Fast track recovery of elderly coronary bypass surgery patients

Preoperative frontal QRS-T angle is an independent correlate of hospital length of stay and predictor of haemodynamic support requirement following off-pump coronary artery bypass graft surgery

OBJECTIVES

With the adoption of novel operative techniques and aggressive care protocols that facilitate earlier extubation and mobilization of patients, postoperative length of stay (LOS) following coronary artery bypass graft surgery (CABG) has declined. However, there is paucity of information regarding preoperative electrocardiographic predictors of LOS following CABG. In this study, we investigated whether frontal QRS-T angle, which is an abnormal repolarization marker in prediction of various cardiovascular events, was an independent correlate of postoperative hospital LOS for off-pump CABG. Furthermore, we evaluated independent predictors of vasopressor agent/intra-aortic balloon pump (IABP) support requirement following off-pump CABG.

METHODS

In this observational study, 78 patients with stable angina, who were scheduled for elective coronary artery bypass surgery following diagnosis of obstructive coronary artery disease by conventional angiography, were enrolled.

RESULTS

Left ventricular ejection fraction (LVEF) was significantly lower and vasopressor agent/IABP support requirement and incidence of sustained atrial or ventricular arrhythmias was higher in patients with wide QRS-T angle (P < 0.05). Postoperative hospital LOS was also longer in this group. From the preoperative characteristics, wide frontal QRS-T angle was found to be an independent correlate of postoperative hospital LOS (B ± SD: 11.97 ± 0.62, P ≤ 0.01). Wide frontal QRS-T angle was also found to be an independent predictor of vasopressor agent/IABP support requirement postoperatively (OR: 7.87, P ≤ 0.01).

CONCLUSIONS

Prediction of the hospital LOS and patient outcome following CABG is of great importance. Being easily obtainable via standard 12-lead electrocardiogram and its low cost may make frontal QRS-T angle a beneficial marker for reducing both patient-based morbidity and economic burden.

Risk factor analysis for fast track protocol failure

BACKGROUND

The introduction of fast-track treatment procedures following cardiac surgery has significantly shortened hospitalisation times in intensive care units (ICU). Readmission to intensive care units is generally considered a negative quality criterion. The aim of this retrospective study is to statistically analyse risk factors and predictors for re-admission to the ICU after a fast-track patient management program.

METHODS

229 operated patients (67 ± 11 years, 75% male, BMI 27 ± 3, 6/2010-5/2011) with use of extracorporeal circulation (70 ± 31 min aortic crossclamping, CABG 62%) were selected for a preoperative fast-track procedure (transfer on the day of surgery to an intermediate care (IMC) unit, stable circulatory conditions, extubated). A uni- and multivariate analysis were performed to identify independent predictors for re-admission to the ICU.

RESULTS

Over the 11-month study period, 36% of all preoperatively declared fast-track patients could not be transferred to an IMC unit on the day of surgery (n = 77) or had to be readmitted to the ICU after the first postoperative day (n = 4). Readmission or ICU stay signifies a dramatic worsening of the patient outcome (mortality 0/10%, mean hospital stay 10.3 ± 2.5/16.5 ± 16.3, mean transfusion rate 1.4 ± 1,7/5.3 ± 9.1). Predicators for failure of the fast-track procedure are a preoperative ASA class > 3, NYHA class > III and an operation time >267 min ± 74. The significant risk factors for a major postoperative event (= low cardiac output and/or mortality and/or renal failure and/or re-thoracotomy and/or septic shock and/or wound healing disturbances and/or stroke) are a poor EF (OR 2.7 CI 95% 0.98-7.6) and the described ICU readmission (OR 0.14 CI95% 0.05-0.36).

CONCLUSION

Re-admission to the ICU or failure to transfer patients to the IMC is associated with a high loss of patient outcome. The ASA > 3, NYHA class > 3 and operation time >267 minutes are independent predictors of fast track protocol failure.

