomarker, growth differentiation factor 15 (GDF-15), a quantitative ELISA was undertaken. Preoperative levels of GDF-15 were compared in regard to duration of intensive care stay, cardiopulmonary bypass time, and indicators of organ dysfunction.

RESULTS

Preoperatively, GDF-15 was highly expressed in addition to several less highly expressed other biomarkers. After qualitative analysis, we could show that preoperatively raised levels of GDF-15 were positively associated with prolonged ICU stay exceeding 48 h (median 713 versus 1041 pg/ml, p = 0.003). It was also associated with prolonged mechanical ventilation and rates of severe sepsis but not with dialysis rates or cardiopulmonary bypass time. In univariate regression, raised GDF-15 levels were predictive of a prolonged ICU stay (OR 1.01, 95% confidence interval 1-1.02, and p = 0.029). On ROC curves, GDF-15 was found to predict prolonged ICU stay (AUC = 0.86, 95% confidence interval 0.71-0.99, and p = 0.003).

CONCLUSION

GDF-15 showed potential as predictor of prolonged intensive care stay following cardiac surgery, which might be valuable for risk stratification models.

Intensive care outcome of left main stem disease surgery: A single center three years’ experience

BACKGROUND

Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.

AIM

To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.

METHODS

Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups.

RESULTS

Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures.

CONCLUSION

Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients’ care.

Preemptive percutaneous coronary intervention for coronary artery disease: identification of the appropriate high-risk lesion

PURPOSE OF REVIEW

Management of patients with coronary artery disease (CAD) has been based on identification of a coronary obstruction causing ischemia and performing a revascularization procedure to reduce that ischemia, with the goal of thereby preventing subsequent major adverse cardiac events (MACEs) in that vascular territory. Recent investigations demonstrate that preemptive percutaneous coronary intervention (PCI) of nonculprit coronary lesions (NCLs) that may not cause ischemia in patients with ST-segment elevation myocardial infarction (STEMI) reduces MACE. In this review, we focus on preemptive PCI, discuss its mechanistic benefits and speculate on its potential value for other coronary syndromes.

RECENT FINDINGS

The COMPLETE trial in STEMI patients treated with primary PCI demonstrated that preemptive PCI of NCL obstructions, which may not cause ischemia, but often exhibit high-risk OCT plaque characteristics, reduced cardiovascular death or nonfatal myocardial infarction. Reduction in MACE from preemptive PCI of NCL was similar for lesions confirmed to cause ischemia (fractional flow reserve <0.80) and for lesions that were only visually assessed to have luminal obstruction at least 70%.The ISCHEMIA trial in patients with stable CAD and moderate/severe ischemia demonstrated that MACE risk increased progressively with more extensive atherosclerosis, but that performing PCI of ischemia-producing lesions did not reduce MACE. Adverse cardiac events likely originated in high-risk plaque areas not treated with PCI.

SUMMARY

In STEMI patients, preemptive PCI of high-risk NCL that may not cause ischemia improves long-term MACE. In stable CAD patients, MACE increases as the atherosclerotic burden increases, but PCI of the ischemia-producing lesion itself does not improve outcomes compared with optimal medical therapy. Adverse events likely originate in high-risk plaque areas that are distinct from ischemia-producing obstructions. Identification of highest-risk atherosclerotic lesions responsible for future MACE may provide an opportunity for preemptive PCI in patients with a variety of coronary syndromes.

Gender difference in long- and short-term outcomes of off-pump coronary endarterectomy

Background

The role of gender in the selection of the most effective method for treatment of patients with diffused coronary artery diseases remains a matter of debate. This study thus evaluated the effect of gender on long- and short-term outcomes of off-pump coronary endarterectomy (CE).

Methods

This was a single-center retrospective study of patients who had undergone coronary artery bypass graft (CABG). The patients were divided into two groups, the CABG and the CABG + CE group, and further stratified into male and female. Long-term survival for each group was estimated by Kaplan-Meier analysis with log-rank testing. In addition, Cox regression analyses of each gender were also carried out to identify the predictors of the primary and secondary endpoints.

Results

Overall, 25.8% of the patients were female. Diseased vessels were not statistically different in the two groups - men and women. There was no significant difference in postoperative outcomes between males and females in the CABG and CABG + CE groups. There was no significant difference in hospital mortality in the two groups between males and females. Kaplan-Meier curves show that there was no significant difference in the 5-year cardiac mortality between males and females belonging to the CABG and CABG + CE groups.

Conclusion

The results of this study show that there was no significant difference in the short- and long-term outcomes of off-pump CABG and CE in both genders although women tend to carry a greater risk.

