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Szychta W, Majstrak F, Opolski G, Filipiak KJ. Blood glucose concentration for predicting poor outcomes in patients with and without impaired glucose metabolism undergoing off-pump coronary artery bypass surgery - long-term observational study. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2016; 12:238-46. [PMID: 27625687 PMCID: PMC5011540 DOI: 10.5114/aic.2016.61646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Accepted: 12/15/2015] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Strict glucose control is an everyday practice in the perioperative period. Elevated glucose level has a deleterious impact on clinical results, but a therapeutic target has not been stated yet. AIM To determine a glucose concentration range affecting long-term outcomes after coronary artery bypass surgery (CABG). MATERIAL AND METHODS This study is a retrospective evaluation of consecutive patients treated in a university hospital in Poland from 2004 to 2008. Patients were divided into 2 groups: an impaired glucose metabolism group (IGM) if they had 1) known DM or 2) perioperative hyperglycaemia defined as ≥ 200 mg/dl; and a non-IGM group. The end point (EP) was all-cause mortality. RESULTS One thousand two hundred and eleven patients were covered by the analysis. The observation time was from 01.01.2004 until 01.08.2012. Patients who had maximal glucose concentrations < 242 mg/dl had the lowest mortality risk (EP in 21.1%); a higher risk was noted in the group with glucose concentrations 242-324 mg/dl (EP in 30.8%); and a very high risk was found for the group where glucose concentration was > 324 mg/dl (EP in 44.2%) (p = 0.041). Patients with IGM had a shorter survival at the end of the study (p < 0.001). The longest survival was observed in patients whose maximal glucose level was ≤ 242 mg/dl (p < 0.001) and the minimal glucose concentration was in the range 61-110 mg/dl (p < 0.001). CONCLUSIONS Tight glucose concentration control should be performed irrespective of a diabetes diagnosis and proper treatment introduced when necessary. Maximal glucose concentration should be kept < 242 mg/dl, while the minimum should be in the range 60-110 mg/dl.
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Affiliation(s)
- Wojciech Szychta
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Franciszek Majstrak
- Department of Cardiac Surgery, 1 Chair of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Grzegorz Opolski
- 1 Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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202
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Moazzami K, Dolmatova E, Maher J, Gerula C, Sambol J, Klapholz M, Waller AH. In-Hospital Outcomes and Complications of Coronary Artery Bypass Grafting in the United States Between 2008 and 2012. J Cardiothorac Vasc Anesth 2016; 31:19-25. [PMID: 27887898 DOI: 10.1053/j.jvca.2016.08.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate the frequency and predictors of in-hospital complications among patients undergoing coronary artery bypass grafting (CABG) in the United States. DESIGN Retrospective national database analysis SETTINGS: United States hospitals. PARTICIPANTS A weighted sample of 1,910,236 patients undergoing CABG surgery identified from the National (Nationwide) Inpatient Sample from 2008 to 2012. INTERVENTIONS CABG surgery MEASUREMENTS AND MAIN RESULTS: The number of CABG surgeries decreased from 436,275 in 2008 to 339,749 in 2012. The Deyo comorbidity index showed a steady increase from 2008 to 2012. The rate of in-hospital mortality decreased from 2.7% in 2008 to 2.2% in 2012 (p<0.001). The most common in-hospital complication was postoperative hemorrhage (30.4%), followed by cardiac (11.34%) and respiratory complications (2.3%). During the 5-year period, the rates of in-hospital cardiac, respiratory and infectious complications decreased (p<0.001), while the rate of postoperative hemorrhage showed a 35.8% relative increase in 2012 compared to 2008. CONCLUSION The annual number of CABG surgeries is declining in the United States. While the burden of comorbidities is increasing, the rates of mortality and most in-hospital complications are improving. The increasing rate of postoperative bleeding necessitates the need to develop strategies to improve the risk of bleeding in this patient population.
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Affiliation(s)
- Kasra Moazzami
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - Elena Dolmatova
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - James Maher
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ; Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - Christine Gerula
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ; Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - Justin Sambol
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - Marc Klapholz
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ; Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ
| | - Alfonso H Waller
- Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ; Division of Cardiology, Department of Medicine, Rutgers New Jersey Medical School, The State University of New Jersey, Newark, NJ.
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203
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Locker C, Schaff HV, Daly RC, Dearani JA, Bell MR, Frye RL, Greason KL, Stulak JM, Joyce LD, Pochettino A, Li Z, Lennon RJ, Lerman A. Multiple arterial grafts improve survival with coronary artery bypass graft surgery versus conventional coronary artery bypass grafting compared with percutaneous coronary interventions. J Thorac Cardiovasc Surg 2016; 152:369-379.e4. [DOI: 10.1016/j.jtcvs.2016.03.089] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/01/2016] [Accepted: 03/15/2016] [Indexed: 12/26/2022]
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204
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Sola M, Ramm CJ, Kolarczyk LM, Teeter EG, Yeung M, Caranasos TG, Vavalle JP. Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2016; 118:418-23. [PMID: 27344271 DOI: 10.1016/j.amjcard.2016.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/05/2016] [Accepted: 05/05/2016] [Indexed: 12/18/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.
