Coronary artery bypass grafting in diabetics: A growing health care cost crisis

Impact of Diabetes in Patients With Acute Myocardial Infarction Undergoing Coronary Artery Bypass Surgery Within 48 Hours

BACKGROUND

Diabetic patients with coronary artery disease may benefit from elective coronary artery bypass graft (CABG) surgery. It is unknown whether this merit is transferable to patients with acute myocardial infarction (AMI) undergoing surgery.

METHOD

A total of 1,427 patients underwent CABG within 48 hours of being diagnosed with AMI at the current institution between 2001 and 2019. Of these patients, 206 (14.4%) had insulin-dependent diabetes mellitus (IDDM) and 148 (10.4%) had non-insulin dependent diabetes mellitus (NIDDM). Retrospective data analysis was performed.

RESULTS

Patients with NIDDM showed the highest perioperative risk profile, with a EuroScore II of 11.6 (±10.3) compared with 7.8 (±8.0) in non-diabetic patients and 8.4 (±7.8) in patients with IDDM (p<0.001). Sub-analysis demonstrated a higher proportion of non-ST-elevation myocardial infarction patients in the NIDDM cohort compared with the IDDM cohort (70.9% vs 56.8%; p=0.005). Postoperatively, NIDDM patients had more sepsis (p<0.01) and longer ventilation times (p<0.001) compared with non-DM and IDDM patients (p<0.01). Wound healing complications were rare, but almost twice as high in NIDDM patients compared with non-DM and IDDM patients (4.7% vs 0.9% vs 2.4%, respectively). The 30-day mortality was highest in the NIDDM cohort (18.3% vs 11.3% vs 7.8%; p=0.012). Analysis of survival for up to 15 years revealed a significantly reduced survival of diabetic patients compared with non-diabetic patients, with lowest survival rates in NIDDM patients (p<0.001).

CONCLUSIONS

Non-insulin dependent diabetes mellitus patients undergoing CABG within 48 hours of being diagnosed with AMI are at increased risk of short-term and long-term complications. Therefore, this particular group should undergo a careful evaluation concerning the expected risks and benefits of CABG in this setting.

A high-volume study on the impact of diabetes mellitus on clinical outcomes after surgical and percutaneous cardiac interventions

BACKGROUND

Type I and type II diabetes mellitus (DM) patients have a higher prevalence of cardiovascular diseases, as well as a higher mortality risk of cardiovascular diseases and interventions. This study provides an update on the impact of DM on clinical outcomes, including mortality, complications and reinterventions, using data on percutaneous and surgical cardiac interventions in the Netherlands.

METHODS

This is a retrospective, nearby nationwide study using real-world observational data registered by the Netherlands Heart Registration (NHR) between 2015 and 2020. Patients treated for combined or isolated coronary artery disease (CAD) and aortic valve disease (AVD) were studied. Bivariate analyses and multivariate logistic regression models were used to evaluate the association between DM and clinical outcomes both unadjusted and adjusted for baseline characteristics.

RESULTS

241,360 patients underwent the following interventions; percutaneous coronary intervention(N = 177,556), coronary artery bypass grafting(N = 39,069), transcatheter aortic valve implantation(N = 11,819), aortic valve replacement(N = 8,028) and combined CABG and AVR(N = 4,888). The incidence of DM type I and II was 21.1%, 26.7%, 17.8%, 27.6% and 27% respectively. For all procedures, there are statistically significant differences between patients living with and without diabetes, adjusted for baseline characteristics, at the expense of patients with diabetes for 30-days mortality after PCI (OR = 1.68; p <.001); 120-days mortality after CABG (OR = 1.35; p <.001), AVR (OR = 1.5; p <.03) and CABG + AVR (OR = 1.42; p =.02); and 1-year mortality after CABG (OR = 1.43; p <.001), TAVI (OR = 1.21; p =.01) and PCI (OR = 1.68; p <.001).

CONCLUSION

Patients with DM remain to have unfavourable outcomes compared to nondiabetic patients which calls for a critical reappraisal of existing care pathways aimed at diabetic patients within the cardiovascular field.

Impact of diabetic versus non-diabetic patients undergoing coronary artery bypass graft surgery on postoperative wound complications: A meta-analysis

The effect of diabetes mellitus (DM) on the incidence of postoperative wound complications in patients with coronary artery bypass grafting (CABG) is still unclear. Thus, we performed a meta-analysis of CABG in DM patients to evaluate existing data from both prospective and historical cohorts. The objective of this trial was to assess the relevance and extent of the effect of diabetes on the outcome of previous CABG procedures. Data sources like Embase and Pubmed were found throughout the research, and the language was limited to English through manual search. The searches were performed up to August 2023. The data were extracted from the study of the inclusion/exclusion criteria, the features of the population, the statistical approach and the clinical results. A qualitative evaluation of the qualifying studies has been carried out. Out of the 1874 studies identified, 21 cohort studies were chosen for analysis. Meta-analyses were performed in 258 454 patients (71 351 diabetic and 187 103 non-diabetic). Twenty-one studies on deep sternal wound infections in CABG patients showed a lower rate of deep sternal wound infections in non-diabetes group compared with those with diabetes (OR, 2.13; 95% CI: 1.97, 2.31, p < 0.00001). And 16 studies of superficial wound infections in patients undergoing CABG were found to be associated with a lower rate of superficial injury (OR, 1.93; 95% CI: 1.53, 2.43, p < 0.00001) compared with those with diabetes; In five trials, perfusion time during CABG (MD, 2.31; 95% CI: -0.16, 4.79, p = 0.07) was observed, and there were no significant differences between diabetes and non-diabetes. Currently, there is a higher risk for CABG in diabetes than in non-diabetes patients with sternal infections and superficial injuries. Future randomized trials will concentrate on the treatment of such perioperatively related complications, which will lower the risk of postoperative wound infection in diabetes.

Very Long-term Outcome of Bilateral Internal Thoracic Artery in Diabetic Patients: A Systematic Review and Reconstructed Time-To-Event Meta-analysis

The benefits of single (SITA) and bilateral internal thoracic arteries (BITA) in diabetics undergoing coronary bypass grafting (CABG) are conflicting. We undertook a study-level meta-analysis to compare early and long-term outcomes of both CABG configurations. PubMed, CENTRAL, and EMBASE were searched for studies comparing BITA versus SITA for isolated CABG surgery in diabetics. Randomized trials or observational studies were considered eligible for the analysis. Kaplan-Meier curves of long-term survival were reconstructed and compared with Cox linear regression; incidence rate ratios (IRR) with 95% confidence intervals (CI) for long-term survival were calculated. Landmark analysis and time-varying hazard ratio (HR) were analyzed. Odds ratios (OR) were extracted for early mortality, postoperative stroke, deep sternal wound infection (DSWI), and myocardial infarction (MI). A random effects meta-analysis was performed. Sensitivity analyses included leave-one-out-analyses and meta-regression. Thirteen studies (7332 patients) were included. Overall, at 20-year follow-up, BITA was associated with higher survival (HR = 0.77; 95% CI, 0.71-0.84; P < 0.0001). Time-varying HR and landmark analysis reported BITA was associated with a higher rate of 10-year survival (HR = 0.75, 95% CI 0.68-0.82, P < 0.0001), while from 10 to 20-year follow-up no difference was revealed (HR = 0.99, 95% CI 0.82-1.19, P = 0.93). There was no increase in early mortality, postoperative MI, stroke, or DSWI between the groups. At meta-regression, the higher the age, the higher the long-term overall survival in patients with BITA. In diabetics, the BITA approach is associated with improved 10-year survival with no increase in early mortality, MI, stroke, or DSWI. In the 10-20-year timeframe, BITA and SITA showed comparable survival.

