Gender's impact on outcome in coronary surgery with minimized extracorporeal circulation

Association Between Adverse Clinical Outcomes After Coronary Artery Bypass Grafting and Perioperative Blood Transfusions

Background

Bleeding is a serious complication of coronary artery bypass grafting that often leads to blood transfusion. Approximately 50% of patients who have the surgery receive blood products, and blood transfusions play a role in adverse outcomes after the surgery.

Objective

To examine the association between perioperative blood transfusion and postoperative adverse outcomes in patients undergoing coronary artery bypass grafting.

Methods

A systematic review of the literature, via the matrix method of quality evaluation, was conducted. PubMed, CINAHL, and Science Direct databases for 2000 through 2016 were searched. Inclusion criteria were articles published in English and original research related to clinical outcomes of blood transfusion after coronary artery bypass grafting. Seventeen articles were included in the review.

Results

Mortality, both short- and long-term, was significantly higher in transfusion patients than in nontransfusion patients. Patients with transfusion of red blood cells had higher resource utilization and more complications, including infection, pneumonia, renal failure, graft occlusion, and atrial fibrillation, than did nontransfusion patients.

Conclusion

An association exists between red blood cell transfusions and adverse clinical outcomes for patients undergoing coronary artery bypass grafting. Transfusion of red blood cells is sometimes unnecessary, may be injurious, and should be used cautiously. Even a single-unit increase in perioperative red blood cell transfusions can have a significant adverse impact on outcomes. Individual benefits and risks should be weighed before transfusion to avoid adverse outcomes. Transfusion guidelines should be reviewed to include the latest evidence to guarantee the most appropriate use of blood products.

Influence of factor XIII activity on post-operative transfusion in congenital cardiac surgery-A retrospective analysis

Objectives

Coagulation factor XIII (FXIII) plays a key role in fibrin clot stabilization—an essential process for wound healing following cardiothoracic surgery. However, FXIII deficiency as a risk for post-operative bleeding in pediatric cardiac surgery involving cardiopulmonary bypass (CPB) for congenital heart disease (CHD) is controversially discussed. Thus, as primary outcome measures, we analyzed the association of pre-operative FXIII activity and post-operative chest tube drainage (CTD) loss with transfusion requirements post-operatively. Secondary outcomes included the influence of cyanosis and sex on transfusion.

Methods

Our retrospective analysis (2009–2010) encompassed a single center series of 76 cardio-surgical cases with CPB (0–17 years, mean age 5.61 years) that were post-operatively admitted to our pediatric intensive care unit (PICU). The observational period was 48 hours after cardiac surgery. Blood cell counts and coagulation status, including FXIII activity were routinely performed pre- and post-operatively. The administered amount of blood products and volume expanders was recorded electronically, along with the amount of CTD loss. Uni- and multivariate logistic regression analysis was performed to calculate the associations (odds ratios) of variables with post-operative transfusion needs.

Results

FXIII activities remained stable following CPB surgery. There was no association of pre- and post-operative FXIII activities and transfusion of blood products or volume expanders in the first 48 hours after surgery. Similarly, FXIII showed no association with CTD loss. Cyanosis and female sex were associated with transfusion rates.

Conclusions

Although essentially involved in wound healing and clotting after surgery, FXIII activity does not serve as a valid predictor of post-operative transfusion need.

Are the Early Postoperative Outcomes of Coronary Artery Bypass Grafting Surgery in Elderly Women Worse Compared to Men's?

Objective

To investigate the impact of gender difference in early postoperative outcomes in elderly patients (aged 70 or older) undergoing coronary artery bypass grafting surgery.

Methods

Between October 2009 and December 2013, a total of 223 elderly patients (aged 70 or older) undergoing isolated primary coronary artery bypass grafting surgery were included in this retrospective observational cohort study. Patients were divided into two groups according to their gender. The patients' medical records were collected, their baseline preoperative characteristics, operative data, and postoperative outcomes were retrospectively reviewed, and the effect of gender difference in the early postoperative outcomes was analyzed.

Results

Group 1 (female patients) and Group 2 (male patients) consisted of 71 and 152 patients, respectively. Mean age of patients was 74.4±3.6 years (range: 70-84 years). The level of EuroSCORE I, the incidence of hypertension and hyperlipidemia were significantly higher in Group 1, while the rate of smoking was significantly higher in Group 2. Mean postoperative intubation time, length of intensive care unit and hospital stay were longer in female patients than in male patients, but these differences were not statistically significant. No statistically significant difference between two groups in terms of the transfusion of blood products was observed. The rates of in-hospital mortality and major postoperative complications were statistically similar between the two groups.