Effect of previous coronary stenting on subsequent coronary artery bypass grafting outcomes

OBJECTIVES

The effect of previous coronary stenting on subsequent coronary artery bypass graft is inconclusive.

METHODS

We used Taiwan's National Health Insurance Database to retrospectively evaluate patients with multivessel coronary artery bypass graft between January 2000 and December 2013. Overall, 32,335 patients who received coronary artery bypass graft were included, of whom 3028 had previous coronary stenting. Propensity-score matching yielded 2977 cases each for evaluation under the previous stenting and no stenting groups. The 30-day mortality and major adverse cardiac events, including all-cause mortality, acute myocardial infarction, and revascularization, were considered primary outcomes.

RESULTS

The number of coronary artery bypass grafts decreased per year. However, the percentage of patients who had previous coronary stent implantation before coronary artery bypass graft increased steadily (P for trend <.001), and the average number of stents implanted in a patient also increased per year (P for trend <.001). The previous stent group had a significantly greater 30-day mortality rate than did the no-stent group (7.2% vs 5.0%; odds ratio, 1.47; 95% confidence interval, 1.19-1.82). The previous stent group had a greater rate of revascularization (14.4% and 10.0%; subdistribution hazard ratio, 1.50; 95% confidence interval, 1.30-1.74) in the last follow-up at year 13.

CONCLUSIONS

Previous coronary stenting before coronary artery bypass graft for multivessel coronary artery disease significantly increased 30-day mortality but did not affect late survival. However, patients who had coronary stenting before coronary artery bypass graft experienced more revascularization events during late follow-up.

Incidence, Predictors, and Impact of Clostridium difficile Infection on Cardiac Surgery Outcomes

BACKGROUND

Clostridium difficile infection (CDI) has been associated with morbidity and mortality after cardiac operations. The present study examined incidence, predictors, and impact of CDI on inpatient mortality and resource utilization.

METHODS

An analysis of adult patients undergoing elective coronary artery bypass grafting or valvular operations from 2005 to 2016 was performed using the National Inpatient Sample. Trends in CDI were assessed using a modified Cochran-Armitage analysis. Multivariable multilevel regressions were used to identify predictors of CDI, and propensity-matched pairs were generated using Mahalanobis 1-to-1 matching to compare mortality, length of stay, and costs of CDI patients with the non-CDI cohort.

RESULTS

The overall rate of CDI for an estimated 2,026,267 patients who underwent elective major cardiac surgery was 0.5% with no change in incidence (P for trend = .99). Predictors of CDI included advanced age (≥65 y; adjusted odds ratio [AOR], 1.88; 95% confidence interval [CI], 1.58-2.24), female gender (AOR, 1.29; 95% CI, 1.15-1.44), heart failure (AOR, 1.57; 95% CI, 1.40-1.76), and combined coronary artery bypass grafting/valve operations (AOR, 1.60; 95% CI, 1.24-2.08). Neither region nor bed size was associated with CDI. In contrast CDI mortality was lower at teaching hospitals compared with rural hospitals. Among matched pairs CDI was independently associated with higher mortality, length of stay, and Gross Domestic Product-adjusted costs.

CONCLUSIONS

CDI occurs in less than 1% of all elective, major cardiac operations. Patient predictors included advanced age, female gender, and several chronic comorbidities. Teaching institutions had the highest odds of CDI but lowest odds of case fatality. Further investigation of factors contributing to CDI is warranted to disseminate institutional best practices.

Coronary Artery Bypass Grafting Among Patients With Prior Percutaneous Coronary Interventions

See Article by Biancari et al .

Predictive Ability of Novel Cardiac Biomarkers ST2, Galectin-3, and NT-ProBNP Before Cardiac Surgery

BACKGROUND

Current preoperative models use clinical risk factors alone in estimating risk of in-hospital mortality following cardiac surgery. However, novel biomarkers now exist to potentially improve preoperative prediction models. An assessment of Galectin-3, N-terminal pro b-type natriuretic peptide (NT-ProBNP), and soluble ST2 to improve the predictive ability of an existing prediction model of in-hospital mortality may improve our capacity to risk-stratify patients before surgery.

METHODS AND RESULTS

We measured preoperative biomarkers in the NNECDSG (Northern New England Cardiovascular Disease Study Group), a prospective cohort of 1554 patients undergoing coronary artery bypass graft surgery. Exposures of interest were preoperative levels of galectin-3, NT-ProBNP, and ST2. In-hospital mortality and adverse events occurring after coronary artery bypass graft were the outcomes. After adjustment, NT-ProBNP and ST2 showed a statistically significant association with both their median and third tercile categories with NT-ProBNP odds ratios of 2.89 (95% confidence interval [CI]: 1.04-8.05) and 5.43 (95% CI: 1.21-24.44) and ST2 odds ratios of 3.96 (95% CI: 1.60-9.82) and 3.21 (95% CI: 1.17-8.80), respectively. The model receiver operating characteristic score of the base prediction model (0.80 [95% CI: 0.72-0.89]) varied significantly from the new multi-marker model (0.85 [95% CI: 0.79-0.91]). Compared with the Northern New England (NNE) model alone, the full prediction model with biomarkers NT-proBNP and ST2 shows significant improvement in model classification of in-hospital mortality.