Influence of fast-track recovery after coronary artery bypass in the elderly

We retrospectively analyzed 711 consecutive patients who had isolated coronary artery bypass grafting between January 2000 and December 2004; 572 younger patients (< 70 years) were compared with 139 elderly patients (> or = 70 years). A rapid recovery program based on an anesthetic protocol for early extubation was applied to all patients. The overall hospital mortality rate was 3.3% for the younger group and 4.3% for the elderly group. There were no significant differences in rates of hospital mortality and postoperative complications between the two groups. Early extubation was achieved in significantly more younger (71%) compared to elderly (57%) patients. Rapid recovery with discharge before the 5(th) postoperative day was achieved in 19% of the elderly compared to 48% of the younger patients. Patients in the younger group were discharged from hospital earlier (6.8 +/- 0.3 vs 8.0 +/- 8.5 days). Application of fast-track treatment in an elderly population appears to be a safe and effective approach if used on a selective basis when criteria for early extubation are met.

Is early too early? Effect of shorter stays after bypass surgery

BACKGROUND

Postoperative stays after coronary artery bypass graft surgery (CABG) decreased substantially in the 1990s. Although shorter stays offer clinical benefits, premature discharge could increase adverse events and offset initial savings. This study examined the effect of early discharge after CABG on readmission/death and cost within 60 days of discharge home. Variability in hospitals' tendencies for early discharge and adverse outcomes was also explored.

METHODS

Analyses were based on clinical and claims data for 55,889 New York CABG patients discharged home 1995 to 1998. Early discharge was defined as a postoperative stay below the 15th percentile for patients with similar risk. The likelihood of early discharge and its effect on readmission/death were examined using hierarchical logistic regression, accounting for patient risk and within-hospital correlation. The correlation between early discharge and adverse outcomes at the hospital level was assessed. The effect of early discharge on subsequent inpatient, outpatient, skilled nursing, and home health costs was examined in the Medicare subset.

RESULTS

Overall, 17% of patients were discharged early, with increasing prevalence over time. The tendency to discharge early varied widely among hospitals (2% to 42% of patients). We found no association between hospitals' tendencies for early discharge and adverse outcomes. Lower postdischarge costs among patients discharged early (mean = 3,491 dollars versus 5,246 dollars for typical stays) resulted in average cumulative savings of 6,309 dollars.

CONCLUSIONS

Patients selected for earlier discharge after CABG did not have increased adverse event rates or higher costs. Variation among hospitals in early discharge suggests that more efficient patient management could be achieved at some hospitals.

Trends in postoperative length of stay after bypass surgery

BACKGROUND

Although single-site studies have reported reductions in coronary artery bypass graft (CABG) surgery length of stay (LOS) over the last 15 years, less information is available regarding overall temporal trends and interhospital variability. This study examined trends in postoperative LOS, associated rates of transfer at discharge and variation among hospitals in LOS at CABG hospitals in New York State.

METHODS

Trends in postoperative LOS and transfers at discharge for 105,842 CABG patients treated in 30 hospitals in New York between 1992 and 1998 were first described graphically. Mixed models were then used to assess temporal trends and interhospital variability in LOS, accounting for differences in patient risk and within-hospital correlation in outcomes. Clinical and LOS data were obtained from the Cardiac Surgery Reporting System. Additional information was extracted from the New York Statewide Planning and Research Cooperative System.

RESULTS

Postoperative LOS decreased 30% between 1992 and 1998 after adjusting for patient risk. A concurrent increase in the probability of nonacute patient transfers occurred over time, with the most pronounced increase in patients with stays exceeding 5 days. Underlying the downward trend in LOS was substantial interhospital variability that peaked in 1994 and remained significant in 1998. Stays were longer at hospitals located in New York City.

CONCLUSIONS

The downward shift in LOS observed in the 1990s was achieved in part by an increase in nonacute care transfers, reflecting a shift in care setting. After decreasing trends in postoperative stays tapered off, significant variability among hospitals remained.

Determining predictors of delayed recovery and the need for transitional cardiac rehabilitation after cardiac surgery

PURPOSE

To examine the relationship between demographic and clinical characteristics of cardiac surgery patients with postoperative length of stay (PLOS) greater than 7 days and determine the demographic, social, and clinical predictors of the need for transitional cardiac rehabilitation (TCR) after cardiac surgery.

