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Kim Y, Cho BS, DeCarlo CS, Latz CA, Majumdar M, Zacharias N, Mohapatra A, Dua A. Multi-institutional outcomes after femoropopliteal bypass in octogenarians. Vascular 2024; 32:84-90. [PMID: 36063379 DOI: 10.1177/17085381221125953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Open lower extremity revascularization is controversial among octogenarians; however, the indications for surgical bypass are higher in the elderly population. The aim of the study was to compare postoperative outcomes between octogenarians and non-octogenarians following femoropopliteal bypass surgery. METHODS Our regional, multi-institutional database was queried for femoropopliteal bypass procedures performed between 1995 and 2020. Electronic medical records were individually reviewed for operative and postoperative data. Univariable and multivariable logistic regression were utilized to determine predictors of postoperative outcomes. RESULTS Among 1315 patients who underwent femoropopliteal bypass, 234 (17.8%) were octogenarians. Octogenarians more frequently underwent bypass for lower extremity tissue loss (48.7% vs 30.2%), whereas claudication was more common among non-octogenarians (24.0% vs 9.8%) (p < .001). Below-knee bypass target (72.2% vs 59.3%) and prosthetic conduit utilization (58.5% vs 43.7%) were more frequent in octogenarians (p < .001 each). Overall hospital length of stay was longer among patients > 80 years (median 6 days [interquartile range [IQR] 4-9] vs 5 days [IQR 4-8], p = .017). The overall 30-day (5.6% vs 1.5%) and one-year mortality rates (25.6% vs 7.9%) were higher among octogenarians (p < .001 each). On multivariable analysis, age greater than 80 years was found to be an independent risk factor for postoperative mortality (OR 3.79 [1.75-8.20], p = .0007). CONCLUSIONS Octogenarians undergoing bypass femoropopliteal bypass surgery have considerably worse postoperative outcomes, compared with non-octogenarians. These data may help inform elderly patients prior to undergoing open lower extremity revascularization.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Bennet S Cho
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Cursino de Moura JF, Oliveira CB, Coelho Figueira Freire AP, Elkins MR, Pacagnelli FL. Preoperative respiratory muscle training reduces the risk of pulmonary complications and the length of hospital stay after cardiac surgery: a systematic review. J Physiother 2024; 70:16-24. [PMID: 38036402 DOI: 10.1016/j.jphys.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 09/11/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
QUESTIONS What is the effect of preoperative respiratory muscle training (RMT) on the incidence of postoperative pulmonary complications (PPCs) after open cardiac surgery? What is the effect of RMT on the duration of mechanical ventilation, postoperative length of stay and respiratory muscle strength? DESIGN Systematic review of randomised trials with meta-analysis. PARTICIPANTS Adults undergoing elective open cardiac surgery. INTERVENTION The experimental groups received preoperative RMT and the comparison groups received no intervention. OUTCOME MEASURES The primary outcomes were PPCs, length of hospital stay, respiratory muscle strength, oxygenation and duration of mechanical ventilation. The methodological quality of studies was assessed using the PEDro scale and the overall certainty of the evidence was assessed using the GRADE approach. RESULTS Eight trials involving 696 participants were included. Compared with the control group, the respiratory training group had fewer PPCs (RR 0.51, 95% CI 0.38 to 0.70), less pneumonia (RR 0.44, 95% CI 0.25 to 0.78), shorter hospital stay (MD -1.7 days, 95% CI -2.4 to -1.1) and higher maximal inspiratory pressure values at the end of the training protocol (MD 12 cmH2O, 95% CI 8 to 16). The mechanical ventilation time was similar in both groups. The quality of evidence was high for pneumonia, length of hospital stay and maximal inspiratory pressure. CONCLUSION Preoperative RMT reduced the risk of PPCs and pneumonia after cardiac surgery. The training also improved the maximal inspiratory pressure and reduced hospital stay. The effects on PPCs were large enough to warrant use of RMT in this population. REGISTRATION CRD42021227779.
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Affiliation(s)
| | | | | | - Mark Russell Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Sydney Education, Sydney Local Health District, Sydney, Australia
| | - Francis Lopes Pacagnelli
- Physiotherapy Department, University of Western São Paulo (UNOESTE), Presidente Prudente, Brazil.