CONCLUSIONS

This study demonstrates a significant improvement of preoperative prediction of in-hospital mortality in patients undergoing coronary artery bypass graft and suggests that biomarkers can be used to identify patients at higher risk.

Early versus delayed coronary artery bypass graft surgery for patients with non-ST elevation myocardial infarction

BACKGROUND

Although coronary artery bypass graft surgery (CABG) has been proven to have mortality and morbidity benefits in patients with non-ST elevation myocardial infarction and multivessel disease, the appropriate timing of this procedure remains unclear. Therefore, we proposed a propensity score-matched analysis comparing the clinical outcomes between patients who underwent CABG within the first 48 h of admission (early CABG) and patients who underwent CABG after 48 h of admission (delayed CABG).

PATIENTS AND METHODS

Using the largest inpatient care database in the USA, the Nationwide Inpatient Sample, we identified patients with a primary diagnosis of acute myocardial infarction using the ICD 9-DM diagnosis codes. We then performed propensity score-matching analysis to control for 24 possible confounders.

RESULTS

We identified 31 969 patients in the Nationwide Inpatient Sample database with a primary diagnosis of acute myocardial infarction who underwent CABG. The mean age of the cohort was 64.5±11.5 years and 33.4% were female. After performing propensity-matching analysis, we obtained a subset of 1555 patients in each group, with a mean age of 64.7±10.1 years; the male to female ratio was ~4 : 1. The incidence of hemorrhage, shock, and cardiac, pulmonary, and renal complications was comparable between the two groups. The incidence of mortality was not statistically significant between the two groups (2% in the early CABG vs. 1.8% in the delayed CABG, P=0.695). The mortality risk factors were as follows: age more than 70 years [odds ratio (OR): 3.42, 95% confidence interval (CI): 1.85-6.34, P<0.001]; cardiogenic shock (OR: 3.22, 95% CI: 1.35-7.67, P=0.008); and mechanical circulatory support with balloon counterpulsation (OR: 2.93, 95% CI: 1.45-5.90, P=0.003).

CONCLUSION

CABG performed within 48 h of admission does not significantly increase the risk for in-hospital mortality compared with undergoing the procedure after 48 h of admission in propensity-matched patients.

Outcomes of Surgeries Performed in Physician Offices Compared With Ambulatory Surgery Centers and Hospital Outpatient Departments in Florida

BACKGROUND

The proportion of outpatient surgeries performed in physician offices has been increasing over time, raising concern about the impact on outcomes.

OBJECTIVE

To use a private insurance claims database to compare 7-day and 30-day hospitalization rates following relatively complex outpatient surgical procedures across physician offices, freestanding ambulatory surgery centers (ASCs), and hospital outpatient departments (HOPDs).

METHODS

A multivariable logistic regression model was used to compare the risk-adjusted probability of hospitalization among patients after any of the 88 study outpatient procedures at physician offices, ASCs, and HOPDs over 2008-2012 in Florida.

RESULTS

Risk-adjusted hospitalization rates were higher following procedures performed in physician offices compared with ASCs for all procedures grouped together, for most procedures grouped by type, and for many individual procedures.

CONCLUSIONS

Hospitalizations following surgery were more likely for procedures performed in physician offices compared with ASCs, which highlights the need for ongoing research on the safety and efficacy of office-based surgery.

Tabula viva chirurgic: a living surgical document

AIM

The purpose of this article is to present the results of a private cardiac surgical practice. This information could also serve as a hermeneutical text for new wisdom.

METHODS

A personal database of 1 750 consecutive patients who had had coronary artery bypass graft (CABG) surgery was statistically analysed. Mortality and major morbidity figures were compared with large registries. Risk factors for postoperative death were determined.

RESULTS

Over a period of 12 years, 1 344 (76.8%) males and 406 (23.2%) females were operated on. The observed mortality rate was 3.03% and the expected mortality rate (EuroSCORE) was 3.87%. After stepwise logistic regression, independent risk factors for death were urgency (intra-aortic balloon pump), renal impairment (chronic kidney disease, stage III), re-operation and an additional procedure. Apart from the 53 deaths, another 91 patients had major complications.

