The early clinical and angiographic outcome of sequential coronary artery bypass grafting with the off-pump technique

No-Touch Sequential Saphenous Venous Harvesting Technique in Off-Pump Bypass Surgery: A Retrospective Study

Background

In the mid-1990s, the Swedish expert team proposed saphenous vein graft (SVG) harvesting with pedicle tissue. The short-term and long-term patency rates of the great saphenous vein obtained by the no-touch (NT) were higher than those obtained by the conventional (CON). In the past, NT harvesting was mainly used in on-pump coronary artery bypass grafting (CABG), and vein grafts were mostly single vein grafts. In this study, we retrospectively analyzed the safety and effectiveness of sequential vein grafts using NT harvesting in off-pump CABG.

Methods

From 2017 to 2019, a total of 505 patients were included in the study. There were 150 patients in the NT group and 355 patients in the CON group. After applying propensity score matching (1:1 matching), 148 patients were included in each group. Baseline data, graft patency, post-operative complications, leg wound complications and 1-year major adverse cardiac and cerebrovascular events (MACCEs) were compared between the two groups.

Results

There was no significant difference in the patency rate of sequential venous grafts between the two groups 1 year after the operation either before [NT: 7.1% (10/141) vs. CON: 11.5% (38/331), p = 0.149) or after matching (NT: 7.1% (10/140) vs. CON: 7.3% (9/124), p = 0.971]. There was no significant difference in the composite clinical endpoint between the two groups either before [NT: 3 (2.3%) vs. CON: 9 (2.8%), p = 1.000] or after matching [NT: 3 (2.3%) vs. CON: 3 (2.5%), p = 1.000]. There were differences in leg wound complications between the two groups both before [NT: 9 (6.9%) vs. CON: 6 (1.9%), p = 0.007] and after matching [NT: 9 (6.9%) vs. CON: 2 (1.7%), p = 0.043].

Conclusions

The application of the NT harvesting in off-pump CABG with sequential vein grafts is safe and effective. NT method has disadvantages in leg wound.

The expansion of no-touch harvesting sequential vein graft after off-pump coronary artery bypass grafting

Background and Aim of the Study

Many studies support that the no‐touch (NT) procedure can improve the patency rate of vein grafts. However, it is not clear that the sequential vein graft early expansion in the NT technique during off‐pump coronary artery bypass grafting (CABG). This study will explore this issue.

Methods

This was a prospective single‐center randomized controlled clinical trial. A total of 100 patients undergoing off‐pump CABG with the sequential saphenous graft were randomly assigned to two groups: the NT and conventional (CON) groups. Perioperative and postoperative data were collected during the hospital stay. The mean diameter of sequential grafts was measured using cardiac computed tomography angiography 3 months after the operation.

Results

There was a significant difference in the average diameter of sequential grafts between the two groups (NT: [2.98 ± 0.42], CON: [3.26 ± 0.51], p = .005). There was no difference in occlusion of sequential venous grafts between the two groups (NT: 4/48 [8.3%], CON: 5/49 [10.2%], p = 1.000). There were differences in surgery time between the two groups (NT: 220 [188,240], CON: 190 [175,230], p = .009).

Conclusions

The sequential graft early expansion in the NT technique is not as pronounced as that in the conventional technique, which may have a long‐term protective effect on the grafts.

Ten-year improved survival in patients with multi-vessel coronary disease and poor left ventricular function following surgery: A retrospective cohort study

OBJECTIVE

Patients with multi-vessel coronary artery disease and poor left ventricular (LV) function (ejection fraction [EF] < 30%) requiring revascularization are considered 'high-risk'. Limited long-term survival data exists comparing percutaneous coronary intervention (PCI) with second-generation drug-eluting stents (DES) versus surgery for this cohort of patients.