The Role of Insulin Resistance in the Development of Complications after Coronary Artery Bypass Grafting in Patients with Coronary Artery Disease

The aim of the study was to investigate the effect of carbohydrate metabolism disorders and insulin resistance indices on the immediate results of coronary artery bypass grafting (CABG).

METHOD

Patients with coronary artery disease who underwent CABG (n = 383) were examined to determine glycemic status, free fatty acid and fasting insulin levels, and insulin resistance indices (Homeostasis Model Assessment of Insulin Resistance (HOMA-IR), McAuley index, Quantitative Insulin Sensitivity Check Index (QUICKI), Revised-QUICKI). Patients were assessed for the development of perioperative complications and their length of stay in the hospital. Two groups were formed: group 1, patients with a combined endpoint (CEP, any complication and/or duration of hospital stay >10 days), n = 291; and group 2 (n = 92) without a CEP. Perioperative characteristics were analyzed, and predictors of hospital complications and prolonged hospital stay were evaluated.

RESULTS

Patients in the CEP group were older, and there were more women among them (p = 0.003). Additionally, in this group, there were more patients with diabetes mellitus (37.5% vs 17.4%, p < 0.001), obesity (p < 0.001), and a higher percentage of combined operations (p = 0.007). In the group with a CEP, the levels of glucose (p = 0.031), glycated hemoglobin (p = 0.009), and free fatty acids (p = 0.007) and the Revised-QUICKI (p = 0.020) were higher than in the group without complications. In a regression analysis, the independent predictors of complications were combined operations (p = 0.016) and the predictors of a long hospital stay (>14 days) were female gender, the left atrium size, and diabetes mellitus (p < 0.001). The predictors of a composite endpoint included female gender, age, the left atrium size, and free fatty acid levels (p < 0.001).

CONCLUSIONS

In the group with in-hospital complications after CABG, not only was the presence of diabetes mellitus more often detected, but there were also higher levels of free fatty acids and a higher Revised-QUICKI. Therefore, additional assessments of insulin resistance and free fatty acid levels are advisable in patients before CABG.

Association of Diabetes Mellitus and Its Types with In-Hospital Management and Outcomes of Patients with Acute Myocardial Infarction

BACKGROUND

Diabetes mellitus (DM) is an important risk factor for adverse outcomes following acute myocardial infarction (AMI), but large-scale studies investigating the differential impact of Type 1 DM (T1DM) and Type 2 DM (T2DM) on AMI outcomes are lacking.

METHODS

All adult discharges for AMI in the National Inpatient Sample (October 2015 to December 2018) were included and stratified into T1DM, T2DM and non-DM (NDM) groups. Outcomes of interests were all-cause mortality, major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and acute ischemic stroke, as well as invasive management. Binomial hierarchical multilevel multivariable logistic regression with adjusted odds ratios (aOR) and 95 % confidence intervals (95 % CI) was used to investigate the association between DM and its subtypes with the AMI outcomes.

RESULTS

Out of 2,587,615 patients, there were 29,250 (1.1 %) T1DM and 1,032,925 (39.9 %) T2DM patients. After multivariable adjustment, patients with T1DM had increased odds of MACCE (aOR 1.20, 95 % CI 1.09-1.31), all-cause mortality (aOR 1.20, 95 % CI 1.08-1.33) and major bleeding (aOR 1.28, 95 % CI 1.13-1.44), whilst T2DM patients had increased odds of MACCE (aOR 1.03, 95 % CI 1.01-1.05) and ischemic stroke (aOR 1.09, 95 % CI 1.05-1.13), compared to NDM patients. The adjusted odds of receiving percutaneous coronary intervention were lower in both T1DM and T2DM patients (aOR 0.70, 95 % CI 0.66-0.75 and aOR 0.95, 95 % CI 0.94-0.96, respectively), but T2DM patients showed higher utilization of composite percutaneous and surgical revascularization (aOR 1.03, 95 % CI 1.03-1.04) compared to NDM patients.

CONCLUSIONS

DM patients presenting with AMI have worse in-hospital clinical outcomes compared to NDM patients. There are important DM type-related differences with T1DM patients having overall worse outcomes and receiving less overall revascularization.

Twenty-year experience with skeletonized bilateral internal thoracic arteries for surgical myocardial revascularization. A single center experience

BACKGROUND AND AIM OF THE STUDY

The mammary artery shows excellent long-term patency and encourages the use of skeletonized bilateral internal thoracic arteries (BITA) for coronary surgery. We analyzed the long-term outcome of patients operated for myocardial revascularization with BITA in a single center.

MATERIALS AND METHODS

Clinical data and surgical details of patients undergoing coronary surgery with BITA were prospectively collected and retrospectively analyzed. Selected variables were studied as risk factors for sternal wound complication and a subanalysis of clinical outcome for patients aged 70 years or greater was performed. A long-term follow-up of the study group is provided.

RESULTS

From January 2001 to November 2021, 750 patients underwent myocardial revascularization using BITA grafts (mean age: 61 ± 9.5 years; males: 91%) at our institute. Patients with triple-vessel disease were 81%, 15.3% of all procedures were performed off-pump and 3.6% were urgent cases. Hospital mortality was 0.5%. Sternal wound complication was observed in 67 patients (9.0%) with 7 deep sternal wound infections (0.9%). Female gender (odds ratios [OR]: 3.7, p < 0.01), BMI >30 (OR: 1.8, p = 0.04), smoking (OR: 1.8, p = 0.02), and chronic kidney failure (OR: 3.7, p = 0.05) were independent predictors for sternal complications. During a mean follow-up time of 8.7 ± 5.3 years, 34 patients (4.5%) underwent a repeated myocardial revascularization, and there were 89 all-cause deaths (11.9%) and the cumulative survival at 5, 10, 15, and 20 years was 97%, 89%, 76%, and 60% for the whole study group 92%, 74%, 47%, and 43% for the subgroup of elderly patients (mean age: 74 ± 3.5 years).

CONCLUSIONS

Use of skeletonized bilateral thoracic arteries shows low-rate of wound infection and good long-term outcome with low risk of repeated revascularizations, regardless of patients' age.

Single versus multiple arterial grafting in diabetic patients at 10 years: the Arterial Revascularization Trial

AIMS

To evaluate the impact of multiple arterial grafting (MAG) vs. single arterial grafting (SAG) in a post hoc analysis of 10-year outcomes in patients with diabetes mellitus (DM) from the Arterial Revascularization Trial (ART).

METHODS AND RESULTS

The primary endpoint was all-cause mortality and the secondary endpoint was a composite of major adverse cardiac events (MACE) at 10-year follow-up. Patients were stratified by diabetes status (non-DM and DM) and grafting strategy (MAG vs. SAG). A total of 3020 patients were included in the analysis; 716 (23.7%) had DM. Overall, 55.8% non-DM patients received MAG and 44.2% received SAG, while 56.6% DM patients received MAG and 43.4% received SAG. The use of MAG compared with SAG was associated with lower 10-year mortality for both non-DM [17.7 vs. 21.0%, adjusted hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.72-1.06] and DM patients (21.5 vs. 29.9%, adjusted HR 0.65, 95% CI 0.48-0.89; P for interaction = 0.12). For both groups, the rate of 10-year MACE was also lower for MAG vs. SAG. Overall, deep sternal wound infections (DSWIs) were uncommon but more frequent in the MAG vs. SAG group in both non-DM (3.3 vs. 2.1%) and DM patients (7.9 vs. 4.8%). The highest rates of DSWI were in insulin-treated patients receiving MAG (9.6 vs. 6.3%, when compared with SAG).

