Trends in isolated coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons adult cardiac surgery database

Predictors of premature termination of cardiac surgery trials: insights from the Clinicaltrial.gov database

OBJECTIVES

Clinical trials that are terminated prematurely may generate incomplete and potentially biased data and the reasons for premature trials termination are poorly understood. Our objective was to describe the incidence of premature trial termination and identify factors associated with it.

METHODS

We performed a systematic search on ClinicalTrials.gov to identify all cardiac surgery trials from 1991 to 2023. Trials that were terminated prematurely were identified. Factors independently associated with premature termination were identified using multivariable logistic regression analysis.

RESULTS

A total of 746 clinical trials were included; of them 577 were completed and 169 (22.6%) were terminated prematurely. Most of the trials originated from North America [294 (39.4%)], Europe [264 (35.4%)] or Asia [141 (18.9%)]. Fourteen of the trials terminated prematurely (8.3%) were phase 1, 75 (44.4%) phase 2, 49 (29.0%) phase 3 and 31 (18.3%) phase 4. Fifty (29.6%) trials were terminated because of slow recruitment, 20 (11.8%) because of sponsor decision and 12 (7.1%) because of lack of funding. Left ventricular assist device trials [odds ratio (OR) 3.65, 95% confidence interval (CI) (1.65-8.00) P = 0.001], valve surgery trials [OR 4.30, 95% CI (2.33-8.00) P < 0.001], aortic surgery trials [OR 2.86 95% CI (1.22-6.43) P = 0.012], phase 2 [OR 3.02, 95% CI (1.31-7.93) P = 0.015] and phase 4 trials [OR 3.62, 95% CI (1.43-10.23) P = 0.010] were at higher risk of premature termination while trials performed in Asia [OR 0.18, 95% CI (0.07-0.39) P ≤ 0.001] and Europe [OR 0.49, 95% CI (0.30-0.80) P = 0.004] were less likely to be terminated prematurely.

CONCLUSIONS

Slow recruitment is the most common reason for premature termination of cardiac surgery trials. Trials on left ventricular assist device, valve surgery, aortic surgery, phase 2 trials and phase 4 trials are more likely to be terminated, while trials conducted in Asia and Europe are less likely to be terminated prematurely.

Protected cardiac surgery: strategic mechanical circulatory support to improve postcardiotomy mortality

PURPOSE OF REVIEW

To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing perioperative low cardiac output syndrome (P-LCOS).

RECENT FINDINGS

P-LCOS is a significant predictor of mortality in cardiac surgery patients. Preoperative risk factors, such as cardiogenic shock and elevated lactate levels, can help identify those at higher risk. Proactive use of MCS, rather than reactive implementation after P-LCOS develops, may lead to improved outcomes by preventing severe organ hypoperfusion. The emerging concept of "protected cardiac surgery" emphasizes early identification of these high-risk patients and planned MCS utilization. Additionally, specific MCS strategies are being developed and refined for various cardiac conditions, including AMI-CS, valvular surgeries, and pulmonary thromboendarterectomy.

SUMMARY

This paper explores the shifting demographics and complexities in cardiac surgery patients. It emphasizes the importance of proactive, multidisciplinary approaches to identify high-risk patients and implement early MCS to prevent P-LCOS and improve outcomes. The concept of protected cardiac surgery, involving planned MCS use and shared decision-making, is highlighted. The paper also discusses MCS strategies tailored to specific cardiac procedures and the ethical considerations surrounding MCS implementation.

Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery

BACKGROUND

The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality.

METHODS

A consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined.

RESULTS

Lower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002).

CONCLUSIONS

We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population

PURPOSE OF REVIEW

To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population.

RECENT FINDINGS

Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.

Surgical Coronary Revascularization in Patients With Underlying Atrial Fibrillation: State-of-the-Art Review

The number of individuals referred for coronary artery bypass grafting (CABG) with preoperative atrial fibrillation (AF) is reported to be 8% to 20%. Atrial fibrillation is a known marker of high-risk patients as it was repeatedly found to negatively influence survival. Therefore, when performing surgical revascularization, consideration should be given to the concomitant treatment of the arrhythmia, the clinical consequences of the arrhythmia itself, and the selection of adequate surgical techniques. This state-of-the-art review aimed to provide a comprehensive analysis of the current understanding of, advancements in, and optimal strategies for CABG in patients with underlying AF. The following topics are considered: stroke prevention, prophylaxis and occurrence of postoperative AF, the role of surgical ablation and left atrial appendage occlusion, and an on-pump vs off-pump strategy. Multiple acute complications can occur in patients with preexisting AF undergoing CABG, each of which can have a significant effect on patient outcomes. Long-term results in these patients and the future perspectives of this scientific area were also addressed. Preoperative arrhythmia should always be considered for surgical ablation because such an approach improves prognosis without increasing perioperative risk. While planning a revascularization strategy, it should be noted that although off-pump coronary artery bypass provides better short-term outcomes, conventional on-pump approach may be beneficial at long-term follow-up. By collecting the current evidence, addressing knowledge gaps, and offering practical recommendations, this state-of-the-art review serves as a valuable resource for clinicians involved in the management of patients with AF undergoing CABG, ultimately contributing to improved outcomes and enhanced patient care.

Heart surgery over two decades: what we have learned about results and changing risks

OBJECTIVES

Using the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients.

METHODS

This serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS).

RESULTS

A total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001.

CONCLUSIONS

Isolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings.

Intraoperative Anemia Mediates Sex Disparity in Operative Mortality After Coronary Artery Bypass Grafting

BACKGROUND

Women undergoing coronary artery bypass grafting (CABG) have higher operative mortality than men.