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205
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Kalogianni A, Almpani P, Vastardis L, Baltopoulos G, Charitos C, Brokalaki H. Can nurse-led preoperative education reduce anxiety and postoperative complications of patients undergoing cardiac surgery? Eur J Cardiovasc Nurs 2016; 15:447-58. [DOI: 10.1177/1474515115602678] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 07/25/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Antonia Kalogianni
- Faculty of Nursing, Technological Educational Institute of Athens, Greece
| | - Panagiota Almpani
- Faculty of Nursing, Technological Educational Institute of Athens, Greece
| | - Leonidas Vastardis
- Intensive Care Unit of Department of Cardiac Surgery, ‘Evangelismos’ General Hospital, Athens, Greece
| | - George Baltopoulos
- Faculty of Nursing, National and Kapodistrian University of Athens, Greece
| | - Christos Charitos
- Cardiothoracic Surgery Department, ‘Evangelismos’, General Hospital of Athens, Greece
| | - Hero Brokalaki
- Faculty of Nursing, National and Kapodistrian University of Athens, Greece
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206
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McNeely C, Markwell S, Vassileva C. Trends in Patient Characteristics and Outcomes of Coronary Artery Bypass Grafting in the 2000 to 2012 Medicare Population. Ann Thorac Surg 2016; 102:132-8. [DOI: 10.1016/j.athoracsur.2016.01.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 12/14/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
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207
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Gaudino M, Di Franco A, Crea F, Girardi LN. Secondary prevention for CABG patients: take two arterial grafts at the time of your coronary operation. J Thorac Dis 2016; 8:1057-9. [PMID: 27293818 DOI: 10.21037/jtd.2016.04.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mario Gaudino
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Antonino Di Franco
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Filippo Crea
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
| | - Leonard N Girardi
- 1 Department of Cardio-thoracic Surgery, Weill-Cornell Medical College, New York, USA ; 2 Department of Cardiovascular Sciences, Catholic University, Rome, Italy
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208
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Affiliation(s)
- John H Alexander
- From the Duke Clinical Research Institute and the Division of Cardiology, Department of Medicine (J.H.A.), and the Division of Cardiothoracic Surgery, Department of Surgery (P.K.S.), Duke Health, Durham, NC
| | - Peter K Smith
- From the Duke Clinical Research Institute and the Division of Cardiology, Department of Medicine (J.H.A.), and the Division of Cardiothoracic Surgery, Department of Surgery (P.K.S.), Duke Health, Durham, NC
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209
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210
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Accola KD. Invited Commentary. Ann Thorac Surg 2016; 101:1682-3. [DOI: 10.1016/j.athoracsur.2015.10.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 10/21/2022]
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211
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Glineur D, Papadatos S, Grau JB, Shaw RE, Kuschner CE, Aphram G, Mairy Y, Vanbelighen C, Etienne PY. Complete myocardial revascularization using only bilateral internal thoracic arteries provides a low-risk and durable 10-year clinical outcome. Eur J Cardiothorac Surg 2016; 50:735-741. [PMID: 27084197 DOI: 10.1093/ejcts/ezw120] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/27/2015] [Accepted: 02/22/2016] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Bilateral internal thoracic artery (BITA) bypass provides long-term survival benefits over strategies that use single internal mammary arteries during coronary artery bypass grafting (CABG). However, the rate of adoption of this strategy remains very low. Moreover, optimal BITA configuration and the use of cardiopulmonary bypass still remain a matter of debate. We investigated the long-term results of a coronary revascularization strategy, utilising exclusively BITA-Y composite grafts using off-pump platform and sequential anastomoses. METHODS From March 2000 to November 2010, all isolated CABGs (n = 2057 patients) were performed using an off-pump platform. Of these, 1240 patients had three-vessel coronary disease (60.3%), with severe coronary disease defined as >70% stenosis and three-vessel disease defined as the presence of 3 vessels with >70% stenosis, of which 784 (63.2%) were treated with two internal thoracic artery grafts in a composite fashion with a no-touch technique avoiding any manipulation of the ascending aorta. The primary end-point was the long-term survival and freedom from major adverse cerebral and cardiovascular events (MACCEs). The follow-up was completed using the annual anniversary method. RESULTS The mean number of anastomoses per patient was 4.0. Hospital mortality occurred in 8 patients (1%). Ninety-day stroke, myocardial infarction and repeat revascularization rates were respectively 0.7, 0.6 and 0.3%. The mean follow-up was 6.6 ± 3.2 years and was obtained for 99% of the patients. The 5- and 10-year survival rates were 93.1 ± 1.6 and 83.8 ± 3.2%, respectively. Freedom from major adverse cardiac and cardiovascular event (MACCE) at 5 and 10 years was: cardiovascular event: 98.7 ± 1.6 and 96.1 ± 1.7%, documented ischaemia: 90.5 ± 2 and 80.2 ± 3.8%, revascularization: 94.0 ± 1.5 and 89.7 ± 2.5%, infarction: 98.1 ± 0.8 and 96.0 ± 1.6%. The patency of left and right internal thoracic artery in a BITA-Y configuration was 91.1 and 88.8% at 5 ± 3 years, respectively. CONCLUSION Performance of an exclusive composite BITA off-pump revascularization strategy optimal and sustained long-term protection from MACCE.
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Affiliation(s)
- David Glineur
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc, Bouge, Belgium .,Division of Cardiac Surgery, Ottawa Heart Institute, Ottawa, Canada
| | - Spiridon Papadatos
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc, Bouge, Belgium
| | - Juan B Grau
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Richard E Shaw
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Cyrus E Kuschner
- Department of Cardiac Surgery, Valley Heart and Vascular Institute, Ridgewood, NJ, USA
| | - Gaby Aphram
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc, Bouge, Belgium
| | - Yves Mairy
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc, Bouge, Belgium
| | | | - Pierre Yves Etienne
- Department of Thoracic and Cardiovascular Surgery, Cliniques St Luc, Bouge, Belgium
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212
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Kurlansky P. Multiple arterial grafting for coronary revascularization: "A guide for the perplexed". Trends Cardiovasc Med 2016; 26:616-23. [PMID: 27180277 DOI: 10.1016/j.tcm.2016.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 04/08/2016] [Indexed: 10/21/2022]
Abstract
The surgical literature abounds with articles extolling the benefits of arterial grafting for patients with advanced coronary artery disease in need of surgical revascularization. However, examination of clinical performance demonstrates that extensive use of arterial grafting is highly selective and generally uncommon. Rather than to merely repeat multiple excellent recent literature reviews, the goal herein is to provide the reader with a guide to the evaluation of the current literature as well as to suggest fruitful areas for further research. More circumspect understanding of the strengths and weaknesses of our current knowledge base will not only help to explain the current apparent disparity between theory and practice but will hopefully inform future decision-making and patient care.
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Affiliation(s)
- Paul Kurlansky
- Department of Surgery, Columbia University, New York, NY.
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213
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Di Mauro M, Iacò AL, Allam A, Awadi MO, Osman AA, Clemente D, Calafiore AM. Bilateral internal mammary artery grafting:in situversus Y-graft. Similar 20-year outcome. Eur J Cardiothorac Surg 2016; 50:729-734. [DOI: 10.1093/ejcts/ezw100] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/25/2015] [Accepted: 02/22/2016] [Indexed: 12/28/2022] Open
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214
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Siregar S, Nieboer D, Vergouwe Y, Versteegh MIM, Noyez L, Vonk ABA, Steyerberg EW, Takkenberg JJM. Improved Prediction by Dynamic Modeling: An Exploratory Study in the Adult Cardiac Surgery Database of the Netherlands Association for Cardio-Thoracic Surgery. Circ Cardiovasc Qual Outcomes 2016; 9:171-81. [PMID: 26933048 DOI: 10.1161/circoutcomes.114.001645] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 01/22/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The predictive performance of static risk prediction models such as EuroSCORE deteriorates over time. We aimed to explore different methods for continuous updating of EuroSCORE (dynamic modeling) to improve risk prediction. METHODS AND RESULTS Data on adult cardiac surgery from 2007 to 2012 (n=95 240) were extracted from the Netherlands Association for Cardio-Thoracic Surgery database. The logistic EuroSCORE predicting in-hospital death was updated using 6 methods: recalibrating the intercept of the logistic regression model; recalibrating the intercept and joint effects of the prognostic factors; re-estimating all prognostic factor effects, re-estimating all prognostic factor effects, and applying shrinkage of the estimates; applying a test procedure to select either of these; and a Bayesian learning strategy. Models were updated with 1 or 3 years of data, in all cardiac surgery or within operation subgroups. Performance was tested in the subsequent year according to discrimination (area under the receiver operating curve, area under the curve) and calibration (calibration slope and calibration-in-the-large). Compared with the original EuroSCORE, all updating methods resulted in improved calibration-in-the-large (range -0.17 to 0.04 versus -1.13 to -0.97, ideally 0.0). Calibration slope (range 0.92-1.15) and discrimination (area under the curve range 0.83-0.87) were similar across methods. In small subgroups, such as aortic valve replacement and aortic valve replacement+coronary artery bypass grafting, extensive updating using 1 year of data led to poorer performance than using the original EuroSCORE. The choice of updating method had little effect on benchmarking results of all cardiac surgery. CONCLUSIONS Several methods for dynamic modeling may result in good discrimination and superior calibration compared with the original EuroSCORE. For large populations, all methods are appropriate. For smaller subgroups, it is recommended to use data from multiple years or a Bayesian approach.