METHODS

We retrospectively reviewed our data for 321 patients with EF < 30% who underwent multi-vessel revascularization from January 2005 to December 2015 using Cox regression analyses and inverse probability treatment weighted (IPTW) methods. We stratified patients that underwent surgical revascularization into on-pump coronary artery bypass grafting (CABG) and off-pump CABG and analyzed all-cause mortality at 10 years compared to PCI.

RESULTS

214 patients underwent CABG (n [on-pump CABG] = 94; n [off-pump CABG] = 120) and 107 patients had PCI with second generation DES. PCI with DES had higher 10-year mortality compared with on-pump CABG (Hazard ratio [HR] = 1.86, 95% confidence interval [CI] = 1.46-2.42; p < 0.001) and off-pump CABG (HR = 2.32, 95% CI = 1.75-3.15; p < 0.001). This was confirmed in IPTW analyses. When adjusting for both measured and unmeasured factors using instrumental variable analyses, PCI with DES had higher 10-year mortality compared with on-pump CABG (Δ = 13.5, 95% CI = 3.2-24.5; p = 0.012) and off-pump CABG (Δ = 16.1, 95% CI = 5.9-25.8; p < 0.001).

CONCLUSION

Surgical revascularization, preferably off-pump CABG, results in better long-term survival compared with PCI using second generation DES for patients with multi-vessel coronary artery disease and poor left ventricular function. Randomized controlled trials in this patient group should be undertaken.

Internal mammary harvesting: Techniques and evidence from the literature

Coronary artery bypass graft (CABG) is one of the most commonly performed cardiac surgeries in the world. CABG using the internal mammary artery (IMA) remains the gold standard intervention for myocardial intervention in multivessel coronary artery disease. IMA harvesting can be performed with various techniques and approaches: pedicled vs skeletonized harvesting technique as well as approaches such as conventional sternotomy, robotic and endoscopic approaches. While each technique and approach have their respective advantages and disadvantages, evidence remains varied between cohorts. Traditionally, IMA has been used as an in situ conduit; however, IMA free grafts also provide satisfactory outcomes in certain situations. This literature review aims to explore the efficacy of different techniques and approaches of IMA harvesting and grafting. With evidence compiled, this will provide an overview of the complexity of CABG and locate gaps in current literature to direct future research.

Sequential Versus Individual Saphenous Vein Grafting During Coronary Arterial Bypass Surgery

BACKGROUND

Although multiarterial grafting or bilateral mammary artery use is being increasingly emphasized for contemporary coronary artery bypass grafting (CABG) practice, saphenous vein graft (SVG) is still the most frequently used CABG conduit, and it accounts for 80% of all CABG conduits. Research focusing on modifiable surgical factors such as anastomosis technique, however, is scarce. This study aimed to compare clinical outcomes and graft patency according to anastomosis methods of vein grafting.

METHODS

From January 2005 through December 2016, patients who underwent CABG using SVG either by a sequential or an individual grafting technique were enrolled in this study. Graft patency was evaluated with coronary computed tomographic angiography. Propensity-score matching was used to compare the clinical outcomes and graft patency of these 2 grafting techniques to reduce treatment selection bias.

RESULTS

Overall 2515 eligible patients, 1,037 in the sequential SVG graft group (41.3%) and 1478 (58.8%) in the individual SVG graft group were enrolled. After propensity-score matching, 901 matched pairs of patients and 891 matched pairs of grafts were included in the final outcome analysis. There were no significant differences in unadjusted (P = .83) and adjusted overall mortality (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.79 to 1.17; P = .67). The composite outcome of death, nonfatal myocardial infarction, and repeat revascularization also did not significantly differ between the sequential SVG and the individual SVG groups for both before (P = .20) and after matching (HR, 0.91; 95% CI, 0.75 to 1.09; P = .30). The sequential grafts showed superior patency as compared with the individual grafts for both before (P = .015) and after adjustment (HR, 0.61; 95% CI, 0.45 to 0.82; P < .001).