CONCLUSION

Mortality and morbidity rates compared favourably with other international registries. Mortality was related to co-morbidities. This outcome contributes to a hermeneutical understanding focusing on new spiritual wisdom and meaning for the surgeon.

The Economics of Cardiac Surgery

Health care practitioners are under increasing pressure to identify and reduce the costs of their interventions. Cardiac surgical procedures have been studied extensively to determine which factors increase costs so the costs of future interventions can be reliably predicted. Knowing the cost components of surgical interventions identifies opportunities for increased efficiency and cost reduction. New technologic advances may initially defy cost reduction efforts until randomized controlled trials and cost analyses can be performed.

Should Risk Adjustment for Surgical Outcomes Reporting Include Sociodemographic Status? A Study of Coronary Artery Bypass Grafting in California

BACKGROUND

Public reporting of surgical outcomes must adjust for patient risk. However, whether patient sociodemographic status (SDS) should be included is debatable. Our objective was to empirically compare risk-adjustment models and hospital ratings with or without SDS factors for patients undergoing coronary artery bypass grafting.

STUDY DESIGN

This is a retrospective analysis of the California Coronary Artery Bypass Grafting Outcomes Reporting Program, 2011-2012. Outcomes included 30-day or in-hospital mortality, perioperative stroke, and 30-day readmission. Sociodemographic status factors included race, language, insurance, ZIP code-based median income, and percent that were a college graduate. The c-statistic and goodness-of-fit were compared between models with and without SDS factors. Differences in hospital performance rating when adjusting for SDS were also compared.

RESULTS

None of the SDS factors predicted mortality. Income, education, and language had no impact on any outcomes. Insurance predicted stroke (MediCal vs private insurance, odds ratio [OR] = 1.91; 95% CI, 1.11-3.31; p = 0.020) and readmissions (Medicare vs private insurance, OR = 1.36; 95% CI, 1.16-1.61; p < 0.001; MediCal vs private insurance, OR = 1.56; 95% CI, 1.26-1.94; p < 0.001). Race also predicted stroke (Asian vs white, OR = 2.26; p < 0.001). Adding SDS factors improved the c-statistic in readmission only (0.652 vs 0.645; p = 0.008). Goodness-of-fit worsened when adding SDS factors to mortality models, but was no different in stroke or readmissions. Hospital performance rating only changed in readmissions; of 124 hospitals, only 1 hospital moved from "better" to "average" when adjusting for SDS.

CONCLUSIONS

Adjusting for insurance improves statistical models when analyzing readmissions after coronary artery bypass grafting, but does not impact hospital performance ratings substantially. Deciding whether SDS should be included in a patient's risk profile depends on valid measurements of SDS and requires a nuanced approach to assessing how these variables improve risk-adjusted models.

Sex Differences in Mortality After CABG Surgery

INTRODUCTION

Numerous studies have shown that women undergoing coronary artery bypass graft surgery present higher mortality rate during hospitalization, and often complications when compared to men.

OBJECTIVE

To compare the mortality of men and women undergoing coronary artery bypass graft surgery and identify factors related to differences occasionally found.

METHODS

Retrospective cohort study conducted with 215 consecutive patients who underwent coronary bypass surgery.

RESULTS

Women had a higher average age. Low body surface and dyslipidemia were more prevalent in women (1.65 vs. 1.85, P <0.001: 53% vs. 30%, P =0.001), whereas history of smoking and previous myocardial infarction were more prevalent in men (35% vs.14.7%, P =0.001; 20% vs. 2.7%, P =0.007). Regarding complications in the postoperative period, there was a higher rate of blood transfusions in women. The overall mortality rate was 5.6%, however there was no statistically significant difference in mortality between men and women. It was observed that among the patients who died, the average body surface area was lower than that of patients who did not have this complication.

CONCLUSION

There was no difference in mortality between the sexes after coronary artery bypass graft in this service.

Development of the Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ)

PURPOSE

Some variability in recovery and outcomes after cardiac surgery may be influenced by psychosocial aspects not routinely captured. Preliminary evidence suggests patient expectations impact health status, but there is no specific measure of expectations for cardiac surgery. The purpose of this study was to adapt an expectations scale to cardiac surgery and assess the psychometric properties of the scale.

METHODS

Before surgery, 93 patients awaiting non-emergent cardiac surgery completed questionnaires, including the adapted Cardiac Surgery Patient Expectations Questionnaire (C-SPEQ). At 1 year after surgery, 68 patients completed questionnaires.