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Affiliation(s)
- Sabrina Siregar
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.).
| | - Daan Nieboer
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Yvonne Vergouwe
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Michel I M Versteegh
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Luc Noyez
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Alexander B A Vonk
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Ewout W Steyerberg
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
| | - Johanna J M Takkenberg
- From the Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands (S.S., M.I.M.V.); Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (D.N., Y.V., E.W.S.); Department of Cardio-Thoracic Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands (L.N.); Department of Cardio-Thoracic Surgery, VU Medical Center, Amsterdam, The Netherlands (A.B.A.V.); and Department of Cardio-Thoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (J.J.M.T.)
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Saxena A, Dhurandhar V, Bannon PG, Newcomb AE. The Benefits and Pitfalls of the Use of Risk Stratification Tools in Cardiac Surgery. Heart Lung Circ 2016; 25:314-8. [PMID: 26857968 DOI: 10.1016/j.hlc.2015.12.094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 12/11/2015] [Accepted: 12/15/2015] [Indexed: 10/22/2022]
Abstract
Risk assessment tools are increasingly used in surgery. In cardiac surgery, risk models are used for patient counselling, surgical decision-making, performance benchmarking, clinical research, evaluation of new therapies and quality assurance, among others. However, they have numerous disadvantages which need to be considered. This article evaluates the utility of risk assessment tools in cardiac surgery including a discussion of their advantages and disadvantages.
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Affiliation(s)
- Akshat Saxena
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Vikrant Dhurandhar
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Baird Institute, Sydney, NSW, Australia
| | - Paul G Bannon
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Discipline of Surgery, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia; The Baird Institute, Sydney, NSW, Australia
| | - Andrew E Newcomb
- Department of Cardiothoracic Surgery, St Vincent's Hospital Melbourne, Melbourne, Vic, Australia.
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216
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Zheng Z, Zhang H, Yuan X, Zhang H, Chen S, Zhao Y, Hua K, Rao C, Wang W, Sun H, Hu S. Response to Letters Regarding Article, "Efficacy of Long-Term β-Blocker Therapy for Secondary Prevention of Long-Term Outcomes After Coronary Artery Bypass Grafting Surgery". Circulation 2016; 133:e394-5. [PMID: 26858300 DOI: 10.1161/circulationaha.115.019468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Zhe Zheng
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Heng Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Xin Yuan
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Haibo Zhang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sipeng Chen
- School of Public Health, Capital Medical University, Beijing, People's Republic of China
| | - Yan Zhao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Kun Hua
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Chenfei Rao
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Hansong Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Shengshou Hu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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LaPar DJ, Rich JB, Isbell JM, Brooks CH, Crosby IK, Yarboro LT, Ghanta RK, Kern JA, Brown M, Quader MA, Speir AM, Ailawadi G. Preoperative Renal Function Predicts Hospital Costs and Length of Stay in Coronary Artery Bypass Grafting. Ann Thorac Surg 2016; 101:606-12; discussion 612. [DOI: 10.1016/j.athoracsur.2015.07.079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 06/24/2015] [Accepted: 07/28/2015] [Indexed: 10/22/2022]
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218
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The art of saphenous vein grafting and patency maintenance. J Thorac Cardiovasc Surg 2016; 151:300-2. [DOI: 10.1016/j.jtcvs.2015.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 09/02/2015] [Indexed: 11/17/2022]
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Abstract
BACKGROUND AND OBJECTIVES Multi-institutional quality improvement registries (QI registries) are a promising approach to quality improvement. They are also used for clinical research, public quality reporting and other valuable purposes. The aim of this study was to identify elements and outcomes of national policies to promote registries in Sweden and to compare them with recent policies in the USA. METHODS This case study draws on previous studies of Swedish registries and on interviews, observations and document studies conducted in Sweden and the USA. RESULTS In Sweden, registries are fostered by favourable patient data regulation and an indirect control approach combining government funding with soft regulation and professional self-governance. This enables the development of high-quality QI registries which are used for improvements by engaged clinicians, for clinical research and for decision support for practitioners and stakeholders. For example, Riks-HIA/Swedeheart achieved improved outcomes in cardiac intensive care, SCAAR/Swedeheart was used in a unique registry-based randomized trial, and the Swedish Rheumatology Quality Register provides a Web interface for patient encounters and clarifies adverse effects of biologic drugs. Still, the system has persistent limitations, especially the administrative burden on participants. In the USA, Medicare's programme for qualified clinical data registries and other recent changes mirror Swedish policies. Automated data capture is a US advantage, but uncertain funding and complex data regulations stall registry development in the USA. CONCLUSION The findings of this study indicate that tailor-made data regulation and a soft regulatory policy approach foster high-quality QI registries with multiple meaningful uses. These findings offer a framework for further cross-country comparative study to evaluate registry policies.
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Affiliation(s)
- C Levay
- Department of Business Administration, Lund University, Lund, Sweden.,Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
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220
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Burstin H, Leatherman S, Goldmann D. The evolution of healthcare quality measurement in the United States. J Intern Med 2016; 279:154-9. [PMID: 26785953 DOI: 10.1111/joim.12471] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Quality measurement is fundamental to systematic improvement of the healthcare system. Whilst the United States has made significant investments in healthcare quality measurement and improvement, progress has been somewhat limited. Public and private payers in the United States increasingly mandate measurement and reporting as part of pay-for-performance programmes. Numerous issues have limited improvement, including lack of alignment in the use of measures and improvement strategies, the fragmentation of the U.S. healthcare system, and the lack of national electronic systems for measurement, reporting, benchmarking and improvement. Here, we provide an overview of the evolution of U.S. quality measurement efforts, including the role of the National Quality Forum. Important contextual changes such as the growing shift towards electronic data sources and clinical registries are discussed together with international comparisons. In future, the U.S. healthcare system needs to focus greater attention on the development and use of measures that matter. The three-part aim of effective care, affordable care and healthy communities in the U.S. National Quality Strategy focuses attention on population health and reduction in healthcare disparities. To make significant improvements in U.S. health care, a closer connection between measurement and both evolving national data systems and evidence-based improvement strategies is needed.