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3
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Mejia OAV, Jatene FB. From Volume to Value Creation in Cardiac Surgery: What is Needed to Get off the Ground in Brazil? Arq Bras Cardiol 2023; 120:e20230036. [PMID: 36856248 PMCID: PMC10263462 DOI: 10.36660/abc.20230036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
- Omar Asdrúbal Vilca Mejia
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Fabio Biscegli Jatene
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasilInstituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
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Choi K, Locker C, Fatima B, Schaff HV, Stulak JM, Lahr BD, Villavicencio MA, Dearani JA, Daly RC, Crestanello JA, Greason KL, Khullar V. Coronary Artery Bypass Grafting in Octogenarians-Risks, Outcomes, and Trends in 1283 Consecutive Patients. Mayo Clin Proc 2022; 97:1257-1268. [PMID: 35738944 DOI: 10.1016/j.mayocp.2022.03.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe the risks, outcomes, and trends in patients older than 80 years undergoing coronary artery bypass grafting (CABG). METHODS We retrospectively studied 1283 consecutive patients who were older than 80 years and underwent primary isolated CABG from January 1, 1993, to October 31, 2019, in our clinic. Kaplan-Meier survival probability and quartile estimates were used to analyze patients' survival. Logistic regression models were used for analyzing temporal trends in CABG cases and outcomes. A multivariable Cox proportional hazards regression model was developed to study risk factors for mortality. RESULTS Operative mortality was overall 4% (n=51) but showed a significant decrease during the study period (P=.015). Median follow-up was 16.7 (interquartile range, 10.3-21.1) years, and Kaplan-Meier estimated survival rates at 1 year, 5 years, 10 years, and 15 years were 90.2%, 67.9%, 31.1%, and 8.2%, respectively. Median survival time was 7.6 years compared with 6.0 years for age- and sex-matched octogenarians in the general US population (P<.001). Multivariable Cox regression analysis identified older age (P<.001), recent atrial fibrillation or flutter (P<.001), diabetes mellitus (P<.001), smoking history (P=.006), cerebrovascular disease (P=.04), immunosuppressive status (P=.01), extreme levels of creatinine (P<.001), chronic lung disease (P=.02), peripheral vascular disease (P=.02), decreased ejection fraction (P=.03) and increased Society of Thoracic Surgeons predicted risk score (P=.01) as significant risk factors of mortality. CONCLUSION Although CABG in octogenarians carries a higher surgical risk, it may be associated with favorable outcomes and increase in long-term survival. Further studies are warranted to define subgroups benefiting more from surgical revascularization.
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Affiliation(s)
- Kukbin Choi
- Department of Cardiovascular Surgery, Rochester, MN
| | - Chaim Locker
- Department of Cardiovascular Surgery, Rochester, MN
| | | | | | | | - Brian D Lahr
- Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
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5
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Zhenyu H, Qiaoli Y, Guangxiang C, Maohua W. The effect of Ulinastatin on postoperative course in cardiopulmonary bypass patients in Asia: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2022; 17:66. [PMID: 35379277 PMCID: PMC8979706 DOI: 10.1186/s13019-022-01811-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES To evaluate the effect of urinary trypsin inhibitor (UTI) or Ulinastatin on postoperative course and clinical outcomes in patients with cardiopulmonary bypass. METHODS We searched PubMed, Embase, Web of Science, and Cochrane Library for the keywords UTI and Cardiopulmonary bypass (CPB). The primary outcome measure was the intensive care unit length of stay (ICU LOS), and results were stratified for relevant subgroups (dosage of UTI). The effects of UTI on mechanical ventilation duration (MVD), hospital LOS, renal failure incidence (RFI), and all-cause mortality were studied as secondary outcomes. RESULTS Twelve randomized controlled trials (enrolling 1620 patients) were evaluated. Eleven studies pooled for subgroup analysis showed that using UTI persistently or with a considerable amount would lead to a shorter ICU LOS (95% CI, - 0.69 to - 0.06; P = 0.0001). Ten studies showed that UTI could shorten MVD in patients (95% CI, - 1.505 to - 0.473; P < 0.0001). RFI generally showed a more favourable outcome with UTI treatment (95%CI, 0.18-1.17; P = 0.10). And the current evidence was insufficient to prove that UTI could reduce the hospital LOS (95% CI, - 0.22 to 0.16; P = 0.75) and the all-cause mortality rate (95% CI, 0.24-2.30; P = 0.60). CONCLUSIONS Various subsets of UTI treatment suggested that UTI could shorten ICU LOS, and it is associated with the dosage of UTI. Considering the substantial heterogeneity and lack of criteria for UTI dosage, more evidence is needed to establish a standard dosing guideline.