CONCLUSION

In this post hoc analysis of the ART, MAG was associated with substantially lower mortality rates at 10 years after coronary artery bypass grafting in patients with DM. Patients with DM receiving MAG had a higher incidence of DSWI, especially if insulin dependent.

High Inflammatory Factor Levels Increase Cardiovascular Complications in Diabetic Patients Undergoing Coronary Artery Bypass Grafting

Objective

To investigate the association between inflammation and clinical outcomes of coronary artery bypass grafting (CABG) in diabetic patients.

Methods

A total of 300 diabetic patients with coronary heart disease who underwent CABG were selected. Patients were divided into a group with cardiovascular events (32 in the MACCE group) and a group without cardiovascular events (268 in the non-MACCE group) according to whether cardiovascular events occurred within 30 days. The differences in clinical parameters; serum levels of TNF-α, IL-6, IL-18, IL-1β, and CRP; factors associated with the occurrence of MACCE; and risk factors affecting the midterm all-cause mortality of patients were compared between the two groups.

Results

The serum levels of TNF-α, IL-6, IL-18, and CRP in the MACCE group were significantly higher than those in the non-MACCE group (p < 0.05). Gender, smoking, hyperlipidemia, duration of diabetes, and levels of TNF-α, IL-6, IL-18, and CRP were closely related to the occurrence of MACCE. The Kaplan-Meier survival analysis evaluation results showed that the levels of IL-6 and CRP significantly affected the midterm all-cause mortality rate (p < 0.05). Multivariate Cox regression analysis showed that the advanced age, hypertension, hyperlipidemia, long duration of diabetes, elevated serum IL-6, and CRP levels could be used as risk factors for midterm all-cause mortality.

Conclusions

Inflammation levels in diabetic patients are associated with complications and midterm all-cause mortality in patients undergoing coronary artery bypass grafting.

Sodium-glucose cotransport-2 inhibitor induced ketoacidosis following coronary artery bypass surgery: implications for management

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in patients with type 2 diabetes (T2D). Diabetic ketoacidosis (DKA) is an uncommon, but well recognised, life-threatening complication of SGLT2i. In a retrospective study of patients with T2D undergoing cardiac surgery at our institution, DKA occurred in 15.3% of patients taking SGLT2i at the time of surgery, compared with 0.47% of non-SGLT2i-treated patients. Intravenous insulin in the first 24 h after surgery was associated with a significantly lower risk of DKA in SGLT2i patients. Use of an insulin infusion should be considered in these patients, especially in those who are unable to cease their SGLT2i pre-operatively.

Use of a Continuous Glucose Monitoring System in High Risk Hospitalized Non-critically ill Patients with Diabetes after Cardiac Surgery and during their Transition of Care from the Intensive Care Unit during Covid-19-A Pilot Study

OBJECTIVE

Continuous glucose monitoring (CGM) has demonstrated benefits in managing inpatient diabetes. We initiated this single-arm pilot feasibility study during the COVID-19 pandemic in 11 patients to determine the feasibility and accuracy of real-time CGM in cardiac surgery patients with diabetes after their transition of care from the intensive care unit(ICU).

METHODS

Clarke Error Grid(CEG) analysis was used to compare CGM and point-of-care(POC) measurements. Mean absolute relative difference(MARD) of the paired measurements was calculated to assess the accuracy of the CGM for glucose measurements during the first 24 hours on CGM, the remainder of time on the CGM as well as for different chronic kidney disease(CKD) strata.

RESULTS

Overall MARD between POC and CGM measurements was 14.80%. MARD for patients without CKD IV and V with eGFR < 20 ml/min/1.73m² was 12.13%. Overall, 97% of the CGM values were within the no-risk zone of the CEG analysis. For the first 24 hours, a sensitivity analysis of the overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m² was 15.42% (+/- 14.44) and 12.80% (+/- 7.85) respectively. Beyond the first 24 hours, overall MARD for all subjects and for those with eGFR > 20 ml/min/1.73m² was 14.54% (+/- 13.21) and 11.86% (+/- 7.64) respectively.

CONCLUSIONS

CGM has great promise to optimize inpatient diabetes management in the noncritical care setting and after the transition of care from the ICU with high clinical reliability, and accuracy. More studies are needed to further assess CGM in patients with advanced CKD.

Relationship between Indices of Vascular Function and Presence of Overt Cardiovascular Disease among Persons with Poorly Controlled Type 2 Diabetes

The aim of this study was to assess the factors associated with impaired vascular function in patients with poorly controlled type 2 diabetes (DM2) with and without overt cardiovascular disease (CVD). Ninety-five patients with DM2 and poor glycemic control were recruited and divided into two groups: Group 1, with known CVD (n = 38), and Group 2, without CVD (n = 57). Patients in Group 2 were further subdivided into those with short (<5 years, group 2b) and long (>5 years, group 2a) diabetes duration. Subclinical markers of atherosclerosis were assessed. Glycemic control was similar in the two groups (HbA1c: 9.2% (1.5) vs. 9.4% (1.8), p = 0.44). In Group 1, lower FMD (3.13 (2.16)% vs. 4.7 (3.4)%, p < 0.05) and higher cIMT (1.09 (0.3) mm vs. 0.96 (0.2) mm, p < 0.05) was seen compared with Group 2, whereas PWV was similar (12.1 (3.4) vs. 11.3 (3.0) m/s, p = 0.10). Patients in Group 2b had significantly lower PWV and cIMT and higher FMD compared to Group 1 (p < 0.05). Among patients with poorly controlled T2D, more pronounced vascular dysfunction was present in those with overt macrovascular disease. In patients with T2D without known CVD, vascular dysfunction was associated with disease duration. The use of vascular indices for cardiovascular risk stratification in patients with T2D requires further study.

The Economic Implications of Introducing Single-Patient ECG Systems for Cardiac Surgery in Australia

Introduction

Sternal wound infections (SWIs) are severe adverse events of cardiac surgery. This study aimed to estimate the economic burden of SWIs following coronary artery bypass grafts (CABG) in Australia. It also aimed to estimate the national and hospital cost-benefit of adopting single-patient electrocardiograph (spECG) systems for CABG monitoring, a measure that reduces the rate of surgical site infections (SSIs).

Material and Methods

A literature review, which focused on CABG-related SSIs, was conducted to identify data which were then used to adapt a published Markov cost-effectiveness model. The model adopted an Australian hospital perspective.

Results

The average SWI-related cost of care increase per patient was estimated at 1022 Australian dollars (AUD), and the annual burden to the Australian health care system at AUD 9.2 million. SWI burden comprised 360 additional intensive care unit (ICU) days; 1979 additional general ward (GW) days; and 186 readmissions. Implementing spECG resulted in 103 fewer ICU days, 565 fewer GW days, 48 avoided readmissions, and a total national cost saving of AUD 2.5 million, annually. A hospital performing 200 yearly CABGs was estimated to save AUD 54,830.

Conclusion

SWIs cause substantial costs to the Australian health care system. Implementing new technologies shown to reduce the SWI rate is likely to benefit patients and reduce costs.