CONCLUSIONS

The sequential grafting technique of SVG showed fairly acceptable safety and efficacy with superior long-term graft patency than individual grafts. Sequential SVG grafts perhaps can be a reasonable option as a second graft in CABG in some clinical situations.

Patency of Individual and Sequential Coronary Artery Bypass in Patients with Ischemic Heart Disease: A Meta-analysis

Objective

To evaluate the patency of individual and sequential coronary artery bypass in patients with ischemic heart disease.

Methods

We searched PubMed, Cochrane Library, Excerpta Medica Database, and ClinicalTrials.gov databases for controlled trials. Endpoints included graft patency, anastomosis patency, occluded rates in left anterior descending (LAD) system and right coronary artery (RCA) system, in-hospital mortality, and follow-up mortality. Pooled risk ratios (RRs) and standardized mean difference (SMD) were used to assess the relative data.

Results

Nine cohorts, including 7100 patients and 1440 grafts under individual or sequential coronary artery bypass. There were no significant differences between individual and sequential coronary artery bypass in the graft patency (RR=0.96; 95% CI=0.91-1.02; P=0.16; I²=87%), anastomosis patency (RR=0.95; 95% CI=0.91-1.00; P=0.05; I²=70%), occluded rate in LAD system (RR=1.03; 95% CI=0.92-1.16; P=0.58; I²=37%), occluded rate in RCA system (RR=1.36; 95% CI=0.72-2.57; P=0.35; I²=95%), in-hospital mortality (RR=1.57; 95% CI=0.92-2.69; P=0.10; I²=0%), and follow-up mortality (RR=0.96; 95% CI=0.36-2.53; P=0.93; I²=0%).

Conclusion

No significant differences on clinical data were observed regarding anastomosis patency, occluded rate in LAD system, occluded rate in RCA system, in-hospital mortality, and follow-up mortality, indicating that the patency of individual and the patency of sequential coronary artery bypass are similar to each other.

Two decades of off-pump coronary artery bypass surgery: Harefield experience

The morbidity and mortality associated with conventional coronary artery bypass grafting (CABG) attributed to invasiveness of cardiopulmonary bypass (CPB) has been well documented. Recognition of this invasiveness with a focus centered on abolishing, or at least reducing the CPB associated morbidity and mortality led to the resurgence of off-pump coronary artery bypass (OPCAB) surgery nearly two decades ago. At about the same time, OPCAB was adopted at Harefield hospital partly as an institutional drive to promote innovation and partly as a strategy to improve outcomes. What was deemed as a challenging technique initially and practiced by a single surgeon has now become a valid substitute to conventional CABG for achieving complete myocardial revascularization. This strategy now accounts for more than 50% of all coronary artery surgery operations at Harefield hospital and is systematically used to treat all coronary anatomies; achieve complete revascularization by accessing all territories subtended by main coronary arteries; and accomplish equivalent quality grafts without restriction in vascular conduit usage. This review article provides an overview of the evolution of OPCAB surgery at an institution with a well-established OPCAB program confirming that as surgeons' experience matures, OPCAB surgery permits safe and effective total myocardial revascularization in virtually all patients with multivessel coronary artery disease.

Off-Pump Coronary Artery Bypass Surgery

Off-pump coronary artery bypass surgery has been adopted enthusiastically worldwide. However, despite more than 6 years’ experience and refinement, many surgeons use it only sporadically and some hardly at all. This reluctance persists despite support for the procedure because of the lack of properly designed risk models and/or randomized studies. Although it has not been overwhelmingly shown that off-pump surgery is superior to the conventional on-pump procedure, the technique has its place in our specialty. It has been shown to be better for noncritical end points in selected patients in the hands of selected surgeons. That there are differences in surgical skill among surgeons is something we all know but rarely discuss in public. Until now, disparities in skill have been most salient with uncommon and extraordinarily challenging operations. Perhaps the off-pump procedure should be regarded as the “challenging” aspect of coronary artery bypass surgery, and self-restraint may need to remain in force if we are to continue to achieve the highest level of clinical excellence.