DATA SOURCES

A retrospective review of characteristics, clinical indices, caregiver availability, and patient status (whether living alone) was completed for 304 patients undergoing cardiac surgery over 24 consecutive months. Univariate analyses and multivariable logistic regression models were used to evaluate risk factor characteristics for PLOS greater than 7 days and to predict discharge disposition to TCR or home.

CONCLUSIONS

Older patients, those with preoperative comorbidities, and those without a caregiver at home experience delays in functional recovery and discharge and are more likely to need TCR services.

IMPLICATIONS FOR PRACTICE

Our findings support the addition of functional recovery and social support risk items to the preoperative cardiac surgery risk assessment.

Readmission and mortality in patients undergoing off-pump coronary artery bypass surgery with fast-track recovery protocol

The development of less invasive methods for myocardial revascularization such as "off-pump" cardiac surgery, and new methods of anesthesia and postoperative care protocols such as "fast-track recovery" (FTRC), have contributed to a significant reduction in postoperative intensive care unit (ICU) and hospital length of stay after cardiac surgical procedures. The objectives of this study were to identify perioperative risk factors of prolonged hospital stay, hospital mortality, and readmission rates in off-pump coronary artery bypass surgery (CABG) patients undergoing the FTRC protocol. Eighty consecutive patients undergoing off-pump coronary artery bypass surgery with FTRC protocol were included in the study. For the first purpose of this protocol, early extubation is defined as removal of the endotracheal tube within 6 h of arrival at the surgical ICU. The second purpose was to obtain a minimal length of stay in the ICU (<24 h) and hospital discharge within 5 days. We analyzed the influence of the preoperative, intraoperative, and postoperative variables on prolonged hospital stay, hospital mortality, and hospital readmission. Three patients died during hospitalization, giving a hospital mortality rate of 3.75%. The causes of hospital death were massive stroke and sepsis. Using multivariate logistic regression analysis, hypertension (P = 0.0185), postoperative stroke (P = 0.0001), and sternal infection (P = 0.0007) were identified as independent predictors of hospital mortality. Mean hospital length of stay was 4.23 +/- 0.75 days. Univariate and multivariate logistic regression analysis revealed that postoperative blood use (P = 0.0095) was the major independent predictor of prolonged hospital stay. During the 30-day observation period, seven patients were readmitted. One of these patients died on postoperative day 45 from mediastinitis and sepsis. Multivariate logistic regression analysis identified age (P = 0.0033) and hypertension (P = 0.045) as independent predictors of hospital readmission. FTRC protocols can be performed safely in patients with off-pump CABG, and the mortality and readmission rates following this protocol were found to be within acceptable ranges.

Off-pump myocardial revascularization is associated with less incidence of stroke in elderly patients

Several recent studies have highlighted the potential benefits of using off-pump coronary artery bypass (OPCAB) surgery, particularly in high-risk patients. The aim of this meta-analysis is to assess the effect of OPCAB on the incidence of stroke compared with coronary artery bypass grafting using cardiopulmonary bypass (CPB) in elderly patients. We performed a meta-analysis of all observational studies, published in MEDLINE between 1999 and 2002 and a comparison between the OPCAB and CPB techniques in elderly patients was performed with the outcome of interest being the incidence of stroke. Elderly patients were defined as those aged 70 years or older. Nine studies are included in the meta-analysis. The total number of subjects included was 4,475 patients, of which, 1,253 underwent OPCAB (28%) and 3,222 (72%) underwent CPB. The meta-analysis showed that the OPCAB technique was associated with significantly lower incidence of stroke in elderly patients compared with the CPB technique (1% vs 3%), with an odds ratio of 0.38% to 95% (CI, 0.22 to 0.65). We did not identify any significant heterogeneity and funnel plot asymmetry between the studies included in the meta-analysis. Meta-regression analysis including variables predicting stroke, mortality, and study characteristics did not show any associations affecting the calculated odds ratio of stroke. Despite the fact that this is a meta-analysis of observational studies and adjustment for differences in baseline risk factors between OPCAB and CPB patients was not possible, we believe that this study suggests that the OPCAB technique might be associated with reduced incidence of stroke in the elderly patients undergoing coronary artery bypass grafting.

The clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery

BACKGROUND

Minimally invasive cardiac surgery is now becoming standard in the correction of simple congenital cardiac malfbrmations. We introduced a clinical pathway for fast track recovery of school activities in children after minimally invasive cardiac surgery, and assessed the function of the pathway in children with atrial or ventricular septal defects, comparing minimally invasive surgery to repair through a conventional full sternotomy.

METHODS

We studied 15 children of school age who underwent repair of an atrial or ventricular septal defect through a lower midline sternotomy, and 10 children undergoing repair through a full sternotomy. The clinical pathway was for extubation to take place in the operating room, echocardiographic evaluation on the 5th postoperative day, and discharge home on the 7th postoperative day, with return to school within 2 weeks, and resumption of all gymnastic activity within 6 weeks of the minimally invasive surgery.

RESULTS

In those having a lower midline sternotomy, postoperative hospital stay was 7.4 +/- 0.8 days, with return to school 8.0 +/- 2.4 days after discharge. They resumed gymnastics 41 +/- 11 days after the minimally invasive surgery. In those having a full sternotomy, in contrast, these parameters were 13.5 +/- 2.7, 23.1 +/- 8.4, and 95 +/- 43 days, respectively. Of the 15 children undergoing a minimally invasive approach, 12 (80%) fulfilled the criterions of our clinical pathway.

CONCLUSIONS

We conclude that minimally invasive cardiac surgery can safely be performed in children. In addition to its cosmetic role, the technique has added value in promoting early return to normal school life, including gymnastics.

[Results of isolated and combined surgical coronary revascularization in patients over 75]

BACKGROUND

Increase in life expectancy is causing an increase of surgical myocardial revascularization procedures in the elderly. We evaluate the evolution of this type of interventions in people older than 75 years, taking into account the risk factors, results and survival.

PATIENTS AND METHOD

Between July 1988 and May 2001, 237 isolated or combined myocardial revascularization procedures were carried out in patients older than 75 years (Group I), while 1177 were performed in younger patients (Group II). We retrospectively analyzed the mortality risk factors, surgical procedures, postoperative complications and survival in Group I patients.

RESULTS

Preoperatively, Group I patients showed a more frequent left ventricular dysfunction, left main coronary stenosis, emergency surgery and combined procedures, while Group II patients displayed more common preoperative myocardial infarction and dyslipemia. Mortality in Group I was 20.7% vs 9.09% in Group II. Mortality was higher for mixed procedures (27.1%) than for isolated myocardial revascularization (13.8%). Postoperative complications were present in 48.5% patients. Significant preoperative risk factors of mortality in Group I were: female sex, high-risk ergometry, III-IV NYHA functional class, and atrial arrhythmia. The preoperative NYHA functional class was also a morbidity risk factor. Survival at 1, 3 and 5 years was present in 98.4%, 92.1% and 81% patients, respectively, NYHA functional class I-II being present in 94.18% patients.

CONCLUSIONS

Myocardial revascularization surgery in people older than 75 years leads to an increase of morbimortality. Anyway, long-term survivors' quality of life makes us think of surgery as a valid treatment alternative.

Off-Pump Coronary Artery Bypass Surgery: Revival of an Old Technique

The ability to perform surgical procedures on the heart was one of the greatest accomplishments of the 20th century. What was once considered an impossible task has become a routine in daily clinical activity. The in troduction of extracorporeal circulation and myocardial protection strategies opened the doors to what was considered by most an insurmountable barrier— unhin dered access to the coronary circulation and intracar diac structures. In the United States, approximately 85% of coronary artery bypass graft procedures are performed with the use of cardiopulmonary bypass (CPB). CPB was and remains the gold standard for this type of cardiac surgical intervention. Over the years, investigators have struggled to find ways of lessening or eliminating the adverse physiologic effects of CPB. These efforts have focused on pharmacologic interven tion, monitoring procedures, blood gas management, and temperature management. Another way of avoid ing these effects is inherently obvious — eliminate the main source of the problem.

Early discharge after coronary artery bypass graft surgery: are patients really going home earlier?

OBJECTIVE

This study was undertaken to determine whether early discharge after coronary artery bypass grafting allows patients to return home earlier or merely increases the use of outpatient nursing and inpatient rehabilitation services.