OBJECTIVES

The purpose of this study was to evaluate the relationship between intraoperative anemia (nadir intraoperative hematocrit), CABG operative mortality, and sex.

METHODS

This was a cohort study of 1,434,225 isolated primary CABG patients (344,357 women) from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022). The primary outcome was operative mortality. The attributable risk (AR) (the risk-adjusted strength of the association of female sex with CABG outcomes) for the primary outcome was calculated. Causal mediation analysis derived the total effect of female sex on operative mortality risk and the proportion of that effect mediated by intraoperative anemia.

RESULTS

Women had lower median nadir intraoperative hematocrit (22.0% [Q1-Q3: 20.0%-25.0%] vs 27.0% [Q1-Q3: 24.0%-30.0%], standardized mean difference 97.0%) than men. Women had higher operative mortality than men (2.8% vs 1.7%; P < 0.001; adjusted OR: 1.36; 95% CI: 1.30-1.41). The AR of female sex for operative mortality was 1.21 (95% CI: 1.17-1.24). After adjusting for nadir intraoperative hematocrit, AR was reduced by 43% (1.12; 95% CI: 1.09-1.16). Intraoperative anemia mediated 38.5% of the increased mortality risk associated with female sex (95% CI: 32.3%-44.7%). Spline regression showed a stronger association between operative mortality and nadir intraoperative hematocrit at hematocrit values <22.0% (P < 0.001).

CONCLUSIONS

The association of female sex with increased CABG operative mortality is mediated to a large extent by intraoperative anemia. Avoiding nadir intraoperative hematocrit values below 22.0% may reduce sex differences in CABG operative mortality.

Coronary artery bypass grafting versus medical therapy in patients with stable coronary artery disease: An individual patient data pooled meta-analysis of randomized trials

OBJECTIVES

It is unclear whether coronary artery bypass grafting (CABG) improves survival compared with medical therapy (MT) in patients with stable coronary artery disease (CAD). The aim of this analysis was to perform an individual-patient data-pooled meta-analysis of contemporary randomized controlled trials that compared CABG and MT in patients with stable CAD.

METHODS

A systematic search was performed in January 2021 to identify randomized controlled trials enrolling adult patients with stable CAD, randomized to CABG or MT. Only trials using at least aspirin, beta-blockers, and statins in the MT arm were included. Individual patient data were obtained from all eligible studies and pooled. The primary outcome was all-cause mortality.

RESULTS

Four trials involving 2523 patients (1261 CABG; 1262 MT) were included with a median follow-up of 5.6 (4.0-9.2) years. CABG was associated with increased risk of all-cause mortality within 30 days (hazard ratio [HR], 4.81; 95% confidence interval [CI], 1.95-11.83) but subsequent reduction in the long-term risk of death (HR, 0.79; 95% CI, 0.69-0.89). As such, the cumulative 10-year mortality rate was lower in patients treated with CABG compared with MT (45.1% vs 51.7%, respectively; odds ratio, 0.70; 95% CI, 0.58-0.85). Age and race were significant treatment effect modifier (interaction P = .003 for both).

CONCLUSIONS

In patients with stable CAD, initial allocation to CABG was associated with greater periprocedural risk of death but improved long-term survival compared with MT. The survival advantage for CABG became significant after the fourth postoperative year and was particularly pronounced in younger and non-White patients.

Temporary mechanical circulatory support & enhancing recovery after cardiac surgery

PURPOSE OF REVIEW

This review highlights the integration of enhanced recovery principles with temporary mechanical circulatory support associated with adult cardiac surgery.

RECENT FINDINGS

Enhanced recovery elements and efforts have been associated with improvements in quality and value. Temporary mechanical circulatory support technologies have been successfully employed, improved, and the value of their proactive use to maintain hemodynamic goals and preserve long-term myocardial function is accruing.

SUMMARY

Temporary mechanical circulatory support devices promise to enhance recovery by mitigating the risk of complications, such as postcardiotomy cardiogenic shock, organ dysfunction, and death, associated with adult cardiac surgery.

Endoscopic Pedicle Saphenous Vein Graft Harvesting

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Perioperative Glycemic Management in Cardiac Surgery: A Narrative Review

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

Mast cell activation and degranulation in acute artery injury: A target for post-operative therapy

The increasing incidence of cardiovascular disease (CVD) has led to a significant ongoing need to address this surgically through coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI). From this, there continues to be a substantial burden of mortality and morbidity due to complications arising from endothelial damage, resulting in restenosis. Whilst mast cells (MC) have been shown to have a causative role in atherosclerosis and other vascular diseases, including restenosis due to vein engraftment; here, we demonstrate their rapid response to arterial wire injury, recapitulating the endothelial damage seen in PCI procedures. Using wild-type mice, we demonstrate accumulation of MC in the femoral artery post-acute wire injury, with rapid activation and degranulation, resulting in neointimal hyperplasia, which was not observed in MC-deficient KitW-sh/W-sh mice. Furthermore, neutrophils, macrophages, and T cells were abundant in the wild-type mice area of injury but reduced in the KitW-sh/W-sh mice. Following bone-marrow-derived MC (BMMC) transplantation into KitW-sh/W-sh mice, not only was the neointimal hyperplasia induced, but the neutrophil, macrophage, and T-cell populations were also present in these transplanted mice. To demonstrate the utility of MC as a target for therapy, we administered the MC stabilizing drug, disodium cromoglycate (DSCG) immediately following arterial injury and were able to show a reduction in neointimal hyperplasia in wild-type mice. These studies suggest a critical role for MC in inducing the conditions and coordinating the detrimental inflammatory response seen post-endothelial injury in arteries undergoing revascularization procedures, and by targeting the rapid MC degranulation immediately post-surgery with DSCG, this restenosis may become a preventable clinical complication.