Hemoglobin A1c and preoperative glycemia as a decision tool to help minimise sternal wound complications: a retrospective study in OPCAB patients

Background

Poor glycemic control has been associated with an increased risk of wound complications after various types of operations. However, it remains unclear how hemoglobin A1c (HbA1c) and preoperative glycemia can be used in clinical decision-making to prevent sternal wound complications (SWC) following off-pump coronary artery bypass grafting (OPCAB).

Methods

We conducted a retrospective study of 1774 consecutive patients who underwent OPCAB surgery between January 2010 and November 2016. A new four-grade classification for SWC was used. The associations of HbA1c and preoperative glycemia with incidence and grade of SWC were analysed using logistic regression analysis and proportional odds models, respectively.

Results

During a median follow-up of 326 days (interquartile range (IQR) 21–1261 days), SWC occurred in 133/1316 (10%) of non-diabetes and 82/458 (18%) of diabetes patients (p < 0.001). Higher HbA1c was significantly associated with a higher incidence of SWC (odds ratio, OR 1.24 per 1% increase, 95% confidence interval, CI 1.04;1.48, p = 0.016) as well as a higher grade of SWC (OR 1.25, 95% CI 1.06;1.48, p = 0.010). There was no association between glycemia and incidence (p = 0.539) nor grade (p = 0.607) of SWC. Significant modifiers of these effects were found: HbA1c was associated with SWC in diabetes patients younger than 70 years (OR 1.41, 95% CI 1.17;1.71, p < 0.001), whereas it was not in those older than 70 years. Glycemia was associated with SWC in patients who underwent non-urgent surgery (OR 2.48, 95% CI 1.26;4.88, p = 0.009), in diabetes patients who received skeletonised grafts (OR 4.83, 95% CI 1.28;18.17, p = 0.020), and in diabetes patients with a BMI < 30 (OR 2.19, 95% CI 1.01;4.76, p = 0.047), whereas it was not in the counterparts of these groups.

Conclusions

Under certain conditions, HbA1c and glycemia are associated SWC following OPCAB. These findings are helpful in planning the procedure with minimal risk of SWC.

Hemoglobin A1c in Patients with Diabetes Predict Long-Term Mortality Following Coronary Artery Surgery

Objective: to estimate the association between preoperative hemoglobin A1c (HbA1c) levels below and above 7%, and the rate of all-cause mortality (ACM) in diabetes mellitus (DM) patients after coronary artery bypass grafting (CABG) within a ten-year follow-up period. Methods: we collected data on patient HbA1c levels that were measured up to 3 months prior to isolated CABG in consecutive patients with DM, and analyzed the rates of ACM over a median of a 5.9-year post-operative period. Results: preoperative HbA1c levels were collected in 579 DM patients. The mean HbA1c was 8.0 ± 1.7%, where 206 (35.6%) patients had an HbA1c ≤ 7% and 373 (64.4%) had an HbA1c > 7%. During the follow-up period, mortality rates were 20.4% and 28.7% in the HbA1c ≤ 7% and HbA1c > 7% groups, respectively (Kaplan-Meier estimates, log-rank p = 0.01). Multivariable Cox proportional hazards regression, adjusted for age, gender, smoking status, chronic obstructive pulmonary disease, hypertension, chronic renal failure, old myocardial infarction, number of coronary artery bypass surgeries, and post-operative glycemic control, showed a hazard ratio of 2.67 for long-term ACM (p = 0.001) in patients with HbA1c > 7%. Conclusions: DM patients with high HbA1c levels prior to CABG are at higher risk for long-term complications, especially late ACM.

The Prediction Model of Medical Expenditure Appling Machine Learning Algorithm in CABG Patients

Most patients face expensive healthcare management after coronary artery bypass grafting (CABG) surgery, which brings a substantial financial burden to the government. The National Health Insurance Research Database (NHIRD) is a complete database containing over 99% of individuals' medical information in Taiwan. Our research used the latest data that selected patients who accepted their first CABG surgery between January 2014 and December 2017 (n = 12,945) to predict which factors will affect medical expenses, and built the prediction model using different machine learning algorithms. After analysis, our result showed that the surgical expenditure (X4) and 1-year medical expenditure before the CABG operation (X14), and the number of hemodialysis (X15), were the key factors affecting the 1-year medical expenses of CABG patients after discharge. Furthermore, the XGBoost and SVR methods are both the best predictive models. Thus, our research suggests enhancing the healthcare management for patients with kidney-related diseases to avoid costly complications. We provide helpful information for medical management, which may decrease health insurance burdens in the future.

Effect of bilateral internal thoracic artery harvesting on deep sternal wound infection in diabetic patients: Review of literature

Instead of its documented superiority of patency and long-term outcomes, the bilateral internal thoracic artery grafts are underused in the general population, and its use is controversial and debatable in diabetic patients due to long surgery duration, post-surgical bleeding, and sternal wound complications such as sternal wound infection, mediastinitis, and sternal wound dehiscence. This review article is particularly focused on deep sternal wound infection (DSWI) of bilateral internal thoracic artery (BITA) grafts in diabetic patients with comparison to single internal thoracic artery (SITA) graft.

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Bilateral internal thoracic artery grafting is superior to single internal thoracic artery grafting in terms of outcomes.

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Bilateral internal thoracic artery grafting is underused, especially in diabetic patients.

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The risk of DSWI in skeletonized BITA grafting in diabetic patients is almost similar to SITA grafting.

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Skeletonized BITA grafting should be encouraged in selected diabetic patients.

Machine-Learning Techniques for Feature Selection and Prediction of Mortality in Elderly CABG Patients

Coronary artery bypass surgery grafting (CABG) is a commonly efficient treatment for coronary artery disease patients. Even if we know the underlying disease, and advancing age is related to survival, there is no research using the one year before surgery and operation-associated factors as predicting elements. This research used different machine-learning methods to select the features and predict older adults' survival (more than 65 years old). This nationwide population-based cohort study used the National Health Insurance Research Database (NHIRD), the largest and most complete dataset in Taiwan. We extracted the data of older patients who had received their first CABG surgery criteria between January 2008 and December 2009 (n = 3728), and we used five different machine-learning methods to select the features and predict survival rates. The results show that, without variable selection, XGBoost had the best predictive ability. Upon selecting XGBoost and adding the CHA2DS score, acute pancreatitis, and acute kidney failure for further predictive analysis, MARS had the best prediction performance, and it only needed 10 variables. This study's advantages are that it is innovative and useful for clinical decision making, and machine learning could achieve better prediction with fewer variables. If we could predict patients' survival risk before a CABG operation, early prevention and disease management would be possible.

Revascularisation of type 2 diabetics with coronary artery disease: Insights and therapeutic targeting of O-GlcNAcylation

AIM

Coronary artery bypass graft (CABG) using autologous saphenous vein continues to be a gold standard procedure to restore the supply of oxygen-rich blood to the heart muscles in coronary artery disease (CAD) patients with or without type 2 diabetes mellitus (T2DM). However, CAD patients with T2DM are at higher risk of graft failure. While failure rates have been reduced through improvements in procedure-related factors, much less is known about the molecular and cellular mechanisms by which T2DM initiates vein graft failure. This review gives novel insights into these cellular and molecular mechanisms and identifies potential therapeutic targets for development of new medicines to improve vein graft patency.