RESULTS

Mean C-SPEQ score was 39.4 ± 9.02, and scores were normally distributed (Cronbach's alpha = 0.86). Higher score indicated negative expectations. Higher presurgery C-SPEQ score was correlated with greater depression (r = 0.32, p = 0.01) and perceived stress (r = 0.36, p = 0.003), but not state anxiety (r = 0.18, p = 0.14), at one-year post-surgery. Higher C-SPEQ was associated with longer recovery time (B = 0.14, p = 0.006) and lower physical HRQL after surgery (B = -0.31, p = 0.005). Higher C-SPEQ was not related to greater odds for perioperative complications (OR 1.01, p = 0.68) or readmissions <30 days (OR 1.05, p = 0.31). C-SPEQ score was not related to survival.

CONCLUSIONS

Adaptation of an expectations questionnaire to cardiac surgery patients was successful with acceptable reliability and validity. Negative expectations had a detrimental impact on recovery and HRQL following cardiac surgery but were not related to clinical outcomes. Although focus is mainly on improving clinical outcomes, there are opportunities to improve non-clinical aspects of the patient experience. Presurgical education might better prepare patients, reduce negative expectations, and improve psychosocial outcomes after cardiac surgery.

Early outcome of Coronary Artery Bypass Graft Surgery in patients with significant Left Main Stem stenosis at a tertiary cardiac care center

Objective:

Primary objective of this study was to evaluate the impact of significant left main stem (LMS) stenosis on the early outcome of coronary artery bypass graft (CABG) surgery.

Methods:

A Retrospective non-randomized analytical study was conducted in Cardiac surgery department, Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, Pakistan. The data of patients who underwent isolated CABG at our institution from February 2008 to March 2014 were analyzed. Two thousand six hundred two (2602) patients of isolated CABG were divided into 2 groups according to the LMS disease. Group I (n=2088): without significant LMS disease and Group II (n=514): with LMS disease. Data was analyzed using SPSS V16. The groups were compared using Student’s t-test for numeric variables. Chi-square test and Fishers Exact test were used for categorical variables. P-value ≤ 0.05 was considered as significant difference.

Results:

Out of two thousand six hundred two, 2088 patients were in Non.LMS group (Control Group) and five hundred fourteen were in LMS Group (Study Group). Patients with LMS disease were older. In both groups there was no statistically significant difference regarding gender distribution, risk factors of IHD, pre-operative renal function and preoperative CKMB levels. Significant number 50 (9.7%) of patients were unstable in LMS group and they needed urgent surgery (p-value <0.0001). Need and duration for inotropic support and intra-aortic balloon counter-pulsation support were significantly high in LMS group (p-value <0.0001, 0.002, 0.003 respectively). Similarly Mechanical ventilation time and hospital stay were higher in LMS group. Incidence of pulmonary complications and operative mortality were significantly higher in LMS group (p-value 0.005 and 0.001 respectively). Mortality of CABG patients with significant left main coronary stenosis was 13 out of five hundred fourteen (2.5%) as compared to just 17 out of two thousand eighty eight (0.8%) in control group.

Conclusion:

This study showed that significant LMS disease is an independent risk factor for early cardiopulmonary morbidity and mortality after CABG surgery.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.

Predicting the risk of death following coronary artery bypass graft made simple: a retrospective study using the American College of Surgeons National Surgical Quality Improvement Program database

INTRODUCTION

Risk models to predict 30-day mortality following isolated coronary artery bypass graft is an active area of research. Simple risk predictors are particularly important for cardiothoracic surgeons who are coming under increased scrutiny since these physicians typically care for higher risk patients and thus expect worse outcomes. The objective of this study was to develop a 30-day postoperative mortality risk model for patients undergoing CABG using the American College of Surgeons National Surgical Quality Improvement Program database.

MATERIAL AND METHODS

Data was extracted and analyzed from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2010). Patients that had ischemic heart disease (ICD9 410-414) undergoing one to four vessel CABG (CPT 33533-33536) were selected. To select for acquired heart disease, only patients age 40 and older were included. Multivariate logistic regression analysis was used to create a risk model. The C-statistic and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the model. Bootstrap-validated C-statistic was calculated.

RESULTS

A total of 2254 cases met selection criteria. Forty-nine patients (2.2%) died within 30 days. Six independent risk factors predictive of short-term mortality were identified including age, preoperative sodium, preoperative blood urea nitrogen, previous percutaneous coronary intervention, dyspnea at rest, and history of prior myocardial infarction. The C-statistic for this model was 0.773 while the bootstrap-validated C-statistic was 0.750. The Hosmer-Lemeshow test had a p-value of 0.675, suggesting the model does not overfit the data.

CONCLUSIONS

The American College of Surgeons National Surgical Quality Improvement Program risk model has good discrimination for 30-day mortality following coronary artery bypass graft surgery. The model employs six independent variables, making it easy to use in the clinical setting.