Early and midterm outcomes after off pump coronary artery bypass surgery

Purpose

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality.

Methods

This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed.

Results

Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24 h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62 years, postoperative renal failure, IABP usage, ventilation time > 24 h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27 days and 6-year survival was 88.7%.

Conclusion

OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Survival and Independent Predictors of Mortality Following Coronary Artery Bypass Graft Surgery in a Single-Unit Practice in the United Kingdom Over 20 Years

BACKGROUND

 The types of graft conduits and surgical techniques may impact the long-term outcomes of patients after coronary artery bypass graft (CABG) revascularization. This study observed a long-term survival rate following CABG surgery over 20 years in the United Kingdom.

METHODS

 A total of 2979 isolated CABG patients were studied from 1999 to 2020, and postoperative data were obtained from the hospital-recorded mortality by the data quality team of the information department. Postdischarge survival was estimated using the Kaplan-Meier method, and statistical significance was obtained with log-rank tests and the Gehan-Breslow test, and the Holm-Sidak method was used for multiple pairwise comparisons.

RESULTS

 The study observed male predominance (80%), and the median age was statistically significant (P <0.001) among the groups, 66 years (interquartile range 58-73) and 72 years (interquartile range 66-78) in survivor and non-survivor groups, respectively. In the Holm-Sidak method analysis, the best survival rate (mean 18.7 years) was observed in the total arterial group with significantly decreased survival for the mixed arterial and venous group (mean 16.12 years) and only the vein group (10.44 years). The Cox regression model observed that the New York Heart Association (NYHA) class III-IV (HR 1.57), chest re-exploration (HR 2.14), preoperative dialysis (HR 3.13), and redo surgery (HR 3.04) were potential predictors of the postoperative mortality (P ≤0.05).

CONCLUSION

 In our series over 20 years, albeit off-pump and on-pump CABG observed similar survival rates, the total arterial myocardial revascularization population has significantly better long-term survival benefits.

Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020

Importance

It has been reported that women undergoing coronary artery bypass have higher mortality and morbidity compared with men but it is unclear if the difference has decreased over the last decade.

Objective

To evaluate trends in outcomes of women undergoing coronary artery bypass in the US from 2011 to 2020.

Design, Setting, and Participants

This retrospective cohort study at hospitals contributing to the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons included 1 297 204 patients who underwent primary isolated coronary artery bypass from 2011 to 2020.

Exposure

Coronary artery bypass.

Main Outcomes and Measures

The primary outcome was operative mortality. The secondary outcome was the composite of operative mortality and morbidity (including operative mortality, stroke, kidney failure, reoperation, deep sternal wound infection, prolonged mechanical ventilation, and prolonged hospital stay). The attributable risk (the association of female sex with coronary artery bypass grafting outcomes) for the primary and secondary outcomes was calculated.

Results

Between 2011 and 2020, 1 297 204 patients underwent primary isolated coronary artery bypass grafting with a mean age of 66.0 years, 317 716 of which were women (24.5%). Women had a higher unadjusted operative mortality (2.8%; 95% CI, 2.8-2.9 vs 1.7%; 95% CI, 1.7-1.7; P < .001) and overall unadjusted incidence of the composite of operative mortality and morbidity compared with men (22.9%; 95% CI, 22.7-23.0 vs 16.7%; 95% CI, 16.6-16.8; P < .001). The attributable risk of female sex for operative mortality varied from 1.28 in 2011 to 1.41 in 2020, with no significant change over the study period (P for trend = 0.38). The attributable risk for the composite of operative mortality and morbidity was 1.08 in both 2011 and 2020 with no significant change over the study period (P for trend = 0.71).

Conclusions and Relevance

Women remain at significantly higher risk for adverse outcomes following coronary artery bypass grafting and no significant improvement has been seen over the course of the last decade. Further investigation into the determinants of operative outcomes in women is urgently needed.

Current concepts in coronary artery revascularisation

Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.

Recognition of Strokes in the ICU: A Narrative Review

Despite the remarkable progress in acute treatment for stroke, in-hospital stroke is still devastating. The mortality and neurological sequelae are worse in patients with in-hospital stroke than in those with community-onset stroke. The leading cause of this tragic situation is the delay in emergent treatment. To achieve better outcomes, early stroke recognition and immediate treatment are crucial. In general, in-hospital stroke is initially witnessed by non-neurologists, but it is sometimes challenging for non-neurologists to diagnose a patient's state as a stroke and respond quickly. Therefore, understanding the risk and characteristics of in-hospital stroke would be helpful for early recognition. First, we need to know "the epicenter of in-hospital stroke". Critically ill patients and patients who undergo surgery or procedures are admitted to the intensive care unit, and they are potentially at high risk for stroke. Moreover, since they are often sedated and intubated, evaluating their neurological status concisely is difficult. The limited evidence demonstrated that the intensive care unit is the most common place for in-hospital strokes. This paper presents a review of the literature and clarifies the causes and risks of stroke in the intensive care unit.

Near-infrared spectroscopy and processed electroencephalogram monitoring for predicting peri-operative stroke risk in cardiothoracic surgery: An observational cohort study

BACKGROUND

Stroke is a feared complication after cardiothoracic surgery, with an incidence of around 2 to 3%. Anaesthesia and postoperative sedation may obscure clinical symptoms of stroke and thus delay diagnosis and timely intervention.

OBJECTIVES

The objective was to assess the value of intra-operative neuromonitoring and blood pressure monitoring for predicting the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery.

DESIGN

Single-centre retrospective observational cohort study.