DATA SYNTHESIS

One important cellular process that has been implicated in the pathogenesis of T2DM is protein O-GlcNAcylation, a dynamic, reversible post-translational modification of serine and threonine residues on target proteins that is controlled by two enzymes: O-GlcNAc transferase (OGT) and O-GlcNAcase (OGA). Protein O-GlcNAcylation impacts a range of cellular processes, including trafficking, metabolism, inflammation and cytoskeletal organisation. Altered O-GlcNAcylation homeostasis have, therefore, been linked to a range of human pathologies with a metabolic component, including T2DM.

CONCLUSION

We propose that protein O-GlcNAcylation alters vascular smooth muscle and endothelial cell function through modification of specific protein targets which contribute to the vascular re-modelling responsible for saphenous vein graft failure in T2DM.

Emerging roles of protein O-GlcNAcylation in cardiovascular diseases: Insights and novel therapeutic targets

Cardiovascular diseases (CVDs) are the leading cause of death globally. While the major focus of pharmacological and non-pharmacological interventions has been on targeting disease pathophysiology and limiting predisposing factors, our understanding of the cellular and molecular mechanisms underlying the pathogenesis of CVDs remains incomplete. One mechanism that has recently emerged is protein O-GlcNAcylation. This is a dynamic, site-specific reversible post-translational modification of serine and threonine residues on target proteins and is controlled by two enzymes: O-linked β-N-acetylglucosamine transferase (OGT) and O-linked β-N-acetylglucosaminidase (OGA). Protein O-GlcNAcylation alters the cellular functions of these target proteins which play vital roles in pathways that modulate vascular homeostasis and cardiac function. Through this review, we aim to give insights on the role of protein O-GlcNAcylation in cardiovascular diseases and identify potential therapeutic targets in this pathway for development of more effective medicines to improve patient outcomes.

Obstructive sleep apnea-induced multi-organ dysfunction after elective coronary artery bypass surgery in coronary heart disease patients

Background

The aim of this study was to explore the underlying impact of obstructive sleep apnea (OSA) on postoperative parameters of multi-organ function among coronary heart disease (CHD) patients following elective coronary artery bypass grafting (CABG).

Methods

Electronic literature databases were searched manually and automatically for relevant English articles. All of the included articles focused on a comparison of the incidence of postoperative parameters of multi-organ function in CHD patients undergoing elective CABG with and without OSA. Studies were excluded if they met any one of the following criteria: (I) duplicate publication; (II) ongoing or unpublished studies; (III) only published as abstracts or conference proceedings; and (IV) less than 30 patients in the patient cohort.

Results

A total of 13 articles met our inclusion criteria. The current study demonstrated OSA significantly increased the incidence of major adverse cardiac and cerebrovascular events (MACCEs) in CHD patients undergoing elective CABG compared with the controls [odds risk (OR), 1.97; 95% CI, 1.50 to 2.59, P<0.0001]. In addition, OSA was associated with an increased risk of new revascularization in CHD patients undergoing elective CABG (OR, 9.47; 95% CI, 2.69 to 33.33, P<0.0001). Moreover, reintubation and tracheostomy in the OSA group was increased 243% (OR, 3.43; 95% CI, 1.35 to 8.71; P=0.009) and 372% (OR, 4.72; 95% CI, 1.23 to 18.13; P=0.024), respectively, compared with the control group. Besides, we also confirmed OSA significantly increased the acute kidney injury (AKI) incidence by 124% (OR, 2.24; 95% CI, 1.07 to 4.72; P<0.0001).

Conclusions

OSA may contribute to postoperative multi-organ dysfunction among CHD patients undergoing elective CABG by increasing the incidence of MACCEs, especially new revascularization, as well as respiratory, and renal complications.

Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients

This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.

The Impact of Statins before High-Risk CABG on Postoperative Multiple Organ Function

Background

The purpose of this cohort study was to investigate the independent relationship between preoperative statin therapy (PST) and postoperative severe multiorgan failure, measured by the Sequential Organ Failure Assessment (SOFA) maximum greater than 11, in high-risk patients undergoing isolated coronary artery bypass grafting (CABG).

Methods

The present study is a perspective, single-center, cohort analysis enrolling high-risk patients undergoing CABG from Jan 1, 2018, to Dec 31, 2018, in Beijing Anzhen hospital.

Results

Among a total of 880 high-risk patients undergoing isolated CABG included in this study, 503 (57.2%) experienced statin therapy before CABG. The SOFA maximum was significantly lower in the PST group compared with the control group (7.8 ± 3.0 v 9.2 ± 3.4, P < 0.0001). Multivariate logistic regression analysis demonstrated the incidence of the severe multiorgan dysfunction, measured by SOFA maximum ≥11, was dramatically reduced in the PST group (OR, 0.68, 95% CI 0.50-0.92, P=0.013). Furthermore, preoperative statin therapy (PST) might be associated with a decreased risk of postoperative major adverse cardiovascular and cerebral events and acute kidney injury, but an increased risk of postoperative hepatic inadequacy.

Conclusion

SOFA maximum was significantly lower in the PST group compared with the control group and the incidence of the severe multiorgan dysfunction was dramatically reduced in the PST group. The findings of this study might shed new light on questions of positive or negative effects of PST on multiple organ function after high-risk CABG, so as to ultimately improve high-risk patient in-hospital outcomes from CABG.

Does Bilateral Internal Mammary Artery Grafting Better Suit Patients With Diabetes? - Two Different Ways to Explore Outcomes

BACKGROUND

This analysis compared short-term mortality, sternal wound infection (SWI), and long-term survival outcomes in diabetic patients who underwent coronary artery bypass grafting (CABG) with bilateral (BIMA) vs. single (SIMA) internal mammary artery, as well as in diabetic vs. non-diabetic patients undergoing BIMA grafting.

METHODS AND RESULTS

Nineteen studies were included in the study, covering 21,143 different patients. Of these patients, 6,464 underwent CABG with BIMA, 10,264 underwent CAGB with SIMA, 11,584 had diabetes, and 6,717 did not. Compared with SIMA, BIMA had a significantly lower risk of in-hospital mortality (odds ratio [OR] 0.73, P=0.02), but a significantly higher risk of SWI (OR 1.30, P=0.04). However, compared with non-diabetic patients who underwent CABG with BIMA, diabetic patients with BIMA grafting did not have significantly higher risks of either mortality (OR 1.22, P=0.53) or SWI (OR 1.10, P=0.72). No significant differences were detected with different harvesting techniques. Longer term, BIMA was associated with a significantly higher rate of survival than SIMA (hazard ratio [HR] 0.76, P<0.001).

CONCLUSIONS

Results from the 2 types of comparisons indicate that BIMA is a preferable option for diabetic patients, even though it has a higher risk of infection. CABG with BIMA is also associated with a long-term survival benefit.

Clinical outcome comparison of percutaneous coronary intervention and bypass surgery in diabetic patients with coronary artery disease: a meta-analysis of randomized controlled trials and observational studies

BACKGROUND

The optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial. The current study aimed to compare adverse clinical endpoints of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM).

METHODS

Relevant studies were found from MEDLINE, OVID, Science Direct, Embase and the Cochrane Central database from January 2010 to April 2019. Risk ratio (RR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables. Outcomes evaluated were all-cause mortality, major adverse cardiac/cerebrovascular events (MACCE), cardiac death, myocardial infarction, stroke, and repeat revascularization.