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Affiliation(s)
- H Burstin
- National Quality Forum, Washington, DC, USA
| | - S Leatherman
- National Quality Forum, Washington, DC, USA.,Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - D Goldmann
- Institute for Healthcare Improvement, Cambridge, MA, USA
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221
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Yilmaz S, Aksoy E, Doğan T, Diken Aİ, Yalcınkaya A, Ozşen K. Angina severity predicts worse sleep quality after coronary artery bypass grafting. Perfusion 2016; 31:471-6. [PMID: 26811429 DOI: 10.1177/0267659115627690] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We sought to reveal whether the severity of angina pectoris affects sleep quality after elective coronary artery bypass grafting. MATERIAL AND METHODS Patients scheduled to undergo isolated coronary artery bypass grafting were divided into two groups, having a recent myocardial infarction (Group 1, n=22, mean age 59.40±7.79 years) or not having a recent myocardial infarction (Group 2, n=30, mean age 59.73±7.72 years). The assessment included the Canadian Cardiovascular Society Angina Score, the visual analogue scale for postoperative pain and the Pittsburgh Sleep Quality Index (PSQI). RESULTS The two groups were similar in regard to baseline characteristics. Cross-clamp time was significantly higher (p=0.007) and the use of inotropes was significantly more common (p=0.01) in those patients with recent myocardial infarction compared to those without. Mean Canadian Cardiovascular Society scores were also higher in patients with recent myocardial infarction (p=0.02). Total Pittsburgh Sleep Quality Index score was significantly higher in patients with recent myocardial infarction (8.45±3.50 vs. 5.03±2.32, respectively, p<0.001). In multivariate analysis, higher angina score (OR: 3.27, 95% CI, 1.20-8.90, p=0.02) and longer time of intensive care unit stay (OR: 6.15, 95% CI, 1.49-25.35, p=0.01) were found to be independent predictors of poor sleep quality. The Canadian Cardiovascular Society angina score showed a significant positive correlation with poor sleep duration score (<0.001), sleep disturbance score (p=0.02), day dysfunction due to sleepiness score (p=0.001), sleep efficiency score (p=0.003), overall sleep quality score (0.03) and total PSQI score (p=0.004). CONCLUSION The severity of angina pectoris in the preoperative period is independently associated with worse sleep quality after elective isolated coronary artery bypass surgery.
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Affiliation(s)
- Seyhan Yilmaz
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Turkey
| | - Eray Aksoy
- Department of Cardiovascular Surgery, Hitit University Corum Education and Research Hospital, Turkey
| | - Tolga Doğan
- Department of Cardiology, Hitit University Corum Education and Research Hospital, Turkey
| | - Adem İlkay Diken
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Turkey
| | - Adnan Yalcınkaya
- Department of Cardiovascular Surgery, Hitit University Faculty of Medicine, Turkey
| | - Kelime Ozşen
- Department of Cardiovascular Surgery Nursing, Hitit University Corum Education and Research Hospital, Turkey
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Abstract
Coronary artery bypass grafting is the most common cardiac surgery operation performed worldwide. It is the most effective revascularization method for several categories of patients affected by coronary artery disease. Although coronary artery bypass grafting has been performed for more than 40 years, no detailed guidelines on the choice of coronary artery bypass grafting conduits have been published and the choice of the revascularization strategy remains more a matter of art than of science. Moreover, there is a clear contradiction between the proven benefits of arterial grafting and its very limited use in everyday clinical practice. In the hope of encouraging wider diffusion of arterial revascularization and to provide a guide for clinicians, we discuss current evidence for the use of different conduits in coronary artery bypass surgery and propose an evidence-based algorithm for the choice of the second conduit during coronary artery bypass operations.
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223
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Mejía OAV, Lisboa LAF, Dallan LAO, Jatene FB. Bilateral Internal Thoracic Artery and Optimal Revascularization Strategy in Insulin-Dependent Diabetic Patients. Braz J Cardiovasc Surg 2016; 30:III-IV. [PMID: 26735608 PMCID: PMC4690654 DOI: 10.5935/1678-9741.20150062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Fabio Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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224
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Parolari A, Poggio P, Myasoedova V, Songia P, Bonalumi G, Pilozzi A, Pacini D, Alamanni F, Tremoli E. Biomarkers in Coronary Artery Bypass Surgery: Ready for Prime Time and Outcome Prediction? Front Cardiovasc Med 2016; 2:39. [PMID: 26779491 PMCID: PMC4700141 DOI: 10.3389/fcvm.2015.00039] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 12/14/2015] [Indexed: 12/27/2022] Open
Abstract
Coronary artery bypass surgery (CABG) is still one of the most frequently performed surgical procedures all over the world. The results of this procedure have been constantly improved over the years with low perioperative mortality rates, with relatively low complication rates. To further improve these outstanding results, the clinicians focused their attention at biomarkers as outcome predictors. Although biological testing for disease prediction has already been discussed many times, the role of biomarkers in outcome prediction after CABG is still controversial. In this article, we reviewed the current knowledge regarding the role of genetic and dynamic biomarkers and their possible association with the occurrence of adverse clinical outcomes after CABG. We also took into consideration that the molecular pathway activation and the possible imbalance may affect hard outcomes and graft patency. We analyzed biomarkers classified in two different categories depending on their possibility to change over time: genetic markers and dynamic markers. Moreover, we evaluated these markers by dividing them, into sub-categories, such as inflammation, hemostasis, renin–angiotensin, endothelial function, and other pathways. We showed that biomarkers might be associated with unfavorable outcomes after surgery, and in some cases improved outcome prediction. However, the identification of a specific panel of biomarkers or of some algorithms including biomarkers is still in an early developmental phase. Finally, larger studies are needed to analyze broad panel of biomarkers with the specific aim to evaluate the prediction of hard outcomes and graft patency.