SETTING

Academic tertiary care medical centre.

PATIENTS

All consecutive patients with cardiothoracic surgery and intra-operative neuromonitoring admitted postoperatively to the Intensive Care Unit (ICU) between 2008 and 2017.

MAIN OUTCOME MEASURES

The primary endpoint was the occurrence of any stroke confirmed by brain imaging within 3 days postcardiothoracic surgery. Areas under the curve (AUC) of intra-operative mean arterial pressure (MAP), cerebral oxygen saturation (ScO2) and bispectral index (BIS) below predefined thresholds were calculated, and the association with early stroke was tested using logistic regression analyses.

RESULTS

A total of 2454 patients admitted to the ICU after cardiothoracic surgery had complete intra-operative data for ScO2, BIS and MAP and were included in the analysis. In 58 patients (2.4%), a stroke was confirmed. In univariate analysis, a larger AUCMAP greater than 60 mmHg [odds ratio (OR) 1.43; 95% confidence interval (CI), 1.21 to 1.68) and larger AUCBIS<25 (OR 1.51; 95% CI, 1.24 to 1.83) were associated with the occurrence of postoperative stroke while ScO2 less than 50% or greater than 20% reduction from individual baseline was not (OR 0.91; 95% CI, 0.50 to 1.67). After multivariable analysis, AUCBIS<25 (OR 1.45; 95% CI, 1.12 to 1.87) and longer duration of MAP less than 60 mmHg (OR 1.52; 95% CI, 1.02 to 2.27) remained independently associated with stroke occurrence.

CONCLUSION

Cumulative intra-operative BIS values below 25 and longer duration of MAP below 60 mmHg were associated with the occurrence of peri-operative stroke within 3 days after cardiothoracic surgery. Prospective studies are warranted to evaluate a causal relationship between low BIS and stroke to establish whether avoiding intra-operative BIS values below 25 might reduce the incidence of peri-operative stroke.

Self-Expanding Versus Balloon Expanding Coronary Stents in Intervention of the Degenerated Saphenous Vein Graft: Memmingen Coronary Artery Bypass Stenosis Trial (MECAST)

Objectives. The aim of this retrospective analysis was to compare the patient outcome after interventional therapy of saphenous vein graft (SVG) stenoses in an all-comers population receiving either self-expanding drug-eluting stents (SExS) or balloon expanding drug-eluting stents (BExS). Background. The interventional therapy of degenerated SVGs remains challenging. Diameter variations of stenotic segments and friable plaques can lead to malapposition and distal embolization with increased major adverse cardiac event (MACE) rates. Methods. 107 patients with a total of 130 SVG interventions were separated into two groups according to either SExS (n = 51) or BExS (n = 56) treatment. Primary endpoint was the MACE rate, which is defined as the composite of cardiac death, myocardial infarction (MI), target vessel (TVR), and target lesion revascularization (TLR) at 30 days and at one-year follow-up. Results. Both patient groups did not differ significantly regarding patient characteristics. The patient outcome was significantly better in the SExS patient group: the MACE rate at 30 days was 1/51 (2.0%) in group SExS vs. 7/56 (12.5%) in group BExS; $p<0.05$ . At one-year follow-up, the MACE rate remained significantly lower in the SExS group 8/51(15.7%) vs. 20/56 (35.7%) in the BExS group, $p<0.02$ . Additionally, cardiac death occurred significantly later within the SExS patient group compared to the BExS group ( $p<0.05$ ). A better overall outcome of patients with de novo SVG-stenosis compared to patients with previous CABG (coronary artery bypass graft) intervention was noted in both groups. Conclusion. Our findings demonstrate that SVG treatment with SExS is safe and provides clinical benefits by comparatively improving short and especially long-term patient outcomes.

Clinical outcomes and quality of life after contemporary isolated coronary bypass grafting: a prospective cohort study

OBJECTIVES

The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life (QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG.

METHODS

The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) [major adverse cardiac events (MACE)] at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke [major adverse cardiac and cerebrovascular events (MACCE)], and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis.

RESULTS

A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 [interquartile range (IQR), 0.9-2.3]. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 [IQR, 0.72-0.92] at baseline to 0.92 [IQR, 0.82-1.00] at 1 year ( P <0.0001).

CONCLUSION

Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.

Determinants and clinical outcomes of stroke following revascularization among patients with reduced ejection fraction

OBJECTIVE

Stoke after revascularization including both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is an uncommon but devastating complication. Patients with reduced ejection fraction (EF) had an increased risk of stroke after revascularization. However, little is known about the determinants and outcomes of stroke among patients with reduced EF following revascularization.

MATERIALS AND METHODS

A cohort study of patients with preoperative reduced EF (≤40%) who received revascularization by either PCI or CABG between January 1, 2005 and December 31, 2014 was performed. Multivariate logistic regression was used to identify independent correlates of stroke. Logistic regression models were applied to evaluate the association of stroke with clinical outcomes.

RESULTS

A total of 1937 patients were enrolled in this study. Of these, 111 (5.7%) patients suffered from stroke during the median 3.5-year follow-up. Older age (odds ratio [OR], 1.03; 95% CI, 1.01-1.05; p = .009), history of hypertension (OR, 1.79; 95% CI, 1.18-2.73; p = .007), and history of stroke (OR, 2.00; 95% CI, 1.19-3.36; p = .008) were found to be independent predictors for stroke. Patients with and without stroke had similar risk of all-cause death (OR, 0.91; 95% CI, 0.59-1.41; p = .670). However, stroke was associated with higher odds ratio of heart failure (HF) hospitalization (OR, 2.77; 95% CI, 1.74-4.40; p < .001) and composite end point (OR, 1.61; 95% CI, 1.07-2.42; p = .021).