RESULTS

Sixteen studies were included (18,224 patients). PCI was associated with the increase risk for MACCE (RR 1.59, 95% CI 1.38-1.85), cardiac death (RR 1.76, 95% CI 1.11-2.80), MI (RR 1.98, 95% CI 1.53-2.57), repeat revascularization (RR 2.61, 95% CI 2.08-3.29). The risks for all-cause mortality (RR 1.23, 95% CI 1.00-1.52) and stroke (RR 0.71, 95% CI 0.48-1.03) were similar between two strategies. Stratified analysis based on studies design and duration of follow-up showed largely similar findings with the overall analyses, except for a significant increased risk of all-cause mortality (RR 1.32, 95% CI 1.04-1.67) in long-term group, and CABG was associated with a higher stroke rate compared to PCI, which are results that were found in RCTs (RR 0.47, 95% CI 0.28-0.79) and mid-term groups (RR 0.39, 95% CI 0.23-0.66).

CONCLUSIONS

CABG was superior to PCI for diabetic patients with complex CAD (including left main CAD and/or MVD), but might be associated with a higher risk of stroke mid-term follow-up.Number of Protocol registration PROSPERO CRD 42019138505.

Does CHA2DS2-VASc Score Predict MACE in Patients Undergoing Isolated Coronary Artery Bypass Grafting Surgery?

Objective

To evaluate the prognostic value of CHA₂DS₂-VASc score in individuals undergoing isolated coronary artery bypass grafting (CABG) surgery.

Methods

Records of consecutive 464 patients who underwent elective isolated CABG, between January 2015 and August 2017, were retrospectively reviewed. A major adverse cardiac event (MACE) was the primary outcome of this study. MACE in patients with low (L) (<2, n: 238) and high (H) (≤2, n: 226) CHA₂DS₂-VASc scores were compared. Univariate logistic regression analysis identified preditors of MACE.

Results

Hypertension, diabetes mellitus, and peripheral vascular disease were more frequent in the H group than in the L group. European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and SYNTAX I scores were similar in both groups while SYNTAX II-CABG score was significantly higher in the H group than in the L group. Postoperative myocardial infarction, need for intra-aortic balloon pump, acute renal failure, and mediastinitis were more frequent in the H group than in the L group. The H group had significantly higher in-hospital mortality and MACE rates than the L group (P<0.01). EuroSCORE I, SYNTAX II-CABG, and CHA₂DS₂-VASc scores were predictors for MACE. SYNTAX II-CABG > 25.1 had 68.4% sensitivity and 52.7% specificity (area under the curve [AUC]: 0.653, P=0.04, 95% confidence interval [CI]: 0.607-0.696) and CHA₂DS₂-VASc > 2 had 52.6% sensitivity and 84.1% specificity (AUC: 0.752, P<0.01, 95% CI: 0.710-0.790) to predict MACE. Pairwise comparison of receiver-operating characteristic curves revealed similar accuracy for both scoring systems.

Conclusion

CHA₂DS₂-VASc score may predict MACE in patients undergoing isolated CABG.

The Cost Effectiveness of Single-Patient-Use Electrocardiograph Cable and Lead Systems in Monitoring for Coronary Artery Bypass Graft Surgery

Background: During admission for coronary artery bypass graft (CABG) surgery patients receive electrocardiograph (ECG) monitoring; for which reusable ECG cable and leads (rECG) are standard. Objective: Evaluate the cost effectiveness of a single-patient-use ECG cable and lead system (spECG). Methods: Review of the Medicare 2011-2014 database followed by a cost-effectiveness model considering a Medicare facility transitioning from rECG ($9 per patient) to spECG ($15). In-hospital ECG monitoring was for ≤8 days. In the model, patients underwent CABG and recovered in the intensive care unit, before transfer to the general ward and discharge. Surgical site infection (SSI) resulted in increased length of stay, readmission, or outpatient care. Health outcomes impacted EQ-5D-measured quality adjusted life years (QALYs). Health and cost outcomes were discounted at 3.5% annually. All costs in 2016 USD. Significance (95% level) was assessed via 2,000 simulations. Results: In 2014, 5.49% of patients had an SSI by 90-days post-surgery, with spECG reducing the odds of an SSI (odds ratio: 0.74, 0.62-0.89). Mean 40-year, per-patient costs to Medicare were $65,497 with rECG and $65,048 with spECG. The $450 saving was significant, with a median (95% credible interval) reduction of $466 ($174 to $989). Cost drivers were days required to treat inpatient SSIs. QALYs increases with spECG were significant but minor (median increase 0.008). Medicare savings may total $40 million per year with use of spECG. Conclusions: Post-operative SSI is a concern for Medicare patients undergoing CABG, and use of spECG is likely to provide cost and patient benefits.

Predictors for euthyroid sick syndrome and its impact on in-hospital clinical outcomes in high-risk patients undergoing coronary artery bypass grafting

Objective:

The purpose of this cohort study was to investigate the independent relationship between euthyroid sick syndrome and in-hospital outcomes in high-risk patients undergoing isolated coronary artery bypass grafting, and we also examined the direct correlation between pre- or intra-operative variables and the incidence of coronary artery bypass grafting–associated euthyroid sick syndrome.

Methods:

The present study enrolled high-risk patients undergoing coronary artery bypass grafting from 1 January 2017 to 31 December 2017 in Beijing Anzhen hospital, including 387 (58.7%) patients with coronary artery bypass grafting–associated euthyroid sick syndrome and 272 (41.3%) patients without coronary artery bypass grafting–associated euthyroid sick syndrome.

Results:

The mean age of euthyroid sick syndrome group was significantly older than that of no euthyroid sick syndrome group (65.9 ± 7.5 vs 60.9 ± 9.6, p < 0.0001). Compared with the control group, significantly higher proportions of patients with euthyroid sick syndrome had presented with the following clinical characteristics at hospital admission: moderate and poor left ventricular ejection fraction (42.9% vs 28.7%, p < 0.0001), higher euroscore II (9.2 ± 4.1 vs 8.0 ± 3.9, p < 0.0001). Multivariate logistic regression analysis on the total patients revealed that the independent risk factors for coronary artery bypass grafting–associated euthyroid sick syndrome were advanced age (odds ratio = 1.07, 95% confidence interval = 1.05-1.09, p < 0.0001), higher euroscore II (odds ratio = 1.06, 95% confidence interval = 1.01-1.11, p = 0.013), and moderate and poor left ventricular ejection fraction (odds ratio = 2.26, 95% confidence interval = 1.61-3.18, p < 0.0001). Furthermore, euthyroid sick syndrome was independently correlated with an increased risk of in-hospital major adverse cardiovascular and cerebral events (odds ratio = 3.40, 95% confidence interval = 1.64-7.02, p = 0.001) and post-infection (odds ratio = 8.11, 95% confidence interval = 3.97-16.57, p < 0.0001) Besides, we also confirmed coronary artery bypass grafting–associated euthyroid sick syndrome was associated with Sequential Organ Failure Assessment maximum greater than 11 (odds ratio = 2.98, 95% confidence interval = 1.90-4.65, p < 0.0001), which predicted an in-hospital death rate of 95%, independently.

Conclusion:

Coronary artery bypass grafting–associated euthyroid sick syndrome exerted detrimental effects on short-term clinical outcomes in high-risk patients undergoing isolated coronary artery bypass grafting. Advanced age, higher euroscore II, and moderate and poor left ventricular ejection fraction were independent risk factors for coronary artery bypass grafting–associated euthyroid sick syndrome.