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Affiliation(s)
- Alessandro Parolari
- Dipartimento di Scienze Biomediche per la Salute, Università Degli Studi di Milano, Milan, Italy; Unità Operativa di Cardiochirurgia e Ricerca Traslazionale, San Donato IRCCS, San Donato Milanese, Milan, Italy
| | - Paolo Poggio
- Centro Cardiologico Monzino IRCCS , Milan , Italy
| | | | - Paola Songia
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Dipartimento di Scienze Farmacologiche e Biomolecolari, Università Degli Studi di Milano, Milan, Italy
| | | | - Alberto Pilozzi
- Sezione Cardiovascolare, Dipartimento di Scienze Cliniche e di Comunità, Università Degli Studi di Milano , Milan , Italy
| | - Davide Pacini
- S.Orsola-Malpighi, Dipartimento di Cardiochirurgia, Università di Bologna , Bologna , Italy
| | - Francesco Alamanni
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Sezione Cardiovascolare, Dipartimento di Scienze Cliniche e di Comunità, Università Degli Studi di Milano, Milan, Italy
| | - Elena Tremoli
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Dipartimento di Scienze Farmacologiche e Biomolecolari, Università Degli Studi di Milano, Milan, Italy
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225
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Parolari A, Poggio P, Myasoedova V, Songia P, Pilozzi A, Alamanni F, Tremoli E. Molecular pathways activation in coronary artery bypass surgery. J Cardiovasc Med (Hagerstown) 2016; 17:54-61. [DOI: 10.2459/jcm.0000000000000293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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226
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Puskas JD, Yanagawa B, Taggart DP. Off-pump, multiple arterial grafting with minimal aortic manipulation: Is it for everyone? J Thorac Cardiovasc Surg 2016; 151:4-6. [DOI: 10.1016/j.jtcvs.2015.09.116] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
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227
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Masri A, Al Halabi S, Karimianpour A, Gillinov AM, Naji P, Sabik JF, Mihaljevic T, Svensson LG, Rodriguez LL, Griffin BP, Desai MY. Impact of additive mitral valve surgery to coronary artery bypass grafting on mortality in patients with coronary artery disease and ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized trials and observational studies. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:33-44. [PMID: 29474587 DOI: 10.1093/ehjqcco/qcv024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Indexed: 11/13/2022]
Abstract
Aims Treatment of ischaemic mitral regurgitation (IMR) remains controversial. While IMR is associated with worse outcomes, randomized controlled trials (RCTs) and observational studies provided conflicting evidence regarding the benefit of mitral valve replacement (MVR) or repair (MVr) in addition to coronary artery bypass grafting (CABG). We conducted a meta-analysis incorporating data from published RCTs and observational studies comparing CABG vs. CABG + MVR/MVr. Methods and results We searched PubMed, MEDLINE, Embase, Ovid, and Cochrane for RCTs and observational studies comparing CABG (Group 1) vs. CABG + MVR/MVr (Group 2). Outcome was 30-day and 1-year mortality after surgical intervention. Mantel-Haenszel odds ratio (OR) was calculated using random-effects meta-analysis for the outcome. Heterogeneity was assessed by I2 statistics. Four RCTs and 11 observational studies met the inclusion criteria (5781 patients, 507 in RCTs, 5274 in observational studies). Group 1 vs. 2 weighted mean left ventricular ejection fraction in RCTs and combined RCTs/observational studies was 41.5 ± 12.3 vs. 40.3 ± 10.4% ( P -value = 0.24) and 45.5 ± 7.2 vs. 38 ± 10% ( P -value < 0.001), respectively. In RCTs, there was no difference in 30-day [OR: 0.95, 95% confidence interval (95% CI): 0.30-3.08, P = 0.94] or 1-year (OR: 0.90, 95% CI: 0.43-1.87, P = 0.78) mortality, respectively. For combined RCTs/observational studies, there was no difference in mortality at 30 days (OR: 0.67, 95% CI: 0.43-1.04, P = 0.08) or at 1 year (OR: 0.90, 95% CI: 0.7-1.15, P = 0.39). Conclusion In a meta-analysis of RCTs and observational studies of IMR patients, the addition of MVR/MVr to CABG did not improve survival.
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Affiliation(s)
- Ahmad Masri
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Shadi Al Halabi
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Ahmadreza Karimianpour
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Alan Marc Gillinov
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Peyman Naji
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Joseph F Sabik
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Tomislav Mihaljevic
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Lars G Svensson
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Luis Leonardo Rodriguez
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Brian P Griffin
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
| | - Milind Y Desai
- Heart Valve Center, Heart and Vascular Institute, Cleveland Clinic , 9500 Euclid Avenue, Desk J1-5, Cleveland, OH 44195 , USA
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228
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Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, Rosengart T, Kappetein AP, Thourani VH, Firestone S, Mitchell JD. The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting. Ann Thorac Surg 2015; 101:801-9. [PMID: 26680310 DOI: 10.1016/j.athoracsur.2015.09.100] [Citation(s) in RCA: 250] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 09/22/2015] [Accepted: 09/24/2015] [Indexed: 12/16/2022]
Abstract
Internal thoracic arteries (ITAs) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated (class of recommendation [COR] I, level of evidence [LOE] B). As an adjunct to left internal thoracic artery (LITA), a second arterial graft (right ITA or radial artery [RA]) should be considered in appropriate patients (COR IIa, LOE B). Use of bilateral ITAs (BITAs) should be considered in patients who do not have an excessive risk of sternal complications (COR IIa, LOE B). To reduce the risk of sternal infection with BITA, skeletonized grafts should be considered (COR IIa, LOE B), smoking cessation is recommended (COR I, LOE C), glycemic control should be considered (COR IIa, LOE B), and enhanced sternal stabilization may be considered (COR IIb, LOE C). As an adjunct to LITA to LAD (or in patients with inadequate LITA grafts), use of a RA graft is reasonable when grafting coronary targets with severe stenoses (COR IIa, LOE: B). When RA grafts are used, it is reasonable to use pharmacologic agents to reduce acute intraoperative and perioperative spasm (COR IIa, LOE C). The right gastroepiploic artery may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B). Use of arterial grafts (specific targets, number, and type) should be a part of the discussion of the heart team in determining the optimal approach for each patient (COR I, LOE C).