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Affiliation(s)
- Hu Zhenyu
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Yuan Qiaoli
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Chen Guangxiang
- Department of Radiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Wang Maohua
- Department of Anesthesiology, Laboratory of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China.
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Baldasseroni S, Di Bari M, Stefàno P, Pratesi A, Mossello E, Ungar A, Del Pace S, Orso F, Herbst A, Lucarelli G, Fumagalli C, Olivo G, Marchionni N. Lower extremity performance predicts length of hospital stay in older candidates to elective cardiac surgery. Exp Gerontol 2022; 164:111801. [DOI: 10.1016/j.exger.2022.111801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/17/2022] [Accepted: 04/03/2022] [Indexed: 11/04/2022]
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7
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Gupta P, Quan T, Patel CJ, Gu A, Campbell JC. Extended length of stay and postoperative complications in octogenarians with hypertension following revision total knee arthroplasty. J Clin Orthop Trauma 2022; 26:101787. [PMID: 35145852 PMCID: PMC8814689 DOI: 10.1016/j.jcot.2022.101787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/26/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prior studies have shown hypertensive patients to be at an increased risk of postoperative complications following various surgeries, including revision total knee arthroplasty (rTKA). However, whether these risks are compounded in octogenarian patients has not yet been well explored. The purpose of this study was to analyze whether hypertensive octogenarians, aged 80 to 89, undergoing rTKA are at an increased risk of postoperative complications relative to the younger hypertensive geriatric population aged 65 to 79. METHODS A national database was used to collect data for all hypertensive patients who underwent rTKA from 2006 to 2018. Patients were stratified into an aged 65 to 79 cohort and an aged 80 to 89 cohort. Demographics, medical comorbidities, and postoperative complications were compared between the two cohorts. Bivariate and multivariate analyses were performed. RESULTS Of the 6,599 hypertensive patients who underwent rTKA, 5,477 (83.0%) patients were in the aged 65 to 79 group and 1,122 (17.0%) patients were in the aged 80 to 89 group. Following adjustment to control for demographic and comorbidity data, relative to patients in the 65 to 79 age group, hypertensive patients who were 80-89 years old had an increased risk of unplanned reintubation (OR 3.52; p = 0.008), urinary tract infection (OR 2.08; p = 0.011), postoperative transfusion (OR 1.90; p < 0.001), myocardial infarction (OR 2.55; p = 0.017), and extended length of hospital stay (OR 1.77; p < 0.001). CONCLUSION Hypertensive octogenarian patients undergoing rTKA have an increased risk of an extended length of stay and other postoperative complications relative to their younger hypertensive geriatric counterparts. Orthopaedic surgeons should consider a multi-disciplinary approach to managing hypertension in these octogenarian patients prior to surgery to minimize this risk. However, even with this risk, an octogenarian age should not be used independently in evaluating if a hypertensive geriatric patient is a safe rTKA candidate.
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Affiliation(s)
| | - Theodore Quan
- Corresponding author. George Washington University School of Medicine and Health Sciences, 2300 Eye St NW, Washington, DC, 20037, USA.