Effects of Preoperative Risk Stratification on Direct In-hospital Costs for Chinese Patients with Coronary Artery Bypass Graft: A Single Center Analysis

The purpose of this study was to analyze the components of inpatient costs for coronary artery bypass graft (CABG) according to preoperative risk stratification and to provide evidence for improvement of diagnosis-related groups (DRGs) payment. All patients (n=458) receiving an isolated CABG between January 2014 and December 2016 in a tertiary referral center, in southwest China, were analyzed. Hospital mortality was predicted by the EuroSCORE II for each patient. The patients were subdivided into two groups according to the observed mortality (1.97%, 9/458): a high-risk group (group H, predicted mortality ≥1.97%) and a low-risk group (group L, predicted mortality <1.97%). Clinical outcomes, resource use, in-hospital direct costs, and reimbursement expenses were compared between the two groups. Significant differences existed between group L and group H in postoperative mortality (0.4% vs. 3.4%; P=0.02), postoperative complications (10.6% vs. 45.7%; P<0.001), postoperative length of hospital stay (17.5±4.9 days vs. 18.8±6.5 days, P=0.01), in-hospital costs ($20 256±3096 vs. $23 334±6332; P<0.001), and reimbursement expenses ($7775±2627 vs. $9639±3917; P<0.001). In general, a higher EuroSCORE II was significantly associated with a worse clinical outcome and increased costs. The CABG cost data provide evidence for improvement of DRGs payment.

Current role of saphenous vein graft in coronary artery bypass grafting

Saphenous vein was the conduit used in the first series of coronary artery bypass grafting (CABG), and, with the exception of surgical revascularization of the left anterior descending artery, it remains the most commonly used bypass conduit. However, its durability and longevity are not ideal. Arterial grafts have better patency than saphenous vein grafts and therefore should be preferred over them. However, in certain situations, like grafting right coronary arteries with lesser degree of proximal stenosis and higher competitive flow, or in certain patient populations, like those at very high risk of wound infections and octogenarians, arterial grafting may not be the best option and saphenous vein grafting should be considered instead.

Costs Five Years After Off-Pump or On-Pump Coronary Artery Bypass Surgery

BACKGROUND

Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump.

METHODS

As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors.

RESULTS

In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes.

CONCLUSIONS

At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.

Decreased contractile response of peripheral arterioles to serotonin after CPB in patients with diabetes

BACKGROUND

Regulation of coronary vasomotor tone by serotonin is significantly changed after cardioplegic arrest and reperfusion. The current study investigates whether cardiopulmonary bypass may also affect peripheral arteriolar response to serotonin in patients with or without diabetes.

METHODS

Human peripheral microvessels (90-180 µm diameter) were dissected from harvested skeletal muscle tissues from diabetic and non-diabetic patients before and after cardiopulmonary bypass and cardiac surgery (n = 8/group). In vitro contractile response to serotonin was assessed by videomicroscopy in the presence or absence of serotonin alone (10^-9-10^-5M) or combined with the selective serotonin 1B receptor (5-HT1B) antagonist, SB224289 (10^-6M). 5-HT1A/1B protein expression in the skeletal muscle was measured by Western-blot and immunohistochemistry.

RESULTS

There were no significant differences in contractile response of peripheral arterioles to serotonin (10^-5M) pre-cardiopulmonary bypass between diabetic and non-diabetic patients. After cardiopulmonary bypass, contractile response to serotonin was significantly impaired in both diabetic and non-diabetic patients compared to their pre-cardiopulmonary bypass counterparts (P < .05). This effect was more pronounced in diabetic patients than non-diabetic patients (P < .05 versus non-diabetic). The contractile response to serotonin was significantly inhibited by the 5-HT1B antagonist in both diabetic and non-diabetic vessels (P < .05 versus serotonin alone). There were no significant differences in the expression/distribution of 5-HT1A/1B between non-diabetic and diabetic groups or between pre- versus post- cardiopulmonary bypass vessels.

CONCLUSIONS

Cardiopulmonary bypass is associated with decreased contractile response of peripheral arterioles to serotonin and this effect was exaggerated in the presence of diabetes. Serotonin-induced contractile response of the peripheral arterioles was via 5-HT1B in both diabetic and non-diabetic patients.

Tissue-engineered smooth muscle cell and endothelial progenitor cell bi-level cell sheets prevent progression of cardiac dysfunction, microvascular dysfunction, and interstitial fibrosis in a rodent model of type 1 diabetes-induced cardiomyopathy

Background

Diabetes mellitus is a risk factor for coronary artery disease and diabetic cardiomyopathy, and adversely impacts outcomes following coronary artery bypass grafting. Current treatments focus on macro-revascularization and neglect the microvascular disease typical of diabetes mellitus-induced cardiomyopathy (DMCM). We hypothesized that engineered smooth muscle cell (SMC)-endothelial progenitor cell (EPC) bi-level cell sheets could improve ventricular dysfunction in DMCM.

Methods

Primary mesenchymal stem cells (MSCs) and EPCs were isolated from the bone marrow of Wistar rats, and MSCs were differentiated into SMCs by culturing on a fibronectin-coated dish. SMCs topped with EPCs were detached from a temperature-responsive culture dish to create an SMC-EPC bi-level cell sheet. A DMCM model was induced by intraperitoneal streptozotocin injection. Four weeks after induction, rats were randomized into 3 groups: control (no DMCM induction), untreated DMCM, and treated DMCM (cell sheet transplant covering the anterior surface of the left ventricle).

Results

SMC-EPC cell sheet therapy preserved cardiac function and halted adverse ventricular remodeling, as demonstrated by echocardiography and cardiac magnetic resonance imaging at 8 weeks after DMCM induction. Myocardial contrast echocardiography demonstrated that myocardial perfusion and microvascular function were preserved in the treatment group compared with untreated animals. Histological analysis demonstrated decreased interstitial fibrosis and increased microvascular density in the SMC-EPC cell sheet-treated group.

Conclusions

Treatment of DMCM with tissue-engineered SMC-EPC bi-level cell sheets prevented cardiac dysfunction and microvascular disease associated with DMCM. This multi-lineage cellular therapy is a novel, translatable approach to improve microvascular disease and prevent heart failure in diabetic patients.

Similar Outcomes in Diabetes Patients After Coronary Artery Bypass Grafting With Single Internal Thoracic Artery Plus Radial Artery Grafting and Bilateral Internal Thoracic Artery Grafting

BACKGROUND

The purpose of this study was to determine in patients with diabetes mellitus whether single internal thoracic artery (SITA) plus radial artery (RA) grafting yields outcomes similar to those of bilateral internal thoracic artery (BITA) grafting.

METHODS

From January 1994 to January 2011, 1,325 diabetic patients underwent primary isolated coronary artery bypass graft surgery with either (1) SITA plus RA with or without saphenous vein (SV) grafts (n = 965) or (2) BITA with or without SV grafts (n = 360); an internal thoracic artery was used in all patients to graft the left anterior descending coronary artery. Endpoints were in-hospital outcomes and time-related mortality. Median follow-up was 7.4 years, with a total follow-up of 9,162 patient-years. Propensity score matching was performed to identify 282 well-matched pairs for adjusted comparisons.

RESULTS

Unadjusted in-hospital mortality was 0.52% for SITA plus RA with or without SV grafts and 0.28% for BITA with or without SV grafts, and prevalence of deep sternal wound infection was 3.2% and 1.7%, respectively. Unadjusted survival at 1, 5, 10, and 14 years was 97%, 88%, 68%, and 51% for SITA plus RA with or without SV grafts, and 97%, 95%, 80%, and 66% for BITA with or without SV grafts, respectively. Among propensity-matched patients, in-hospital mortality (0.35% versus 0.35%) and prevalence of deep sternal wound infection (1.4% versus 1.4%) were similar (p > 0.9) in the two groups, as was 1-, 5-, 10-, and 14-year survival: 97%, 90%, 70%, and 58% for SITA plus RA with or without SV grafting versus 97%, 93%, 79%, and 64% for BITA with or without SV grafting, respectively (early p = 0.8, late p = 0.2).