CONCLUSIONS

Further research appears warranted to minimize the complication of stroke and improve long-term outcomes among patients with reduced EF who underwent such high risk revascularization procedural.

Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction

Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.

Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

Diagnostic and therapeutic advances during the past decades have substantially improved health outcomes for patients with acute coronary syndrome. Both age-related physiological changes and accumulated cardiovascular risk factors increase the susceptibility to acute coronary syndrome over a lifetime. Compared with younger patients, outcomes for acute coronary syndrome in the large and growing demographic of older adults are relatively worse. Increased atherosclerotic plaque burden and complexity of anatomic disease, compounded by age-related cardiovascular and noncardiovascular comorbid conditions, contribute to the worse prognosis observed in older individuals. Geriatric syndromes, including frailty, multimorbidity, impaired cognitive and physical function, polypharmacy, and other complexities of care, can undermine the therapeutic efficacy of guidelines-based treatments and the resiliency of older adults to survive and recover, as well. In this American Heart Association scientific statement, we (1) review age-related physiological changes that predispose to acute coronary syndrome and management complexity; (2) describe the influence of commonly encountered geriatric syndromes on cardiovascular disease outcomes; and (3) recommend age-appropriate and guideline-concordant revascularization and acute coronary syndrome management strategies, including transitions of care, the use of cardiac rehabilitation, palliative care services, and holistic approaches. The primacy of individualized risk assessment and patient-centered care decision-making is highlighted throughout.

Systemic Delivery of Clopidogrel Inhibits Neointimal Formation in a Mouse Vein Graft Model

ABSTRACT

Clopidogrel inhibits platelet aggregation and has beneficial effects on patients undergoing coronary artery bypass grafting surgery, but it is unknown whether clopidogrel inhibits the neointima formation of grafted veins. In this study, we used a murine vein graft model to study the effect of clopidogrel on intima hyperplasia of the vein graft. Vein grafting was performed among C57BL/6J mice, immediately after surgery; 1 mg/kg clopidogrel and vehicle control were used to inject mice peritoneally daily for 2 weeks. As compared with the vehicle, clopidogrel significantly inhibited the neointima formation of vein grafts at 4 weeks after surgeries. The immunohistochemistry study showed that as compared with the vehicle, clopidogrel significantly decreased the rate of proliferating cell nuclear antigen-positive cells in the wall of vein grafts and significantly increased the expression of vascular smooth muscle cell (VSMC) contractile protein markers (α-smooth muscle actin, calponin, and SM22) within the neointima area of vein grafts. Clopidogrel significantly decreased the plasma interleukin 6 (IL-6) level at 1 week after surgery as compared with the vehicle. We isolated VSMCs from mouse aortic arteries. As compared with the vehicle, clopidogrel significantly inhibited thrombin-induced VSMC proliferation and migration, significantly decreased IL-6 mRNA expression and protein secretion, and increased intracellular cyclic adenosine monophosphate generation in a dose-dependent manner. In conclusion, systemic delivery of clopidogrel inhibits neointima formation of the mouse vein graft, the mechanisms of which are associated with its inhibitory effects on VSMC proliferation, migration, and the tendency to synthetic phenotype after vein graft surgery, reducing the expression of IL-6 and increasing the intracellular cyclic adenosine monophosphate level.

Combined pectoralis and rectus abdominis flaps are associated with improved outcomes in sternal reconstruction

BACKGROUND

Mortality increases nearly 5-fold in the approximately 5% of patients who develop sternal wound complications after cardiothoracic surgery. Flap-based reconstruction can improve outcomes by providing well-vascularized soft tissue for potential space obliteration, antibiotic delivery, and wound coverage; however, reoperation and readmission rates remain high. This study used the high case volume at a tertiary referral center and a diverse range of reconstructive approaches to compare various types of flap reconstruction. Combined (pectoralis and rectus abdominis) flap reconstruction is hypothesized to decrease sternal wound complication-related adverse outcomes.

METHODS

A retrospective cohort study of consecutive adult patients treated for cardiothoracic surgery sternal wound complications between 2008 and 2018 was performed. Patient demographics, comorbidities, wound characteristics, surgical parameters, and perioperative data were collected. Multivariable regression modeling with stepwise forward selection was used to characterize predictive factors for sternal wound-related readmissions and reoperations.

RESULTS

In total, 215 patients were assessed for sternal wound reconstruction. Patient mortality at 1 year was 12.4%. Flap selection was significantly associated with sternal wound-related readmissions (P = .017) and reoperations (P = .014). Multivariate regression demonstrated rectus abdominis flap reconstruction independently predicted increased readmissions (odds ratio 3.4, P = .008) and reoperations (odds ratio 2.9, P = .038). Combined pectoralis and rectus abdominis flap reconstruction independently predicted decreased readmissions overall (odds ratio 0.4, P = .031) and in the deep sternal wound subgroup (odds ratio 0.1, P = .033).

CONCLUSION

Although few factors can be modified in this complex highly comorbid population with a challenging and rare surgical problem, consideration of a more surgically aggressive multiflap reconstructive approach may be justified to improve outcomes.

Left main coronary disease: evolving management concepts

Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.

Minimally-invasive cardiac surgery: a bibliometric analysis of impact and force to identify key and facilitating advanced training

Background

The number of citations an article receives is a marker of its scientific influence within a particular specialty. This bibliometric analysis intended to recognise the top 100 cited articles in minimally-invasive cardiac surgery, to determine the fundamental subject areas that have borne considerable influence upon clinical practice and academic knowledge whilst also considering bibliometric scope. This is increasingly relevant in a continually advancing specialty and one where minimally-invasive cardiac procedures have the potential for huge benefits to patient outcomes.