Conclusion

In conclusion, the female gender was not associated with worse early postoperative outcomes in elderly patients undergoing coronary artery bypass grafting surgery.

Tabula viva chirurgic: a living surgical document

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cardiac surgery as a stressor and the response of the vulnerable older adult

In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

OBJECTIVES

A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

SETTINGS

23 Austrian centres randomly selected and stratified by region and level of care.

PARTICIPANTS

We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

MAIN OUTCOME MEASURES

Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

RESULTS

In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

CONCLUSIONS

The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

Sex and the Risk of AKI Following Cardio-thoracic Surgery: A Meta-Analysis

BACKGROUND AND OBJECTIVES

Being a woman is a well established risk factor for the development of cardiothoracic surgery-associated AKI. In striking contrast, women are less likely to develop AKI associated with noncardiac surgical procedures than men. In an attempt to ascertain why being a woman might be protective for ischemic AKI after general surgery but deleterious in patients undergoing cardiothoracic surgery, we examined cardiothoracic surgery-associated AKI in greater detail.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a systematic review and meta-analysis of cardiothoracic surgery-associated AKI studies published between January of 1978 and December of 2015 to further explore the relationship between sex and cardiothoracic surgery-associated AKI.

RESULTS

Sixty-four studies were identified that provided sex-specific data regarding the incidence of cardiothoracic surgery-associated AKI among 1,057,412 subjects. Using univariate analysis, women were more likely than men to develop AKI postoperatively (odds ratio, 1.21; 95% confidence interval, 1.09 to 1.33; P<0.001). However, when the analysis was restricted to the 120,464 subjects reported in 29 studies that used the Acute Kidney Injury Network criteria, the RIFLE criteria, or the Kidney Disease Improving Global Outcomes criteria to define AKI, there was no significant sex-related difference in risk. Seventeen studies used multivariate analysis to assess risk factors for cardiothoracic surgery-associated AKI and provided sex-specific odd ratios. Among the 1,587,181 individuals included in these studies, the risk of developing cardiothoracic surgery-associated AKI was not significantly associated with sex (odds ratio, 1.04; 95% confidence interval, 0.92 to 1.19; P=0.51). However, when the analysis was restricted to the 5106 subjects reported in four studies that used the Acute Kidney Injury Network criteria to define AKI, the risk of developing AKI was significantly lower in women compared with in men (odds ratio, 0.75; 95% confidence interval, 0.65 to 0.87; P<0.001).

CONCLUSIONS

Our systematic review and meta-analysis contradict the generally held consensus that being a woman is an independent risk factor for the development of cardiothoracic surgery-associated AKI.

Gender differences in outcomes following isolated coronary artery bypass grafting: long-term results

Background

The main purpose of this study was to evaluate the impact of gender on outcomes after isolated coronary artery bypass grafting, in terms of 5-year rates of overall death, cardiac-related death, myocardial infarction, re-hospitalization, repeat percutaneous or surgical revascularization, stroke, new pacemaker implantation, postoperative renal failure, heart failure and need for long-term care.

Methods

Two propensity-score matched cohorts, each of 1331 patients, undergoing isolated surgical coronary revascularization at the regional public and private centers of Emilia-Romagna region (Italy) from January 1st 2003 to December 31th 2013, were used to compare long-term outcomes of male (5976 patients) versus female gender (1332 patients).

Results

In the matched cohort, males received significantly more bypass grafts (3.0 ± 1.0 vs 2.8 ± 1.0, p = 0.001). Left internal mammary artery use and total arterial revascularization were similarly performed in both matched subgroups. Both groups reported similar cumulative rate of all-cause, cardiac-related mortality and stroke at five years. Females experienced significantly higher rate of myocardial infarction, and not significantly higher occurrence of heart failure, and need for long-term care. Males experienced significantly higher rate of cumulative re-hospitalization and higher need for pacemaker implantation. Female gender was not an independent predictor of death at long-term follow-up.

Conclusions

Women are more likely to be readmitted with myocardial infarction and congestive heart failure after CABG but experience survival similar to that observed in men. Female gender was not an independent risk factor for mortality. Prevention of new occurrence of postoperative myocardial infarction and enhancement of complete coronary revascularization should be future endpoints.

Long-term outcome in men and women after CABG; results from the IMAGINE trial

BACKGROUND

The aim of this study is to determine sex differences in long-term outcome after coronary artery bypass grafting (CABG).