The impact of high-risk cases on hospitals' risk-adjusted coronary artery bypass grafting mortality rankings

BACKGROUND

Risk-adjusted mortality (RAM) models are increasingly used to evaluate hospital performance, but the validity of the RAM method has been questioned. Providers are concerned that these methods might not adequately account for the highest levels of risk and that treating high-risk cases will have a negative impact on RAM rankings.

METHODS

Using cases of isolated coronary artery bypass grafting (CABG) performed at 1002 sites in the United States participating in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 2008 to 2010 (N = 494,955), the STS CABG RAM model performance in high-risk patients was assessed. The ratios of observed to expected (O/E) perioperative mortality were compared among groups of hospitals with varying expected risks. Finally, RAM rates during the overall study period for each site were compared with its performance in a simulated "nightmare year" in which the site's highest risk cases over a 3-year period were concentrated into a 1-year period of exceptional risk.

RESULTS

The average predicted mortality for center risk groups ranged from 1.46% for the lowest risk quintile to 2.87% for the highest. The O/E ratios for center risk quintiles 1 to 5 during the overall period were 1.01 (95% confidence interval, 0.96% to 1.06%), 1.00 (0.95% to 1.04%), 0.98 (0.94% to 1.03%), 0.97 (0.93% to 1.01%), and 0.80 (0.77% to 0.84%), respectively. The sites' risk-adjusted mortality rates were not increased when the centers' highest risk cases were concentrated into a single "nightmare year."

CONCLUSIONS

Our results show that the current risk-adjusted models accurately estimate CABG mortality and that hospitals accepting more high-risk CABG patients have equal or better outcomes than do those with predominately lower-risk patients.

Performance of InsCor and three international scores in cardiac surgery at Santa Casa de Marília

OBJECTIVE

To apply and to compare the Society of Thoracic Surgery score (STS), EuroSCORE (Eurosc1), EuroSCORE II (Eurosc2) and InsCor (IS) for predicting mortality in patients undergoing to coronary artery bypass graft and/or valve surgery at the Santa Casa Marilia.

METHODS

The present study is a cohort. It is a prospective, observational, analytical and unicentric. We analyzed 562 consecutive patients coronary artery bypass graft and/or valve surgery, between April 2011 and June 2013 at the Santa Casa Marilia. Mortality was calculated for each patient through the scores STS, Eurosc1, Eurosc2 and IS. The calibration was calculated using the Hosmer Lemeshow test and discrimination by ROC curve.

RESULTS

The hospital mortality was 4,6%. The calibration is generally adequate group P=0.345, P=0.765, P=0.272 and P=0.062 for STS, Eurosc1, Eurosc2, and IS respectively. The discriminatory power of STS score 0.649 (95% CI 0.529 to 0.770, P=0.012), Eurosc1 0.706 (95% CI 0.589 to 0.823, P ≤0.001), Eurosc2 was 0.704 (95% CI 0.590-0.818 P=0.001) and InsCor 0.739 (95% CI 0.638 to 0.839, P ≤0.001).

CONCLUSION

We can say that overall, the InsCor was the best model, mainly in the discrimination of the sample. The InsCor showed good accuracy, in addition to being effective and easy to apply, especially by using a smaller number of variables compared to the other models.

Coronary artery bypass grafting: Part 1--the evolution over the first 50 years

Surgical treatment for angina pectoris was first proposed in 1899. Decades of experimental surgery for coronary artery disease finally led to the introduction of coronary artery bypass grafting (CABG) in 1964. Now that we are approaching 50 years of CABG experience, it is appropriate to summarize the advancement of CABG into a procedure that is safe and efficient. This review provides a historical recapitulation of experimental surgery, the evolution of the surgical techniques and the utilization of CABG. Furthermore, data on contemporary clinical outcomes are discussed.

Outcomes of cardiac surgery in the elderly

The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.

The Dutch hospital standardised mortality ratio (HSMR) method and cardiac surgery: benchmarking in a national cohort using hospital administration data versus a clinical database

Objective

To compare the accuracy of data from hospital administration databases and a national clinical cardiac surgery database and to compare the performance of the Dutch hospital standardised mortality ratio (HSMR) method and the logistic European System for Cardiac Operative Risk Evaluation, for the purpose of benchmarking of mortality across hospitals.

Methods

Information on all patients undergoing cardiac surgery between 1 January 2007 and 31 December 2010 in 10 centres was extracted from The Netherlands Association for Cardio-Thoracic Surgery database and the Hospital Discharge Registry. The number of cardiac surgery interventions was compared between both databases. The European System for Cardiac Operative Risk Evaluation and hospital standardised mortality ratio models were updated in the study population and compared using the C-statistic, calibration plots and the Brier-score.