Ten-year outcome analysis of off-pump sequential grafting: single surgeon, single center experience

OBJECTIVES

Despite increasing recognition that off-pump coronary artery bypass surgery and sequential grafting strategy individually are associated with improved outcomes, concerns persist regarding the safety and efficacy of combining these 2 techniques. We compared in-hospital and midterm outcomes for off-pump multivessel sequential and conventional coronary artery bypass grafting.

METHODS

From September 1998 to September 2008, 689 consecutive patients received off-pump multivessel sequential coronary artery bypass grafting performed by a single surgeon. These patients were propensity matched to 689 patients who underwent off-pump coronary artery bypass grafting without sequential anastomoses. A retrospective analysis of prospectively collected perioperative data was performed. In addition, medical notes and charts of all the study patients were reviewed. The mean duration of follow-up was 5.1 ± 2.0 years.

RESULTS

The major in-hospital clinical outcomes in the sequential and control groups were found to be similar. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.86-1.50; P = .31), medium-term mortality (hazard ratio [HR], 1.26; 95% CI, 1.06-1.32; P = .92), and readmission to hospital (HR, 1.12; 95% CI, 0.96-1.20; P = .80). Sequential grafting was an independent predictor of receiving more than 3 distal anastomoses (OR, 7.46; 95% CI, 4.27-11.45; P < .0001). Risk-adjusted survival was 89% for sequential grafting patients and 88% for conventional grafting patients (P = .96) during the medium-term follow-up.

CONCLUSION

Our analysis confirms the short- and midterm safety and efficacy of off-pump sequential coronary artery bypass grafting.

In-hospital outcomes of off-pump multivessel total arterial and conventional coronary artery bypass grafting: single surgeon, single center experience

BACKGROUND

Despite increasing recognition that off-pump coronary artery bypass surgery and total arterial revascularization individually are associated with improved outcomes, concerns persist regarding the safety of combining these two techniques. We compared in-hospital outcomes for off-pump multivessel total arterial and conventional coronary artery bypass grafting.

METHODS

From September 1998 to September 2008, 580 consecutive patients receiving off-pump multivessel arterial grafts only were compared with a control group of patients (n = 806) undergoing off-pump coronary artery bypass grafting with internal thoracic artery and saphenous veins operated on by the same surgeon. Two different statistical approaches were used to compare groups in this retrospective analysis. First, propensity score analysis was used to match patients from each group. Second, a multivariate analysis was performed looking at a combined patient outcome of death, intraaortic balloon counterpulsation utilization, myocardial infarction, stroke, prolonged ventilation, and reoperation for any cause on all patients in both groups.

RESULTS

After matching by propensity score, the major clinical outcomes in total arterial (n = 346) and control (n = 346) groups were found to be similar. The in-hospital mortality in the total arterial group was 1.2% as compared with 2.0% in matched patients (p = 0.8). However, patients in the total arterial group were found to have a significantly increased incidence of reexploration for bleeding (p < 0.0001) and blood product usage (p < 0.0001). There was a higher incidence of combined morbidity outcome (18.8% versus 12.1%; p = 0.001) for the control group compared with the total arterial group. Multivariate analysis failed to show that total arterial grafting was an independent predictor of the combined morbidity outcome.

CONCLUSIONS

Off-pump multivessel total arterial grafting can be performed safely with superior in-hospital outcomes compared with off-pump conventional coronary artery bypass grafting.

Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial

OBJECTIVE

To compare the clinical, angiographic, neurocognitive, and quality of life outcomes of off-pump coronary artery bypass surgery with conventional coronary artery bypass grafting surgery using cardiopulmonary bypass.

DESIGN

Randomised controlled clinical trial.

SETTING

Tertiary cardiothoracic centre in Middlesex, England.

PARTICIPANTS

168 patients (27 women) requiring primary isolated coronary artery bypass grafting surgery.