CONCLUSIONS

For diabetic patients, SITA plus RA with or without SV grafting and BITA with or without SV grafting yield similar in-hospital outcomes and long-term survival after coronary artery bypass graft surgery. Therefore, both SITA plus RA and BITA plus SV grafting should be considered for these patients.

Hospitalization costs and clinical outcomes in CABG patients treated with intensive insulin therapy

BACKGROUND

The financial impact of intensive (blood glucose [BG] 100-140mg/dl [5.5-7.8mM] vs. conservative (141-180mg/dl (7.9-10.0mM) glucose control in the ICU in patients, with and without diabetes, undergoing coronary artery bypass graft (CABG) surgery is not known.

METHODS

This post-hoc cost analysis determined differences in hospitalization costs, resource utilization and perioperative complications in 288 CABG patients with diabetes (n=143) and without diabetes (n=145), randomized to intensive (n=143) and conservative (n=145) glucose control.

RESULTS

Intensive glucose control resulted in lower BG (131.4±14mg/dl-(7.2±0.8mM) vs. 151.6±17mg/dl (8.4±0.8mM, p<0.001), a nonsignificant reduction in the median length of stay (LOS, 7.9 vs. 8.5days, p=0.17) and in a composite of perioperative complications including wound infection, bacteremia, acute renal and respiratory failure, major cardiovascular events (42% vs 52%, p=0.10) compared to conservative control. Median hospitalization costs were lower in the intensive group ($39,366 vs. $42,141, p=0.040), with a total cost savings of $3654 (95% CI: $1780-$3723), than conservative control. Resource utilization for radiology (p=0.008), laboratory (p=0.014), consultation service (p=0.013), and ICU utilization (p=0.007) were also lower in the intensive group. Compared to patients without perioperative complications, those with complications had longer hospital length of stay (10.7days vs. 6.7days, p<0.001), higher total hospitalization cost ($48,299 vs. $32,675, p<0.001), and higher resource utilization units (2745 vs. 1710, p<0.001).

CONCLUSION

Intensive glycemic control [BG 100-140mg/dl (5.5-7.8mM)] in patients undergoing CABG resulted in significant reductions in hospitalization costs and resource utilization compared to patients treated with conservative [BG 141-180mg/dl (7.9-10.0mM)] glucose control.

Glycemic control strategies and the occurrence of surgical site infection: a systematic review

OBJECTIVE

To analyze the evidence available in the scientific literature regarding the relationship between the glycemic control strategies used and the occurrence of surgical site infection in adult patients undergoing surgery.

METHOD

This is a systematic review performed through search on the databases of CINAHL, MEDLINE, LILACS, Cochrane Database of Systematic Reviews and EMBASE.

RESULTS

Eight randomized controlled trials were selected. Despite the diversity of tested interventions, studies agree that glycemic control is essential to reduce rates of surgical site infection, and should be maintained between 80 and 120 mg/dL during the perioperative period. Compared to other strategies, insulin continuous infusion during surgery was the most tested and seems to get better results in reducing rates of surgical site infection and achieving success in glycemic control.

CONCLUSION

Tight glycemic control during the perioperative period benefits the recovery of surgical patients, and the role of the nursing team is key for the successful implementation of the measure.

OBJETIVO

Analisar as evidências disponíveis na literatura científica sobre a relação entre as estratégias de controle glicêmico efetuadas e a ocorrência de infecção do sítio cirúrgico em pacientes adultos submetidos à cirurgia.

MÉTODO

Trata-se de revisão sistemática, por meio das bases de dados CINAHL, MEDLINE, LILACS, Cochrane Database of Systematic Reviews e EMBASE.

RESULTADOS

Foram selecionados oito ensaios clínicos randomizados. Apesar da diversidade de intervenções testadas, os estudos concordam que o controle glicêmico é essencial para a redução das taxas de infecção do sítio cirúrgico e deve ser mantido entre 80 e 120 mg/dL durante o perioperatório. A infusão contínua de insulina no transoperatório foi a mais testada e parece obter melhores resultados na redução das taxas de infecção do sítio cirúrgico e sucesso no controle glicêmico comparada às demais estratégias.

CONCLUSÃO

O controle glicêmico rigoroso durante o perioperatório beneficia a recuperação do paciente cirúrgico, destacando-se a atuação da equipe de enfermagem para a implantação bem-sucedida da medida.

Myocardial revascularization in patients with coronary heart disease and type 2 diabetes

The review discusses myocardial revascularization in patients with coronary heart disease and type 2 diabetes. The data presented include findings from recent research and international and national recommendations and provides evidence on the advantages of coronary artery bypass surgery over percutaneous coronary intervention for patients with diabetes mellitus, stable coronary artery disease and multiple coronary artery lesions. Type 2 diabetes remains a significant predictor of adverse long-term outcomes of coronary artery bypass surgery. Therefore, we review studies showing that different strategies of coronary revascularization and preoperative preparation can affect the results of coronary intervention in patients with diabetes.

Physiology of in-situ arterial revascularization in coronary artery bypass grafting: Preoperative, intraoperative and postoperative factors and influences

Surgical revascularization with coronary artery bypass grafting (CABG) has become established as the most effective interventional therapy for patients with moderately severe and severe stable ischemic heart disease (SIHD). This recommendation is based on traditional 5-year outcomes of mortality and avoidance of myocardial infarction leading to reintervention and/or cardiac death. However, these results are confounded in that they challenge the traditional CABG surgical tenets of completeness of anatomic revascularization, the impact of arterial revascularization on late survival, and the lesser impact of secondary prevention following CABG on late outcomes. Moreover, the emergence of physiologic-based revascularization with percutaneous cardiovascular intervention as an alternative strategy for revascularization in SIHD raises the question of whether there are similar physiologic effects in CABG. Finally, the ongoing ISCHEMIA trial is specifically addressing the importance of the physiology of moderate or severe ischemia in optimizing therapeutic interventions in SIHD. So it is time to address the role that physiology plays in surgical revascularization. The long-standing anatomic framework for surgical revascularization is no longer sufficient to explain the mechanisms for short-term and long-term outcomes in CABG. Novel intraoperative imaging technologies have generated important new data on the physiologic blood flow and myocardial perfusion responses to revascularization on an individual graft and global basis. Long-standing assumptions about technical issues such as competitive flow are brought into question by real-time visualization of the physiology of revascularization. Our underestimation of the impact of Guideline Directed Medical Therapy, or Optimal Medical Therapy, on the physiology of preoperative SIHD, and the full impact of secondary prevention on post-intervention SIHD, must be better understood. In this review, these issues are addressed through the perspective of multi-arterial revascularization in CABG, which is emerging (after 30 years) as the “standard of care” for CABG. In fact, it is the physiology of these arterial grafts that is the mechanism for their impact on long-term outcomes in CABG. Moreover, a better understanding of all of these preoperative, intraoperative and postoperative components of the physiology of revascularization that will generate the next, more granular body of knowledge about CABG, and enable surgeons to design and execute a better surgical revascularization procedure for patients in the future.