Methods

The Web of Science (Clarivate Analytics) data citation index database was searched with the following terms: [Minimal* AND Invasive* AND Card* AND Surg*]. Results were limited to full text English language manuscripts and ranked by citation number. Further analysis of the top 100 cited articles was carried out according to subject, author, publication year, journal, institution and country of origin.

Results

A total of 4716 eligible manuscripts were retrieved. Of the top 100 papers, the median (range) citation number was 101 (51–414). The most cited paper by Lichtenstein et al. (Circulation 114(6):591–596, 2006) published in Circulation with 414 citations focused on transapical transcatheter aortic valve implantation as a viable alternative to aortic valve replacement with cardiopulmonary bypass in selected patients with aortic stenosis. The Annals of Thoracic Surgery published the most papers and received the most citations (n = 35; 3036 citations). The United States of America had the most publications and citations (n = 52; 5303 citations), followed by Germany (n = 27; 2598 citations). Harvard Medical School, Boston, Massachusetts, published the most papers of all institutions. Minimally-invasive cardiac surgery pertaining to valve surgery (n = 42) and coronary artery bypass surgery (n = 30) were the two most frequent topics by a large margin.

Conclusions

This work establishes a comprehensive and informative analysis of the most influential publications in minimally-invasive cardiac surgery and outlines what constitutes a citable article. Undertaking a quantitative evaluation of the top 100 papers aids in recognising the contributions of key authors and institutions as well as guiding future efforts in this field to continually improve the quality of care offered to complex cardiac patients.

Are there differences in cardiothoracic surgery performed by trainees versus fully trained surgeons?

OBJECTIVES

We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons.

METHODS

EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. Eight hundred and ninety-two results were obtained, 27 represented best evidence (2-meta-analyses, 1-RCT, and 24 retrospective cohort studies).

RESULTS

In all 474,160 operative outcomes were assessed for 434,535 coronary artery bypass grafting (CABG) (431,329 on-pump vs. 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital, and 4797 thoracic procedures. In all 398,058 cases were performed by trainees and 75,943 by consultants. One hundred fifty-nine cases were indeterminate. There were no statistically significant differences in the patients' preoperative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function, and reoperation cases that were undertaken by consultants. There were no differences in cardiopulmonary bypass and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the postoperative outcomes including perioperative myocardial infarction, resternotomy for bleeding, stroke, renal failure, intensive therapy unit length of stay, and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or midterm mortality out to 5-years.

DISCUSSION

Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.

Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study

BACKGROUND

Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied.

OBJECTIVES

To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes.

METHODS

Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics.

RESULTS

In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization.

CONCLUSIONS

Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.

Patency and adverse outcomes of sequential vs. individual saphenous vein grafts in coronary artery bypass: A meta-analysis

Objectives

To undertake a systematic review and meta-analysis of cohort studies to compare the patency and adverse outcomes of sequential and individual saphenous vein grafts (SVGs) in coronary artery bypass grafting (CABG).

Methods

We searched PubMed, Embase, and the Cochrane Library for cohort studies. Endpoints for vein graft failure, perioperative and follow-up adverse events were extracted as risk ratio (RR) with 95% confidence intervals (95% CI). Statistical heterogeneity across the studies was examined using the I² statistic. Potential of publication bias was evaluated quantitatively by the Egger's test. Sensitivity analysis was also performed to assess the robustness of our outcomes.

Results

The 15 studies were analyzed, including 22,004 patients, 4,580 grafts, and seven different adverse events under individual or sequential CABG. The sequential group had inferior graft failure (RR = 0.68; 95% CI, 0.60–0.77) and long-term mortality (RR = 0.76; 95%CI, 0.61–0.95), but with an increased risk of perioperative repeat revascularization (RR = 1.58; 95%CI, 1.16–2.14) than the individual group.

Conclusion

Taken together, our analysis of the aggregated evidence comparing the sequential and individual saphenous vein grafts for coronary heart disease patients showed that the use of the sequential graft was associated with inferior graft failure and long-term mortality respectively, but with an increased risk of perioperative repeat revascularization. According to our study, both surgical techniques have their own advantages in efficacy and safety, and the selection of surgical techniques should be based on patients and surgeons. Sequential saphenous vein grafts should be more recommended to experienced surgeons in order to both reduce perioperative adverse events and improve long-term patency.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022326992.

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans

BACKGROUND

Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG.

METHODS

Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA.

RESULTS

Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p < .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF >55% (p < .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p < .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use.

CONCLUSION

The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication.

The Effect of COVID-19 on Cardiac Surgical Volume and its Associated Costs

The COVID-19 pandemic significantly affected health care and in particular surgical volume. However, no data surrounding lost hospital revenue due to decreased cardiac surgical volume have been reported. The National Inpatient Sample database was used with decreases in cardiac surgery at a single center to generate a national estimate of decreased cardiac operative volume. Hospital charges and provided charge to cost ratios were used to create estimates of lost hospital revenue, adjusted for 2020 dollars. The COVID period was defined as January to May of 2020. A Gompertz function was used to model cardiac volume growth to pre-COVID levels. Single center cardiac case demographics were internally compared during January to May for 2019 and 2020 to create an estimate of volume reduction due to COVID. The maximum decrease in cardiac surgical volume was 28.3%. Cumulative case volume and hospital revenue loss during the COVID months as well as the recovery period totaled over 35 thousand cases and 2.5 billion dollars. Institutionally, patients during COVID months were younger, more frequently undergoing a CABG procedure, and had a longer length of stay. The pandemic caused a significant decrease in cardiac surgical volume and a subsequent decrease in hospital revenue. This data can be used to address the accumulated surgical backlog and programmatic changes for future occurrences.

