Short-Term Complications and Resource Utilization in Matched Subjects After On-Pump or Off-Pump Primary Isolated Coronary Artery Bypass

Sex differences in resource use after on-pump and off-pump coronary artery bypass surgery: a propensity score-matched cohort

BACKGROUND

Previous studies have demonstrated that off-pump coronary artery bypass surgery (OPCAB) is associated with less use of hospital resources compared with on-pump coronary artery bypass surgery (ONCAB).

OBJECTIVE

To determine whether there is a sex effect between the two procedures regarding resource utilization.

METHODS

Between 1996 and 2004, 13,522 patients (10,637 men and 2885 women) underwent coronary artery bypass grafting surgery at the Toronto General Hospital (Toronto, Ontario). Among the men, 10,121 patients underwent ONCAB and 516 underwent OPCAB. The female population consisted of 2723 ONCAB and 162 OPCAB patients. Both groups were matched to standard preoperative risk factors. A propensity score macro-matched 471 OPCAB men to 471 ONCAB men, and 148 OPCAB women to 148 ONCAB women.

RESULTS

The mean (+/- SD) postoperative length of stay (7.5+/-6.5 days versus 6.4+/-5.5 days; P<0.0001) was significantly higher in ONCAB compared with OPCAB in the male population. The mean length of stay in the intensive care unit and the mean ventilation time was similar between the groups. However, in the female population, there were no differences in mean postoperative length of stay (8+/-5.9 days versus 8+/-6 days; P=0.4), mean length of stay in the intensive care unit (43+/-38 h versus 53+/-81 h; P=0.4) or mean ventilation time (9.8+/-9.7 h versus 11+/-13 h; P=0.8).

CONCLUSION

These results suggest that the benefits of OPCAB in terms of hospital resource use are influenced by sex. The potential beneficial effects are not demonstrated in the female population.

Atrial fibrillation after cardiac transplantation: experience in 498 consecutive cases

BACKGROUND

Some contemporary surgical treatments for atrial fibrillation involve creating only a subset of the lesions made in the classic Cox Maze procedure. This subset often consists of pulmonary vein isolation and partial cardiac denervation. Orthotopic heart transplantation, by necessity, results in pulmonary vein isolation, albeit with total cardiac denervation. Although postoperative atrial fibrillation (POAF) and atrial fibrillation may differ in cause, they have similar underlying mechanisms and often respond to the same treatments. Therefore, we reviewed the incidence of POAF in heart transplant recipients to assess the antiarrhythmic effects of pulmonary vein isolation and cardiac denervation.

METHODS

We reviewed the charts of 498 consecutive patients who underwent orthotopic heart transplantation at a single institution during a 15-year period.

RESULTS

Twenty-seven patients (5.4%) experienced POAF within 60 days of transplant. In 9 of these patients, POAF occurred within 2 weeks of a biopsy-proven transient rejection episode; excluding these patients from the analysis revealed a non-rejection-associated POAF rate of 18 of 489 patients (3.7%).

CONCLUSIONS

Despite the long ischemic times, extensive manipulation of the transplanted heart, and the postoperative administration of proarrhythmic inotropic agents that cardiac transplantation typically involves, this procedure is associated with a low incidence of POAF, particularly if patients in whom rejection and POAF were temporally related are excluded. These findings suggest that complete cardiac denervation and pulmonary vein isolation protect heart transplant recipients from POAF, thus supporting the notion that similar lesions may be useful in the treatment of other types of atrial fibrillation.

Supraventricular Dysrhythmias

Cardiovascular nursing practice includes accountability for the clinical and organizational processes to ensure positive outcomes for patients having cardiac dysrhythmias. For patients with supraventricular dysrhythmias, nurses have studied patient outcomes related to mortality, morbidity, quality of life, psychological and physical functioning, and symptoms. Nurses have also explored these same outcomes associated with the management of supraventricular dysrhythmias. In addition, nurses have contributed to understanding organizational outcomes such as healthcare utilization and costs associated with these patients. For patients with atrial fibrillation after cardiac surgery, nurses have studied patient and organizational outcomes related to mortality, morbidity, symptoms, psychological and physical functioning, and economic outcomes. This research has included numerous interdisciplinary studies, and most of it has been descriptive or observational in design. Areas for future nursing outcomes research, including more interventional studies, are discussed.

To pump or not to pump?

Coronary artery bypass grafting is performed on the beating heart and thus requires the use of cardiopulmonary bypass. To avoid the complications associated with cardiopulmonary bypass, off-pump bypass (OPB) is viewed as a desirable alternative. Technological advancements have made OPB a viable option in an expanding population of patients. As a result, the number of OPB surgeries performed annually in the United States has increased. Critical care nurses are increasingly likely to provide care for patients after off-pump surgery. The differences between on-pump and OPB surgeries affect the postoperative nursing care requirements. While there are many common aspects of postoperative cardiac care for these 2 groups of surgical patients, there is a need to focus on the unique aspects of care for OPB patients. Despite promising short-term results in OPB patients, questions surrounding this procedure remain. Studies are under way to determine long-term graft patency.

Neurologic complications of cardiac surgery: Current concepts and recent advances

Neurologic complications following cardiac surgery result in increased morbidity and mortality. The incidence of stroke is 2% to 4%, but is substantially higher in patients with a prior history of stroke. The success of off-pump techniques in altering this risk is controversial. The efficacy and safety of simultaneous carotid endarterectomy and coronary artery bypass surgery are still debated. Mechanical clot retrievers may offer new opportunity to treat postoperative large, middle cerebral artery strokes. The risk of cognitive deficits is debatable but may be due to factors other than the use of bypass and may not differ from similar deficits after noncardiac surgery. Short-term cognitive deficits usually resolve by 1 to 3 months. Long-term risks are not clearly established. Novel approaches may decrease the incidence of neurocognitive dysfunction. Postoperative seizures may result from global or focal cerebral ischemia due to hypoperfusion, particulate or air emboli, or metabolic causes. Newer anticonvulsant drugs may offer additional management opportunities.