INTERVENTIONS

Patients were randomised to conventional coronary artery bypass grafting surgery using cardiopulmonary bypass (n = 84) or off-pump coronary artery bypass surgery (n = 84), carried out by one surgeon. Angiographic examination was carried out at three months postoperatively. Neurocognitive tests were carried out at baseline and at six weeks and six months postoperatively.

MAIN OUTCOME MEASURES

Clinical outcome, graft patency at three months, neurocognitive function at six weeks and six months, and health related quality of life.

RESULTS

Graft patency was evaluated by angiography in 151 (89.9%) patients and was similar between the cardiopulmonary bypass and off-pump groups (risk difference - 1%, 95% confidence interval - 5% to 4%), with the off-pump group considered the treatment group. Patients in the off-pump group required fewer blood transfusions (1.7 units v 1.0 unit, P = 0.02), shorter duration of mechanical ventilation (7.7 hours v 3.9 hours, P = 0.03), and shorter hospital stay (10.8 days v 8.9 days). Scores for neurocognitive function showed a significant difference in three memory subtests at six weeks and two memory subtests at six months in favour of the off-pump group.

CONCLUSIONS

Patients who underwent off-pump coronary artery bypass surgery showed similar patency of grafts, better clinical outcome, shorter hospital stay, and better neurocognitive function than patients who underwent conventional coronary artery bypass grafting surgery using cardiopulmonary bypass.

Acute Effect of Cerivastatin on Cardiac Regional Ischemia in a Rat Model Mimicking Off-Pump Coronary Surgery

BACKGROUND

Although the off-pump technique is becoming widely used in coronary bypass surgery, there has been no experimental rat heart model of regional reversible ischemia. The aims of this study were to investigate the optimal duration of coronary occlusion for making reversible ischemia and to examine whether cerivastatin increases myocardial tolerance against prolonged coronary occlusion.

METHODS

Study 1--Male Sprague-Dawley rats (350 to 450 g) underwent temporary occlusion of either left anterior descending artery (LAD; for 3, 5, 7.5, 10, 12.5, 15, or 20 min) or circumflex artery (CX; for 5, 10, or 15 min). Study 2--Rats were divided into two groups, control and cerivastatin groups, which had 0.1 mg/kg cerivastatin intravenously after anesthesia. LAD was occluded for 10, 15, or 20 minutes. In the both studies, hearts were stained to determine the area at risk (AR) and infarcted (IF) area 24 hours after reperfusion.

RESULTS

In LAD occlusion, IF/AR increased in a time dependent manner: 4.5 +/- 3.2%, 9.7 +/- 5.2%, 17.2 +/- 3.0%, 16.8 +/- 2.7%, 23.9 +/- 9.5% (p < 0.01 vs. 3 min), 62.4 +/- 2.9% (p < 0.0001), and 63.4 +/- 2.9% (p < 0.0001) at 3, 5, 7.5, 10, 12.5, 15, and 20 min, respectively. Also in CX, IF/AR increased with time: 14.3 +/- 2.3%, 25.9 +/- 2.1%, and 40.9 +/- 6.2% (p < 0.001 vs. 5 min) at 5, 10, and 15 min, respectively. Cerivastatin significantly reduced IF/AR at 15 minutes (43.7 +/- 6.2%) and at 20 minutes (44.6 +/- 5.3%) compared to control (62.4 +/- 2.9% and 60.6 +/- 2.5%, respectively, p < 0.05).

CONCLUSION

Cerivastatin increased myocardial tolerance after prolonged coronary occlusion over 10 minutes, which was considered to be the upper limit for creating a regional reversible ischemia in rats.

Total Arterial Myocardial Revascularization Using Composite and Sequential Grafting With the Off-Pump Technique

BACKGROUND

Multiple arterial myocardial revascularizations are increasingly undertaken using off-pump techniques; however, various arterial grafting techniques are utilized. This study aimed to review the outcome of combining arterial composite and sequential grafting with off-pump techniques.