The Effect of Low Preoperative Ejection Fraction on Mortality After Cardiac Surgery in Indonesia

Background

Among cardiac surgery patients, low preoperative left ventricular ejection fraction (LVEF) is common and has been associated with poor outcomes. The objective of this study was to assess the association between LVEF and postoperative mortality in patients undergoing open-heart surgery in several hospitals in Indonesia.

Methods

We conducted a multicenter study with the retrospective design using data from patients undergoing open-heart surgery in 4 institutions in Indonesia. Data regarding LVEF and other potential risk factors were extracted from medical records and compiled in one datasheet. Statistical analyses were performed to assess if low LVEF was associated with postoperative mortality and identify other potential risk factors.

Results

A total of 4789 patients underwent cardiac surgery in participating centers during the study period. Of these, 189 subjects (3.9%) had poor preoperative LVEF. Poor LVEF was associated with postoperative mortality (adjusted OR 2.761, 95% CI 1.763–4.323, p < 0.001). Based on types of surgery, LVEF had a significant association with mortality only in CABG patients, while there was no such association in valve surgery and inconclusive in congenital surgery patients. Other significant independent predictors of in-hospital mortality included age more than 65 years old, non-elective surgery, the complexity of procedures, history of cardiac surgery, organ failure, CARE score ≥ 3, NYHA class ≥ III, and poor right ventricular function.

Conclusion

Patients with low preoperative LVEF undergoing open-heart surgery had a higher risk of postoperative mortality. Cardiac surgery can be performed with acceptable mortality rates. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcomes.

A COMPARISON OF AKIN, KDIGO AND RIFLE DEFINITIONS TO DIAGNOSE ACUTE KIDNEY INJURY AND PREDICT THE OUTCOMES AFTER CARDIAC SURGERY IN A SOUTH ASIAN COHORT

BACKGROUND

Acute kidney injury (AKI) after cardiac surgery is associated with an increased mortality and morbidity. Different definitions for AKI have been used such as Acute Kidney Injury Network (AKIN), Kidney Disease: Improving Global Outcomes (KDIGO) or risk, injury, failure, loss, end-stage kidney disease (RIFLE). Each of these definitions have their own benefits and limitations for predicting the degree of AKI and adverse outcomes following cardiac surgery. This study was aimed to compare the three AKI definitions to diagnose AKI and their predictive ability for mortality and morbidity after isolated coronary artery bypass surgery (CABG) in a South Asian cohort.

MATERIAL AND METHODS

A single center retrospective review was conducted on 1508 patients having undergone isolated CABG surgery during January 2015 to January 2019. AKI was assessed on three definitions and comparative receiver operating characteristics curves were built against the outcomes to assess discriminative power of each.

RESULTS

Mean age of participants was 59.43 (±1.12) years, predominantly males (82.6%). Patient with AKI were elder, more likely to be diabetic and hypertensive. AKI by any definition occurred in 58.7% (885/1508) patients. Frequency of AKI was 508 (33.7%), 517 (34.4%) and 871 (57.8%) on AKIN, KDIGO and RIFLE criteria, respectively. The proportion of patients with RIFLE- risk 619 (41%) was greater compared with AKIN stage 1 [342 (22.7%)], and KDIGO stage 1 [330 (21.9%)], while for stage 2 and 3 the proportions were comparable across the three systems. Area under the curve (AUC) for 30-day mortality for AKIN was [0.786, (95% CI: 0.764 to 0.806)], KDIGO: [0.796, (95% CI: 0.775 to 0.816)], and for RIFLE [0.844, (95% CI: 0.825 to 0.862)]. AUC for overall morbidity were in undesirable ranges (i.e. >0.5 to ≤ 0.7) for all three definitions.

CONCLUSION

In a South Asian cohort, performance of AKIN and KDIGO criteria was comparable to diagnose AKI, while RIFLE definition, though overestimated the incidence of AKI particularly stage 1, and had an excellent discriminatory power to predict mortality compared to other two definitions.

A novel nomogram for predicting 3-year mortality in critically ill patients after coronary artery bypass grafting

Background

The long-term outcomes for patients after coronary artery bypass grafting (CABG) have been received more and more concern. The existing prediction models are mostly focused on in-hospital operative mortality after CABG, but there is still little research on long-term mortality prediction model for patients after CABG.

Objective

To develop and validate a novel nomogram for predicting 3-year mortality in critically ill patients after CABG.

Methods

Data for developing novel predictive model were extracted from Medical Information Mart for Intensive cart III (MIMIC-III), of which 2929 critically ill patients who underwent CABG at the first admission were enrolled.

Results

A novel prognostic nomogram for 3-year mortality was constructed with the seven independent prognostic factors, including age, congestive heart failure, white blood cell, creatinine, SpO₂, anion gap, and continuous renal replacement treatment derived from the multivariable logistic regression. The nomogram indicated accurate discrimination in primary (AUC: 0.81) and validation cohort (AUC: 0.802), which were better than traditional severity scores. And good consistency between the predictive and observed outcome was showed by the calibration curve for 3-year mortality. The decision curve analysis also showed higher clinical net benefit than traditional severity scores.

Conclusion

The novel nomogram had well performance to predict 3-year mortality in critically ill patients after CABG. The prediction model provided valuable information for treatment strategy and postdischarge management, which may be helpful in improving the long-term prognosis in critically ill patients after CABG.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01408-8.

Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada

Background:

Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR.

Methods:

We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020).

Results:

The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts.

Interpretation:

Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.