Results

The number of cardiac surgery interventions performed could not be assessed using the administrative database as the intervention code was incorrect in 1.4–26.3%, depending on the type of intervention. In 7.3% no intervention code was registered. The updated administrative model was inferior to the updated clinical model with respect to discrimination (c-statistic of 0.77 vs 0.85, p<0.001) and calibration (Brier Score of 2.8% vs 2.6%, p<0.001, maximum score 3.0%). Two average performing hospitals according to the clinical model became outliers when benchmarking was performed using the administrative model.

Conclusions

In cardiac surgery, administrative data are less suitable than clinical data for the purpose of benchmarking. The use of either administrative or clinical risk-adjustment models can affect the outlier status of hospitals. Risk-adjustment models including procedure-specific clinical risk factors are recommended.

Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population

BACKGROUND

Quality improvement initiatives in cardiac surgery largely rely on risk prediction models. Most often, these models include isolated populations and describe isolated end-points. However, with the changing clinical profile of the cardiac surgical patients, mixed populations models are required to accurately represent the majority of the surgical population. Also, composite model end-points of morbidity and mortality, better reflect outcomes experienced by patients.

METHODS

The model development cohort included 4,270 patients who underwent aortic or mitral valve replacement, or mitral valve repair with/without coronary artery bypass grafting, or isolated coronary artery bypass grafting. A composite end-point of infection, stroke, acute renal failure, or death was evaluated. Age, sex, surgical priority, and procedure were forced, a priori, into the model and then stepwise selection of candidate variables was utilized. Model performance was evaluated by concordance statistic, Hosmer-Lemeshow Goodness of Fit, and calibration plots. Bootstrap technique was employed to validate the model.

RESULTS

The model included 16 variables. Several variables were significant such as, emergent surgical priority (OR 4.3; 95% CI 2.9-7.4), CABG + Valve procedure (OR 2.3; 95% CI 1.8-3.0), and frailty (OR 1.7; 95% CI 1.2-2.5), among others. The concordance statistic for the major adverse cardiac events model in a mixed population was 0.764 (95% CL; 0.75-0.79) and had excellent calibration.

CONCLUSIONS

Development of predictive models with composite end-points and mixed procedure population can yield robust statistical and clinical validity. As they more accurately reflect current cardiac surgical profile, models such as this, are an essential tool in quality improvement efforts.

[Correlation between previous coronary artery stenting and early mortality in patients undergoing coronary artery bypass graft surgery]

BACKGROUND

In this study, we examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome in patients undergoing coronary artery bypass graft surgery (CABG).

METHODS

Outcomes of 240 CABG patients, collected consecutively in an observational study, were compared. Gp A (n=35) had prior PCI before CABG and Gp B (n=205) underwent primary CABG.

RESULTS

Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 48.6% vs 36.6% (P=0.003), distribution of CAD (P=0.0001), unstable angina: 45.7% vs 39% (P=0.04). For intraoperative data, the total number of established bypasses was 2.6 (GpA) vs 2.07 (Gp B) (P=0.017), with the number of arterial bypass grafts being: 20% vs 13% (P=ns). Regarding the postoperative course, no significant difference in troponine I rate, 24-hour bleeding: 962 ml (Gp A) vs 798 ml (Gp B) (P=0.004), transfusion (PRBC unit): 3.63 (Gp A) vs 2.5 (Gp B) (P=0.006). Previous PCI emerged as an independent predictor of postoperative in-hospital mortality (OR 2.24, 95% CI [1.52-2.75], P<0.01).

CONCLUSION

Patients with prior PCI presented for CABG with more severe CAD. Thirty-day mortality and morbidity were significantly higher in patients with prior PCI.

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.

The effect of the metabolic syndrome on the risk and outcome of coronary artery bypass graft surgery

Background

The individual components of the metabolic syndrome are risk factors for coronary artery disease. The underlying pathophysiology of a low-grade inflammatory process postulates that the metabolic syndrome could compromise a procedure such as coronary artery bypass graft surgery (CABG) done on cardiopulmonary bypass (CPB).

Methods

From a single institution, 370 patients with the metabolic syndrome (IDF and ATP III criteria) and 503 patients without the metabolic syndrome were identified. The influence of the metabolic syndrome on the pre-operative core risk factors for CABG mortality as well as its effect on the mortality and major morbidity post surgery were investigated.

Results

Patients with the metabolic syndrome were operated on less urgently than those without the metabolic syndrome. The EuroSCORE was also lower in those with the metabolic syndrome. Patients with the metabolic syndrome required fewer units of homologous red blood cells, but stayed statistically longer in hospital.

Conclusions

In this surgical population the metabolic syndrome had no detrimental clinical effect on either the pre-operative risk factors or the outcome after CABG.