METHODS

We retrospectively reviewed the records of 107 consecutive patients who underwent coronary bypass surgery with off-pump and arterial composite grafting techniques between April 2001 and March 2004. The left internal thoracic artery (LITA) was harvested in all patients, and the right internal thoracic artery (RITA), the radial artery (RA), and the gastroepiploic artery (GEA) were harvested in 69 patients, in 83 patients, and in 53 patients, respectively. Early postoperative angiograms were evaluated in 97 patients.

RESULTS

There were 488 distal anastomoses, an average of 4.5 per patient. Forty-four in situ LITAs were used as LITA Y-composite grafts with a free RITA (n = 19), RA (n = 24), or free GEA (n = 1). Forty-three in situ RITAs were used as RITA-RA grafts (n = 42) or a RITA-GEA graft (n = 1). Twenty-one in situ GEAs were used as composite grafts with the RA (n = 17) or a free RITA (n = 4). There were no hospital deaths. The patency of the LITA was 100%, and that of the RA was 97.3%, while patencies of both in situ and free RITA and GEA were 100%. During the follow-up period (mean: 22.1 months), there were 3 late deaths, but none were cardiac related.

CONCLUSIONS

Total arterial revascularization with composite and sequential grafting is a safe and effective technique in patients undergoing off-pump coronary artery bypass surgery.

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting

BACKGROUND

Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization.

METHODS

From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique.

RESULTS

There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses).

CONCLUSIONS

A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.

Off-Pump Coronary Artery Bypass (OPCAB) surgery reduces risk-stratified morbidity and mortality: a United Kingdom Multi-Center Comparative Analysis of Early Clinical Outcome

OBJECTIVE

Off-Pump Coronary Artery Bypass (OPCAB) surgery is gaining more popularity worldwide. The aim of this United Kingdom (UK) multi-center study was to assess the early clinical outcome of the OPCAB technique and perform a risk-stratified comparison with the conventional Coronary Artery Bypass Grafting (CABG) using the Cardio-Pulmonary Bypass (CPB) technique.

METHODS

Data were collected on 5,163 CPB patients from the database of the National Heart and Lung institute, Imperial College, University of London, and on 2,223 OPCAB patients from eight UK cardiac surgical centers, which run established OPCAB surgery programs. All patients had undergone primary isolated CABG for multi-vessel disease through a midline sternotomy approach, between January 1997 and April 2001. Postoperative morbidity and mortality were compared between the CPB and OPCAB patients after adjusting for case-mix. The mortality of the OPCAB patients was also compared, using risk stratification, to the mortality figures reported by the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) based on 28,018 patients in the national database who were operated on between January 1996 and December 1999.

RESULTS

Morbidity and mortality were significantly lower in the OPCAB patients compared with the CPB patients and the UK national database of CABG patients, over the same period of time, after adjusting for case-mix.

CONCLUSIONS

This study demonstrates that risk stratified morbidity and mortality are significantly lower in OPCAB patients than CPB patients and patients in the UK national database.

Is the use of cardiopulmonary bypass for multivessel coronary artery bypass surgery an independent predictor of operative mortality in patients with ischemic left ventricular dysfunction?

BACKGROUND

l Coronary artery bypass grafting for patients with ischemic left ventricular dysfunction (ILVD) remains superior to medical therapy in terms of long-term survival. Recently, off-pump coronary artery bypass surgery has been shown to be very promising in achieving functional improvements with favorable operative mortality in this challenging group of patients. The aim of this study was to assess the risk factors responsible for operative mortality in this group of patients.