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Affiliation(s)
- Gabriel S Aldea
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington.
| | - Faisal G Bakaeen
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - Jay Pal
- Division of Cardiothoracic Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Stephen Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, and Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Joseph Sabik
- Center of Heart Valve Disease, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Todd Rosengart
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | - A Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - Vinod H Thourani
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - John D Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Bhatt DL, Drozda JP, Shahian DM, Chan PS, Fonarow GC, Heidenreich PA, Jacobs JP, Masoudi FA, Peterson ED, Welke KF. ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise. J Am Coll Cardiol 2015; 66:2230-2245. [DOI: 10.1016/j.jacc.2015.07.010] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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230
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Bhatt DL, Drozda JP, Shahian DM, Chan PS, Fonarow GC, Heidenreich PA, Jacobs JP, Masoudi FA, Peterson ED, Welke KF, Heidenreich PA, Albert NM, Chan PS, Curtis LH, Bruce Ferguson T, Fonarow GC, Michael Ho P, Jurgens C, O’Brien S, Russo AM, Thomas RJ, Ting HH, Varosy PD. ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise. Circ Cardiovasc Qual Outcomes 2015; 8:634-48. [DOI: 10.1161/hcq.0000000000000013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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231
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Gaudino M, Girardi LN, Salemi A. Don't Be Afraid of the Skeleton: It Is Your Patient's Best Friend! Cardiology 2015; 133:109-10. [PMID: 26516772 DOI: 10.1159/000440996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 09/10/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, N.Y., USA
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232
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McIlroy DR, Myles PS. Does the use of statins improve outcomes in coronary artery bypass graft surgery? Expert Rev Cardiovasc Ther 2015; 13:1285-8. [PMID: 26473309 DOI: 10.1586/14779072.2015.1099434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Statins (3-hydroxy-3-methylglutaryl CoA reductase inhibitors) are one of the most frequently prescribed medications throughout the world with beneficial effects that extend beyond their lipid-lowering activity. It has been suggested that statins may offer a simple and cost-effective strategy to reduce some of the complications that occur in association with coronary artery bypass graft (CABG) surgery. Limited existing randomized trial evidence in the setting of cardiac surgery suggests that statins may reduce the incidence of postoperative atrial fibrillation. However, any effect of statins on other outcomes is less clear. The clinical significance of specific statin agent and dose, acute statin withdrawal and the potential benefits associated with statin reloading remain important yet currently unresolved issues. Despite limited high-quality evidence, class I recommendations have been made that all patients undergoing coronary artery bypass graft surgery should receive statin therapy unless contraindicated.
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Affiliation(s)
- David R McIlroy
- a Department of Anaesthesia and Perioperative Medicine , Alfred Hospital and Monash University , Melbourne , Victoria , Australia
| | - Paul S Myles
- a Department of Anaesthesia and Perioperative Medicine , Alfred Hospital and Monash University , Melbourne , Victoria , Australia
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233
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Bhatt DL, Drozda JP, Shahian DM, Chan PS, Fonarow GC, Heidenreich PA, Jacobs JP, Masoudi FA, Peterson ED, Welke KF. ACC/AHA/STS Statement on the Future of Registries and the Performance Measurement Enterprise: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and The Society of Thoracic Surgeons. Ann Thorac Surg 2015; 100:1926-41. [PMID: 26438978 DOI: 10.1016/j.athoracsur.2015.07.078] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 07/28/2015] [Accepted: 07/28/2015] [Indexed: 11/24/2022]
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234
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Tatoulis J, Wynne R, Skillington PD, Buxton BF. Total Arterial Revascularization: Achievable and Prognostically Effective—A Multicenter Analysis. Ann Thorac Surg 2015; 100:1268-75; discussion 1275. [DOI: 10.1016/j.athoracsur.2015.03.107] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/25/2015] [Accepted: 03/30/2015] [Indexed: 10/23/2022]
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235
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Kurlansky PA, Traad EA, Dorman MJ, Galbut DL, Ebra G. Bilateral Versus Single Internal Mammary Artery Grafting in the Elderly: Long-Term Survival Benefit. Ann Thorac Surg 2015; 100:1374-81; discussion 1381-2. [DOI: 10.1016/j.athoracsur.2015.04.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 03/27/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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236
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The Society of Thoracic Surgeons Voluntary Public Reporting Initiative. Ann Surg 2015; 262:526-35; discussion 533-5. [DOI: 10.1097/sla.0000000000001422] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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237
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Osnabrugge RL, Kappetein AP, Head SJ, Kolh P. Doing better in more complex patients: leading the way for QUIP. Eur J Cardiothorac Surg 2015; 49:397-8. [PMID: 26242898 DOI: 10.1093/ejcts/ezv262] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | - Stuart J Head
- Erasmus University Medical Center, Rotterdam, Netherlands
| | - Philippe Kolh
- Department of Cardiovascular Surgery, University Hospital (CHU, ULg) of Liège, Liège, Belgium
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Pilarczyk K, Boening A, Jakob H, Langebartels G, Markewitz A, Haake N, Heringlake M, Trummer G. Preoperative intra-aortic counterpulsation in high-risk patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials†. Eur J Cardiothorac Surg 2015; 49:5-17. [PMID: 26245629 DOI: 10.1093/ejcts/ezv258] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 01/12/2015] [Indexed: 01/04/2023] Open
Abstract
In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in all investigated populations with a greater effect in the total population [fixed-effects model: standard mean difference (SMD) -0.931 ± 0.198, P < 0.001] as well as in the subgroup of CAGB patients (fixed-effects model: SMD -1.240 ± 0.156, P < 0.001), compared with the off-pump group (fixed-effects model: SMD -0.723 ± 0.128, P < 0.001). Despite contradictory results from recent trials, the present study confirms the findings of previous meta-analyses that prophylactic aortic counterpulsation reduces hospital mortality, incidence of LCOS and ICU requirement in high-risk patients undergoing on-pump cardiac surgery. However, owing to small sample sizes and the lack of a clear-cut definition of high-risk patients, an adequately powered, prospective RCT is necessary to find a definite answer to the question, if certain groups of patients undergoing cardiac surgery benefit from a prophylactic IABP insertion.
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Affiliation(s)
- Kevin Pilarczyk
- Department of Thoracic and Cardiovascular Surgery, West German Heart Centre Essen, University Hospital Essen, Essen Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, Justus-Liebig University Gießen, Giessen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart Centre Essen, University Hospital Essen, Essen Germany
| | - Georg Langebartels
- Department of Cardiothoracic Surgery, Cologne University Heart Centre, Cologne, Germany
| | - Andreas Markewitz
- Department of Cardiovascular Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Nils Haake
- Department of Cardiovascular Surgery, School of Medicine, University of Schleswig-Holstein, Kiel, Germany
| | | | - Georg Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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239
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Calafiore AM, Iacò AL, Di Mauro M. Spending 30 minutes to add years to a patient's life: Why is the last step so difficult? J Thorac Cardiovasc Surg 2015; 150:321-2. [DOI: 10.1016/j.jtcvs.2015.05.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
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240
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Winkley Shroyer AL, Bakaeen F, Shahian DM, Carr BM, Prager RL, Jacobs JP, Ferraris V, Edwards F, Grover FL. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery. Semin Thorac Cardiovasc Surg 2015; 27:144-51. [PMID: 26686440 DOI: 10.1053/j.semtcvs.2015.07.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Annie Laurie Winkley Shroyer
- Research and Development Service, Northport Veterans Affairs Medical Center, Northport, New York; Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York.