Radial artery or saphenous vein for Coronary artery bypass grafitng

Coronary artery disease (CAD) is the most common cardiovascular disease worldwide, affecting over 18 million American adults. Coronary artery bypass grafting (CABG) is the standard of care for patients with left main or triple vessel CAD. Historically, the saphenous vein (SV) has been utilized to bypass the majority of the coronary vessels in patients undergoing CABG, but more recent data suggest that the use of the radial artery (RA), rather than the SV, is associated with improved cardiac outcomes and better survival. The aim of this review is to summarize the current literature on the use of RA and SV for CABG in patients with multivessel CAD.

Sex and age difference in risk factor distribution, trend, and long-term outcome of patients undergoing isolated coronary artery bypass graft surgery

BACKGROUND

Preoperative coronary artery disease risk factors (CADRFs) distribution and pattern may also have an important role in determining major adverse cardiovascular events (MACEs). In this study, we aimed to evaluate the CADRFs distribution and trend over 10 years and also the long-term outcome of CABG in different age-sex categories.

METHOD

In this registry-based serial cross-sectional study, we enrolled 24,328 patients who underwent isolated CABG and evaluated the prevalence of CADRFs according to sex and age. We used inverse probability weighting (IPW) to compare survival and MACE between the sexes. We also used Cox regression to determine each CADRFs effect on survival and MACEs.

RESULTS

In general, DLP (56.00%), HTN (53.10%), DM (38.40%), and positive family history (38.30%) were the most frequent risk factors in all patients. Prevalence of HTN, DLP, DM, obesity, and positive family history were all higher in women, all statistically significant. The median follow-up duration was 78.1 months (76.31-79.87 months). After inverse probability weighting (to balance risk factors and comorbidities), men had lower MACEs during follow-up (HR 0.72; 95% CI 0.57-0.91; P value 0.006) and there was no significant difference in survival between sexes. DM and HTN were associated with higher mortality and MACEs in both sexes.

CONCLUSION

Although DLP is still the most frequent CADRF among the CABG population, the level of LDL and TG is decreasing. Women experience higher MACE post CABG. Therefore, health care providers and legislators must pay greater attention to female population CADRFs and ways to prevent them at different levels.

Coronary revascularization in acute coronary syndrome: does the choice of the conduit matter?

BACKGROUND

Our retrospective study evaluates the impact on short - and long-term outcome according to the graft selection during emergency coronary revascularization surgery.

METHODS

339 Patients with acute coronary syndrome undergoing emergency coronary bypass surgery at our institution from 2008 until 2018 were analyzed using propensity score analysis. The primary endpoint was in-hospital survival. Secondary endpoints were postoperative bleeding, contractile dysfunction, postoperative percutaneous coronary intervention, myocardial infarction and wound infection. Patients were divided in two groups according to the bypass grafts received ((group 0, (n = 222): combined arterial and venous grafts for the and group 1 (n = 117): complete arterial revascularization).

RESULTS

There is significant improvement of left ventricular function postoperatively in patients undergoing emergency coronary revascularization for acute myocardial infarction where arterial grafts were used. Furthermore, there is significant difference between postoperative cardiac enzymes with lower values in group 1 (creatine kinase myocardial band p=0.0001; Troponin T p= 0,010). There was no significant difference in short and long-term survival between two groups. 5-years survival analysis between both groups did not show significant difference with Log-Rank test adjusted p-value = 0,49 (unadjusted p-value = 0.005). There was no significant difference in perioperative myocardial infarction, postoperative bleeding, and the need for postoperative coronary angiography.

CONCLUSIONS

Emergency coronary artery bypass grafting with arterial grafts shows significant improvement of left ventricular function postoperatively. However, utilization of bilateral internal mammary artery grafts in emergency coronary revascularization has no significant impact on short term or 5-year survival.

Representation of Women in Randomized Trials in Cardiac Surgery: A Meta-Analysis

Background

Women have traditionally been underrepresented in randomized clinical trials (RCTs). We performed a systematic evaluation of the inclusion of women in cardiac surgery RCTs published in the past 2 decades.

Methods and Results

MEDLINE, EMBASE, and the Cochrane Library were searched (2000 to July 2020) for RCTs written in English, comparing ≥2 adult cardiac surgical procedures. The percentage of women enrolled and its association with year of publication, sample size, mean age, funding source, geographic location, number of sites involved, and interventions tested were analyzed using a meta‐analytic approach. Fifty‐one trials were included. Of 25 425 total patients, 5029 were women (20.8%; 95% CI, 17.6–24.4; range, 0.5%–57.9%). The proportion of women dropped significantly during the study period (29.6% in 2000 versus 13.1% in 2019, P<0.001). Women were significantly more represented in European trials (26.2%; 95% CI, 21.2–31.9), and less represented in trials of coronary bypass surgery versus other interventions (16.8%; 95% CI, 12.3–22.7 versus 33.6%; 95% CI, 27.4–40.5; P=0.0002) and in trials enrolling younger patients (P=0.009); the percentage of women was higher in industry‐sponsored versus non‐industry sponsored trials (31.7%; 95% CI, 27.2–36.6 versus 15.5%; 95% CI, 10.0–23.2; P=0.0004) and was not associated with trial sample size (P=0.52) or study design (multicenter versus monocenter: P=0.22). After exclusion of trials conducted at Veteran Affairs centers, women representation was 24.4% (95% CI, 21.1–28.0; range, 10.4%–57.9%), with no significant changes during the study period.

Conclusions

The proportion of women in cardiac surgery trials is low and likely inadequate to provide meaningful estimates of the treatment effect.

Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data

AIMS

Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men.

METHODS AND RESULTS

The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes.

CONCLUSIONS

Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.