METHODS

The records of 305 consecutive ILVD patients, who underwent primary isolated coronary artery bypass grafting for multivessel disease at The National Heart and Lung Institute, Imperial College, University of London, between January 1999 and January 2002, were reviewed retrospectively. Patients were considered to have ILVD if they had a left ventricular ejection fraction of 0.30 or less on preoperative coronary angiography. One hundred six patients were operated on using the off-pump coronary artery bypass surgery technique, and 199 patients were operated on using the conventional coronary artery bypass grafting technique with cardiopulmonary bypass. RESU;TS: Seven (6.6%) patients died in the off-pump coronary artery bypass surgery group, whereas 28 (14.1%) patients died in the cardiopulmonary bypass group (p = 0.05). Univariate analysis of all the preoperative characteristics was performed to identify the potential predictors of mortality in the whole group of ILVD patients. Potential predictors of mortality included symptom status (stable/unstable), chronic obstructive airway disease, dyspnea grade III and IV on the New York Heart Association classification, intravenous nitrates, preoperative use of intraaortic balloon pump, ventricular tachycardia or ventricular fibrillation, body surface area less than 2, and cardiopulmonary bypass. Only ventricular tachycardia or ventricular fibrillation was proved to act as an independent predictor of operative mortality in this group of ILVD patients, with an odds ratio of 29.6 (95% confidence interval, 8.9 to 98).

CONCLUSIONS

This study showed that using cardiopulmonary bypass for multivessel coronary artery bypass grafting in patients with ILVD was not proved to act as an independent predictor of operative mortality.

Evaluating outcomes of hospital care following coronary artery bypass surgery in Rome, Italy

OBJECTIVE

Monitoring health outcomes across hospitals has become a growing interest as a potential means to promote quality of care, but in Italy it is at the beginning stage. We aimed at comparing the performance of different cardiac surgery units and testing the utility of routinely collected data in this respect.

METHODS

From the Lazio region hospital information system (HIS), we selected a cohort of 1603 individuals (84% males; mean age 63 years, SD 8) residing in Rome (2,685,890 inhabitants), who underwent isolated coronary artery bypass surgery (CABG, ICD-9-CM code: 36.1) in the period 1996-97 in seven major cardiac surgery units in the city. They were identified as A, B, C (teaching), D and E (non-teaching) units. Information on vital status at 30 days after the CABG surgery was obtained through an automatic record linkage with the Municipal Registry of Rome. The association between cardiac surgery units and outcome was evaluated through logistic regression taking into account the following a priori risk factors in different models: gender, age, socio-economic status, type of ischaemic heart disease and comorbidities.

RESULTS

The overall mortality was 5.4% (range 2.1-11.4%). Statistically significant predictors of outcome included: age (OR=7.5 for age> or =70 vs. 35-49 years), acute myocardial infarction (OR=32.7 vs. acute-subacute forms/angina), chronic myocardial ischaemia (OR=4.2 vs. acute-subacute forms/angina), other heart diseases (OR=4.8), chronic renal disease (OR=16.0) and peripheral arterial disease (OR=2.9). Statistically significant variability in mortality was observed across hospitals; taking hospital A as reference, hospital D showed the highest risk (OR=5.7, 95% CI=1.9-17.3, in the fully adjusted model).

CONCLUSIONS

We suggest that a true variation in quality of care play a role in the observed differences across hospitals, although chance and inaccurately measured risk factors cannot be excluded. Despite some limitations, the HIS is a valid tool for screening cardiac surgery units with poor performance.

Mitral annulus distortion during beating heart surgery: a potential cause for hemodynamic disturbance--a three-dimensional echocardiography reconstruction study

BACKGROUND

Positioning for access to the coronary arteries leads to hemodynamic instability during off-pump cardiac surgery. External changes have been well described, but a description of the intracardiac structures in humans has not been described.

METHODS

With multiplane intraoperative echocardiography, the mitral annulus at end diastole was reconstructed in the different positions and correlated with hemodynamic changes in the right heart and left atrium.

RESULTS

Significant distortion of the mitral annulus with enlargement of the left atrium and pulmonary veins was demonstrated, which correlated with high left atrial pressures.

CONCLUSIONS

Mitral valve distortion can significantly contribute to hemodynamic instability during positioning for off-pump cardiac surgery.