| | - Faisal Bakaeen
- Department of Surgery, Baylor College of Medicine and Michael E. DeBakey VAMC, Houston, Texas
| | - David M Shahian
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brendan M Carr
- Research and Development Service, Northport Veterans Affairs Medical Center, Northport, New York; Department of Surgery, Stony Brook University School of Medicine, Stony Brook, New York
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan Health Care System, Ann Arbor, Michigan
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children׳s Heart Institute, Johns Hopkins University, Saint Petersburg and Tampa, Florida
| | - Victor Ferraris
- Department of Surgery, University of Kentucky School of Medicine, Lexington, Kentucky
| | - Fred Edwards
- Department of Surgery, University of Florida School of Medicine, Jacksonville, Florida
| | - Frederick L Grover
- Department of Surgery, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Surgery, Denver Veterans Affairs Medical Center, Denver, Colorado
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241
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Raza S, Blackstone EH, Sabik JF. The diabetes epidemic and its effect on cardiac surgery practice. J Thorac Cardiovasc Surg 2015; 150:783-4. [PMID: 26298871 DOI: 10.1016/j.jtcvs.2015.07.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 07/10/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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242
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Zheng L, Fan QM, Wei ZY. Serum S-100β and NSE levels after off-pump versus on-pump coronary artery bypass graft surgery. BMC Cardiovasc Disord 2015; 15:70. [PMID: 26179379 PMCID: PMC4504080 DOI: 10.1186/s12872-015-0050-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/01/2015] [Indexed: 12/22/2022] Open
Abstract
Background We aimed to evaluate serum levels of S-100 beta (S-100β) and neuron specific enolase (NSE) in patients with coronary heart disease (CHD) after off-pump versus on-pump coronary artery bypass graft (CABG) surgery. Methods The PubMed (~2013) and the Chinese Biomedical Database (CBM) (1982 ~ 2013) were searched without language restrictions. After extraction of relevant data from selected studies, meta-analyses were conducted using STATA software (Version 12.0, Stata Corporation, College Station, Texas USA). Possible sources of heterogeneity were examined through univariate and multivariate meta-regression analyses and verified by Monte Carlo Simulation. Results Eleven studies with a total of 411 CHD patients met the inclusion criteria. Our meta-analysis showed no significant difference in serum S-100β and NSE levels between the on-pump group and the off-pump group before surgery. In the on-pump group, there was a significant difference in serum S-100β levels of CHD patients between before and after surgery, especially within the first 24 h after surgery. Furthermore, in the on-pump group, there was a significant difference in serum NSE levels of CHD patients between before and after surgery, particularly at 0 h after surgery. In the off-pump group, there was an obvious difference in serum S-100β levels between before and after surgery, especially within 24 h after surgery. Our results also demonstrated that serum S-100β and NSE levels of CHD patients in the on-pump group were significantly higher than those of patients in the off-pump group, especially within 24 h after surgery. Conclusions Our findings provide empirical evidence that off-pump and on-pump CABG surgeries may increase serum S-100β and NSE levels in CHD patients, which was most prominent within 24 h after on-pump CABG surgery.
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Affiliation(s)
- Lei Zheng
- Department of Cardiovascular Surgery, Yantai Yuhuangding Hospital, No.20 Yuhuangding East Road, Yantai, 264000, P.R. China.
| | - Qing-Ming Fan
- Department of Cardiovascular Surgery, Yantai Yuhuangding Hospital, No.20 Yuhuangding East Road, Yantai, 264000, P.R. China.
| | - Zhen-Yu Wei
- Department of Cardiovascular Surgery, Yantai Yuhuangding Hospital, No.20 Yuhuangding East Road, Yantai, 264000, P.R. China.
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243
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LaPar DJ, Quader M, Rich JB, Kron IL, Crosby IK, Kern JA, Tribble CG, Speir AM, Ailawadi G. Institutional Variation in Mortality After Stroke After Cardiac Surgery: An Opportunity for Improvement. Ann Thorac Surg 2015; 100:1276-82; discussion 1282-3. [PMID: 26188969 DOI: 10.1016/j.athoracsur.2015.04.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Postoperative stroke remains one of the most devastating complications after cardiac surgery. Variations in stroke rates and ability to rescue from mortality after stroke between surgical centers are not understood. This study evaluated patient risk and institutional factors associated with likelihood of postoperative stroke as well as hospital variation in risk-adjusted stroke and rates of failure to rescue (FTR) after stroke after cardiac surgery. METHODS Patient records from The Society of Thoracic Surgeons' multiinstitutional certified database for cardiac operations (2001 to 2011) were analyzed. The relative contribution of patient- and hospital-related factors to the likelihood of postoperative stroke was assessed by univariate and multivariate analyses. Variations in risk-adjusted stroke and rates of FTR after stroke were compared, and impact of stroke on hospital resource utilization and costs were evaluated. RESULTS A total of 57,387 patients was included. Postoperative stroke rate was 1.5%, with significant variation across hospitals (range, 0.8% to 2%, p < 0.001). Stroke patients (versus no stroke patients) presented with more comorbid disease and higher risk profiles (The Society of Thoracic Surgeons predicted risk of mortality, 3% versus 1%, p < 0.001). Mortality was expectedly higher after stroke compared with no stroke (18% versus 2%, p < 0.001). Postoperative stroke was associated with nearly double the total cost of hospitalization. After risk adjustment, individual hospitals demonstrated a strong association with likelihood for stroke (p < 0.001). Furthermore, high-performing hospitals with low stroke rates performed fewer aortic valve operations, more coronary artery bypass graft operations, and accrued longer intensive care unit lengths of stay. Significant hospital variations were observed for risk-adjusted stroke and rates of FTR after stroke (both p < 0.001). CONCLUSIONS Institutional variation, more so than individual patient risk factors, is highly associated with postoperative stroke and FTR rates after stroke after cardiac surgery. Postoperative stroke remains significantly associated with mortality and morbidity. Institutional practice patterns may confer a disproportionate influence on postoperative stroke independent of case mix. Understanding differences between high and low performing centers is essential to improving outcomes, costs, and hospital quality.
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Affiliation(s)
| | | | | | | | | | - John A Kern
- University of Virginia, Charlottesville, Virginia
| | | | - Alan M Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia
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244
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Valooran GJ, Nair SK, Chandrasekharan K. Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era. Indian Heart J 2015; 67:351-8. [PMID: 26304568 PMCID: PMC4561793 DOI: 10.1016/j.ihj.2015.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 04/09/2015] [Accepted: 05/14/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong. METHODS Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization. RESULTS The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature. CONCLUSIONS Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.
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Affiliation(s)
- George Jose Valooran
- Consultant, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, India
| | - Shiv Kumar Nair
- Senior Consultant and HOD, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, India.