METHODS

The international randomized controlled IMAGINE study included 2553 consecutive patients with a left ventricular ejection fraction of >40% who underwent isolated CABG. Median follow-up was 32 months (IQR 17-42 months). The composite endpoint comprised of death, myocardial infarction (MI), cerebrovascular event, angina, revascularization and congestive heart failure. Cox regression analysis was used to examine sex differences in outcome post-CABG.

RESULTS

Of the 2553 patients, 2229 were men and 324 (13%) were women. Women were older and more often reported diabetes and hypertension. Smoking and impaired renal function were more prevalent in men. Women experienced a higher event rate during follow-up (composite endpoint 18% vs 12%; P = 0.007). Cox regression showed an increased risk of the composite endpoint in women after adjustment for age (HR 1.48 (95% CI: 1.11-1.97)) which was non-significant after additional adjustment for other confounders (HR 1.26 (95% CI: 0.92-1.72)).

CONCLUSION

Women have a worse long-term outcome after CABG than men in univariate analysis. However, after adjusting for potential confounders female sex became a non-significant predictor for prognosis, possibly due to the small sample size of women. Definite answers regarding sex-differences in long-term outcome after CABG should come from future pooling of studies comprising a larger number of women.

Do low-income coronary artery bypass surgery patients have equal opportunity to access excellent quality of care and enjoy good outcome in Taiwan?

BACKGROUND

Equity is an important issue in the healthcare research field. Many studies have focused on the relationship between patient characteristics and outcomes of care. These studies, however, have seldom examined whether patients' characteristics affected their access to quality healthcare, which further affected the care outcome. The purposes of this study were to determine whether low-income coronary artery bypass surgery (CABG) patients receive healthcare services with poorer quality, and if such differences in treatment result in different outcomes.

METHODS

A retrospective multilevel study design was conducted using claims data from Taiwan's universal health insurance scheme for 2005-2008. Patients who underwent their CABG surgery between 2006 and 2008 were included in this study. CABG patients who were under 18 years of age or had unknown gender or insured classifications were excluded. Hospital and surgeon's performance indicators in the previous one year were used to evaluate the level of quality via k-means clustering algorithm. Baron and Kenny's procedures for mediation effect were conducted to explore the relationship among patient's income, quality of CABG care, and inpatient mortality.

RESULTS

A total of 10,320 patients were included in the study. The results showed that 5.65% of the low-income patients received excellent quality of care, which was lower than that of patients not in the low-income group (5.65% vs.11.48%). The mortality rate of low-income patients (12.10%) was also higher than patients not in the low-income group (5.25%). Also, the mortality of patients who received excellent care was half as low as patients receiving non-excellent care (2.63% vs. 5.68%). Finally, after the procedure of mediation effect testing, the results showed that the relationship between patient income level and CABG mortality was partially mediated by patterns of quality of care.

CONCLUSIONS

The results of the current study implied that worse outcome in low-income CABG patients might be associated with poorer quality of received services. Health authorities should pay attention to this issue, and propose appropriate solutions.

Early postoperative results for females undergoing isolated coronary artery bypass surgery: comparison of the pre- and postmenopausal periods

PURPOSE

In this retrospective study, we investigated the demographic data and evaluated our early postoperative results of premenopausal and postmenopausal females who underwent coronary artery bypass graft surgery (CABG).

METHODS

A total of 730 female patients who underwent CABG between April 2004 and January 2012 were included in the study. Patients were divided into two groups based on whether they were pre- (group 1) or postmenopausal (group 2). The groups were compared in terms of the demographic and peri-operative parameters.

RESULTS

Smoking and the preoperative hematocrit levels were higher in group 1, whereas the incidence of hypertension and obesity and the European system for cardiac operative risk evaluation values were higher in group 2 (p values <0.01; <0.01; <0.01; 0.004 and <0.01 respectively). The utilization of a left internal mammary artery graft and the postoperative drainage volumes were higher in group 1; however, the number of grafts per patient, cardiopulmonary bypass duration, number of patients who needed inotropic support, blood transfusion volumes, the duration of ventilatory support and the hospital stay were higher in group 2 (p values 0.038; 0.040; 0.026; 0.032; 0.014; 0.001; <0.01 and <0.01, respectively).

CONCLUSIONS

Although the mortality rates were not significantly different, postmenopausal patients require more intensive postoperative care in comparison to premenopausal patients following CABG.