METHODS

Patterns of discharge were analyzed in 407 patients undergoing bypass grafting in 1990, when there were no early extubations or fast track protocols, and compared with 379 patients in 1998, when these protocols were used.

RESULTS

Patients in 1998 had a higher prevalence of class IV angina (35.3% vs 22.8%; P =.006), urgent/emergency surgery (58.3% vs 44.9%; P =.015), and lower ejection fractions (48.9% +/- 16.4% vs 52.9% +/- 13.5%; P =.0002). Despite these increased risk factors, 1998 patients spent less time receiving ventilatory support (10.2 +/- 9.2 vs 26.7 +/- 15.7 hours; P <.001) and had a shorter length of stay (5.4 +/- 2.5 vs 9.2 +/- 4.3 days; P <.001). However, fewer 1998 patients were discharged home (56.7% vs 97.0%; P <.0001). A higher percentage of 1998 patients (43.3% vs 2.9%; P <.00001) were discharged to extended care facilities where their average length of stay was 10.6 +/- 15.1 days. Readmission to the Boston Medical Center was also more common in 1998 patients (5.3% vs 0.5%; P <.0001).

CONCLUSIONS

Early extubation and fast track protocols have resulted in earlier discharge from acute care facilities. However, the anticipated earlier return to home has been offset by the increased use of outpatient nursing services, discharges to extended care facilities, and hospital readmissions.

[The use of propofol does not increase the cost of the management of patients in heart surgery with extracorporeal circulation]

OBJECTIVES

Evaluation of the cost of propofol used for fast-track in cardiac surgery and its impact on global cost of management for anaesthesia and intensive care.

STUDY DESIGN

Case-control study, prospective (1998) and retrospective (1994).

PATIENTS

Twenty patients operated for cardiac surgery in 1998 and scheduled for fast-track anaesthesia. Twenty patients in 1994 matched for different criteria to the patient of 1998.

METHODS

In 1998, all drugs, materials used and X-rays, biochemical assays performed were prospectively collected and their cost calculated. In 1994, similar calculations were done retrospectively. Comparison of duration of mechanical ventilation, hospitalization in intensive care and in the hospital were performed.

RESULTS

Cost of anaesthesia was similar in 1994 and 1998 (2,646 FF versus 2,294 FF). Global cost of management was significantly lower in 1998 in comparison to 1994 (5,439 FF versus 8,558 FF). Duration of mechanical ventilation, hospitalization in intensive care and in the hospital were shorter in 1998 than in 1994.

CONCLUSION

Despite a higher cost of propofol for anaesthesia and postoperative sedation in comparison to midazolam, the global cost of management decreased significantly in relation to a one day decrease in hospitalization in the intensive care unit.

Clinical outcomes and resource usage in 100 consecutive patients after off-pump coronary bypass procedures

BACKGROUND

Cardiopulmonary bypass initiates a cascade of inflammatory processes that may result in end-organ damage, leading to the increased prevalence of noncardiac complications. Therefore, off-pump coronary artery bypass graft (OP-CAB) procedures have recently been introduced into clinical practice.

METHODS

This study was a case-controlled study that compared the outcomes and cost of 100 consecutive OP-CAB procedures with a control group of 100 contemporary matched conventional coronary artery bypass grafting procedures. All operations were performed by a single surgeon (J.H.L. ) and complete revascularization that used off-pump techniques was achieved with the use of innovative exposure techniques to the lateral and posterior wall vessels.

RESULTS

An average of 3.1 grafts per patient were performed in the OP-CAB group (range, 1-5). The incidence of conversion to conventional coronary artery bypass grafting was 1%. The overall mortality rate was 2.0%. There were no instances of stroke, renal failure, or sternal infections in the OPCAB group. Thus, the OP-CAB group had a shorter length of stay (6.1+/-2.5 versus 7.1+/-3.3 d; P =.003), with a corresponding reduction in variable direct cost per case of 29% (P<.001).

CONCLUSION

Our experience suggests that OP-CAB procedures are feasible for most patients who currently require complete revascularization. It is associated with very a low morbidity rate and may represent the ideal revascularization strategy for patients at high risk for undergoing cardiopulmonary bypass.