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245
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Doering LV, McGuire A, Eastwood JA, Chen B, Bodán RC, Czer LS, Irwin MR. Cognitive behavioral therapy for depression improves pain and perceived control in cardiac surgery patients. Eur J Cardiovasc Nurs 2015; 15:417-24. [PMID: 26115954 DOI: 10.1177/1474515115592292] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/01/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Depression after cardiac surgery (CS) is associated with increased pain and decreased sleep quality. While cognitive behavioral therapy (CBT) aimed at depression is effective in relieving depressive symptoms after cardiac surgery, little is known about its ability to ameliorate other common postoperative problems that affect recovery and quality of life. AIMS The purpose of this study was to evaluate the effects of CBT for depression on pain severity, pain interference, sleep, and perceived control in patients recovering from CS. METHODS Depressed patients recovering from CS were randomized to receive either eight weeks of CBT or usual care. At baseline and post-intervention, patients completed questionnaires for depressive symptoms, pain, sleep, and perceived control. Group comparisons were conducted using t-tests or chi square analysis. Repeated measures analysis was used to assess the effect of the intervention in changes over time. RESULTS The sample (n=53) included 16.9% women and had a mean age of 67.8±9.2 years. CBT for depression increased perceived control (p<0.001) and decreased pain interference (p=0.02) and pain severity (p=0.03). Group effects remained significant (p<0.05) for perceived control and pain interference and a trend was observed for pain severity (p<0.10) after controlling for variables that differed at baseline. There were no group differences in sleep disturbance over time. CONCLUSIONS A depression-focused CBT intervention yields benefits in other common postoperative problems, specifically improved perceived control and decreased pain in depressed cardiac surgery patients.
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Affiliation(s)
| | - Anthony McGuire
- School of Nursing, California State University, Long Beach, USA
| | | | - Belinda Chen
- School of Nursing, University of California, USA
| | - Rebecca C Bodán
- School of Nursing, California State University, Fullerton, USA
| | | | - Michael R Irwin
- Cousins Center for Psychoneuroimmunology, University of California, USA
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246
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Zhang Y, Ma L, Zhao H. Efficacy of Mitral Valve Repair as an Adjunct Procedure to Coronary Artery Bypass Grafting in Moderate Ischemic Mitral Regurgitation: A Meta-Analysis of Randomized Trials. J Card Surg 2015; 30:623-30. [PMID: 26081462 DOI: 10.1111/jocs.12585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yiran Zhang
- Department of Cardiothoracic Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Liang Ma
- Department of Cardiothoracic Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Haige Zhao
- Department of Cardiothoracic Surgery; First Affiliated Hospital of Zhejiang University; Hangzhou China
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247
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Gaudino M. On diet, exercise … and arterial grafting. Int J Cardiol 2015; 189:232-3. [PMID: 25897914 DOI: 10.1016/j.ijcard.2015.04.095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 04/14/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, USA; Department of Cardiovascular Sciences, Catholic University, Rome, Italy.
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248
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Mocanu V, Buth KJ, Johnston LB, Davis I, Hirsch GM, Légaré JF. The Importance of Continued Quality Improvement Efforts in Monitoring Hospital-Acquired Infection Rates: A Cardiac Surgery Experience. Ann Thorac Surg 2015; 99:2061-9. [DOI: 10.1016/j.athoracsur.2014.12.075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 12/21/2014] [Accepted: 12/29/2014] [Indexed: 10/23/2022]
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249
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LaPar DJ, Crosby IK, Rich JB, Quader MA, Speir AM, Kern JA, Tribble C, Kron IL, Ailawadi G. Bilateral Internal Mammary Artery Use for Coronary Artery Bypass Grafting Remains Underutilized: A Propensity-Matched Multi-Institution Analysis. Ann Thorac Surg 2015; 100:8-14; discussion 14-5. [PMID: 26002440 DOI: 10.1016/j.athoracsur.2015.02.088] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/19/2015] [Accepted: 02/26/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bilateral internal mammary arterial (BIMA) grafts have repeatedly demonstrated superior outcomes compared with single IMA (SIMA) after coronary artery bypass grafting (CABG). Despite known survival benefits with BIMA use, perceived perioperative challenges often preclude BIMA use. We hypothesized that the use of BIMA remains underutilized, even in low-risk patients. METHODS A total of 43,823 primary, isolated CABG patients in a regional Society of Thoracic Surgeons Database were evaluated. Patients were stratified by BIMA versus SIMA use. Surgical candidates considered "low risk" for BIMA use included the following: age less than 70 years; no or mild chronic lung disease; body mass index less than 30; and absence of diabetes. The BIMA patients (n = 1,333) were 1:1 propensity matched to SIMA patients (n = 1,333) and outcomes were compared. RESULTS Overall, BIMA use was 3%; 24% (n = 10,327) of patients met "low-risk" criteria for BIMA use. Among "low-risk" patients, BIMA utilization was 6%. Propensity-matched comparisons revealed similar preoperative risk profiles between BIMA and SIMA patients (Predicted Risk of Mortality [PROM] 1.1% vs 1.1%, p > 0.05). The BIMA use was associated with longer cross-clamp time (71 vs 62 minutes, p < 0.05). Importantly, BIMA use was not associated with increased postoperative mortality, morbidity, or hospital length of stay (all p > 0.05). However, hospital readmission within 30 days was 41% greater for BIMA patients compared with SIMA patients (p = 0.01). CONCLUSIONS Bilateral IMA graft use appears to remain underutilized in the modern surgical era, even in low surgical risk patients. The BIMA use does not appear to increase the risk of postoperative morbidity, although requires longer operative times and a higher risk for readmission. Efforts to more clearly understand surgeon motivators for the use of BIMA grafting are needed.
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Affiliation(s)
| | | | | | | | - Alan M Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - John A Kern
- University of Virginia, Charlottesville, Virginia
| | - Curt Tribble
- University of Virginia, Charlottesville, Virginia
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250
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Khera R, Vaughan-Sarrazin M, Rosenthal GE, Girotra S. Racial disparities in outcomes after cardiac surgery: the role of hospital quality. Curr Cardiol Rep 2015; 17:29. [PMID: 25894800 PMCID: PMC4780328 DOI: 10.1007/s11886-015-0587-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients from racial and ethnic minorities experience higher mortality after cardiac surgery compared to white patients, both during the early postoperative phase as well as long term. A number of factors likely explain poor outcomes in black and minority patients, which include differences in biology, comorbid health conditions, socioeconomic background, and quality of hospital care. Recent evidence suggests that a major factor underlying excess mortality in these groups is due to their over-representation in low-quality hospitals, where all patients regardless of race have worse outcomes. In this review, we examine the factors underlying racial disparities in outcomes after cardiac surgery, with a primary focus on the role of hospital quality.
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Affiliation(s)
- Rohan Khera
- Department of Internal Medicine, University of Iowa Hospitals & Clinics, 200 Hawkins Drive, E325 GH, Iowa City, IA, 52242, USA,
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