Preoperative anxiety as a predictor of mortality and major morbidity in patients aged >70 years undergoing cardiac surgery

The present study examined the association between patient-reported anxiety and postcardiac surgery mortality and major morbidity. Frailty Assessment Before Cardiac Surgery was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals from 2008 to 2009. The patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale, a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was a high level of anxiety, defined by a Hospital Anxiety and Depression Scale score of ≥ 11. The main outcome measure was all-cause mortality or major morbidity (e.g., stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression analysis examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for the Society of Thoracic Surgeons predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the Hospital Anxiety and Depression Scale. High levels of preoperative anxiety were present in 7% of patients. No differences were found in the type of surgery and Society of Thoracic Surgeons predicted risk across the preoperative levels of anxiety. After adjusting for potential confounders, high preoperative anxiety was remained independently predictive of postoperative mortality or major morbidity (odds ratio 5.1, 95% confidence interval 1.3 to 20.2; p = 0.02). In conclusion, although high levels of anxiety were present in few patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

Edifoligide and long-term outcomes after coronary artery bypass grafting: PRoject of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) 5-year results

BACKGROUND

Edifoligide, an E2F transcription factor decoy, does not prevent vein graft failure or adverse clinical outcomes at 1 year in patients undergoing coronary artery bypass grafting (CABG). We compared the 5-year clinical outcomes of patients in PREVENT IV treated with edifoligide and placebo to identify predictors of long-term clinical outcomes.

METHODS

A total of 3,014 patients undergoing CABG with at least 2 planned vein grafts were enrolled. Kaplan-Meier curves were generated to compare the long-term effects of edifoligide and placebo. A Cox proportional hazards model was constructed to identify factors associated with 5-year post-CABG outcomes. The main outcome measures were death, myocardial infarction (MI), repeat revascularization, and rehospitalization through 5 years.

RESULTS

Five-year follow-up was complete in 2,865 patients (95.1%). At 5 years, patients randomized to edifoligide and placebo had similar rates of death (11.7% and 10.7%, respectively), MI (2.3% and 3.2%), revascularization (14.1% and 13.9%), and rehospitalization (61.6% and 62.5%). The composite outcome of death, MI, or revascularization occurred at similar frequency in patients assigned to edifoligide and placebo (26.3% and 25.5%, respectively; hazard ratio 1.03 [95% CI 0.89-1.18], P = .721). Factors associated with death, MI, or revascularization at 5 years included peripheral and/or cerebrovascular disease, time on cardiopulmonary bypass, lung disease, diabetes mellitus, and congestive heart failure.

CONCLUSIONS

Up to a quarter of patients undergoing CABG will have a major cardiac event or repeat revascularization procedure within 5 years of surgery. Edifoligide does not affect outcomes after CABG; however, common identifiable baseline and procedural risk factors are associated with long-term outcomes after CABG.

Surgical candidacy and selection biases in nonemergent left main stenting: implications for observational studies

OBJECTIVES

This study sought to characterize reasons for surgical ineligibility in patients undergoing nonemergent unprotected left main (ULM) percutaneous coronary intervention (PCI) and to assess the potential for these reasons to confound comparative effectiveness studies of coronary revascularization.

BACKGROUND

Although both PCI and coronary artery bypass graft surgery are treatments for ULM disease, some patients are not eligible for both treatments, which may result in treatment selection biases.

METHODS

In 101 consecutive patients undergoing nonemergent ULM PCI, mixed methods were used to determine the prevalence of treatment selection dictated by surgical ineligibility and to identify the reasons cited for avoiding coronary artery bypass graft surgery. We then determined whether these reasons were captured by the ACC-NCDR (American College of Cardiology-National Cardiovascular Data Registry) Cath-PCI dataset to assess the ability of this registry to account for biases in treatment selection. Finally, the association of surgical eligibility with long-term outcomes after ULM PCI was assessed.

RESULTS

Treatment selection was dictated by surgical ineligibility in over half the ULM PCI cohort with the majority having reasons for ineligibility not captured by the ACC-NCDR. Surgical ineligibility was a significant predictor of mortality after adjustment for Society of Thoracic Surgeons (hazard ratio [HR]: 5.4, 95% confidence interval [CI]: 1.2 to 25), EuroSCORE (European System for Cardiac Operative Risk Evaluation) (HR: 5.9, 95% CI: 1.3 to 27), or NCDR mortality scores (HR: 6.2, 95% CI: 1.4 to 27).

CONCLUSIONS

Surgical ineligibility dictating treatment selection is common in patients undergoing nonemergent ULM PCI, occurs on the basis of risk factors not captured by the ACC-NCDR, and is independently associated with worse long-term outcomes after adjusting for standard risk scores.