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8
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Attia RQ, Katumalla E, Cyclewala S, Rochon M, Marczin N, Raja SG. Do in-hospital outcomes of isolated coronary artery bypass grafting vary between male and female octogenarians? Interact Cardiovasc Thorac Surg 2021; 34:958-965. [PMID: 34718583 PMCID: PMC9159460 DOI: 10.1093/icvts/ivab281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 08/11/2021] [Accepted: 08/27/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Female gender and advanced age are regarded as independent risk factors for adverse outcomes after isolated coronary artery bypass grafting (CABG). There is paucity of evidence comparing outcomes of CABG between male and female octogenarians. We aimed to analyse in-hospital outcomes of isolated CABG in this cohort. METHODS All octogenarians that underwent isolated CABG, from January 2000 to October 2017, were included. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. A propensity score was generated for each patient from a multivariable logistic regression model based on 25 pre-treatment covariates. A total of 156 matching pairs were derived. RESULTS Five hundred and sixty-seven octogenarians underwent isolated CABG. This included 156 females (mean age 82.1 [SD: 0.9]) and 411 males (mean age 82.4 [SD: 2.1 years]). More males were current smokers (P = 0.002) with renal impairment (P = 0.041), chronic obstructive pulmonary disease (P = 0.048), history of cerebrovascular accident (P = 0.039) and peripheral vascular disease (P = 0.027) while more females had New York Heart Association class 4 (P = 0.02), left ventricular ejection fraction 30-49% (P = 0.038) and left ventricular ejection fraction <30% (P = 0.049). On-pump, CABG was performed in 140 males and 52 females (P = 0.921). There was no difference in in-hospital mortality (5.4% vs 6.4%; P = 0.840), stroke (0.9% vs 1.3%; P = 0.689), need for renal replacement therapy (17.0% vs 13.5%; P = 0.732), pulmonary complications (9.5% vs 8.3%; P = 0.746) and sternal wound infection (2.7% vs 2.6%; P = 0.882). The outcomes were comparable for the propensity-matched cohorts. CONCLUSIONS No gender difference in outcomes was seen in octogenarians undergoing isolated CABG.
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Affiliation(s)
- Rizwan Q Attia
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | - Eve Katumalla
- Department of Cardiac Surgery, Harefield Hospital, London, UK
| | | | - Melissa Rochon
- Department of Quality & Safety (Surveillance section), Harefield Hospital, London, UK
| | - Nandor Marczin
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Department of Anaesthesia, Harefield Hospital, London, UK
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK
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9
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Zhang G, Gao Q, Chen S, Chen Y. OPCAB experience in octogenarians: A comparison of perioperative events and long-term survival between patients aged 75 to 80 years and patients aged ≥80 years. J Card Surg 2019; 34:948-956. [PMID: 31376213 DOI: 10.1111/jocs.14154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The advantages of off-pump coronary artery bypass grafting (OPCAB) in octogenarians are still undetermined. METHODS We retrospectively collected the data of 338 patients aged ≥75 with at least two coronary-artery diseases who underwent OPCAB. Then, the two groups were divided into follow-up survival and follow-up death subgroups. The baseline and perioperative data were compared for the younger and octogenarian groups, as well as for the subgroups. Moreover, long-term survival rates in the follow-up survival and follow-up death subgroups were compared; a Cox regression model was built to explore the independent risk factors that influence long-term survival. RESULTS NYNA ≥ III (39.4% vs 23.2%, P = .006), AMI (45.1% vs 24.3%, P = .001), and three diseased vessels with LM disease (38.0% vs 25.8%, P = .043) were more prevalent among octogenarians. Octogenarians required more intraoperative (11.3% vs 0.40%, P = .000) and postoperative (9.9% vs 2.2%, P = .003) IABP insertions and more ventilation time (P = .053), and they spent a longer time in the ICU (174.1 ± 34.9 vs 81.0 ± 6.4 hours, P = .010), had a longer total hospital stay (32.7 ± 3.1 vs 24.6 ± 0.8 days, P = .015), and had a longer postoperative hospital stay (20.5 ± 2.5 vs 14.5 ± 0.7 days, P = .021); however, fewer LIMA grafts were used among octogenarians (71.8% vs 90.3%, P = .000). The mortality and the postoperative complications between the two groups were similar. Long-term survival at 1, 5, and 10 years were satisfactory at 98.4 vs 91.5%, 89.7 vs 82.8%, and 61.1 vs 52.1% for the younger group and the octogenarians, respectively (P = .440). The Cox regression analysis results suggest that malignant ventricular arrhythmias (HR 4.058, CI, 1.760-9.358, P = .001; HR 7.256, CI, 2.112-24.932, P = .001) and reintubation (HR 3.593, CI, 1.646-7.845, P = .001; HR 4.252, CI, 1.797-10.060, P = .001) were independent risk factors that affect the long-term survival in both overall OPCAB patients and in the younger patient group. CONCLUSIONS OPCAB can be safely performed, with acceptable operative mortality and complication rates and satisfactory survival outcomes. The Cox regression analysis results demonstrated that malignant ventricular arrhythmia and reintubation were independent risk factors that affect long-term survival in both overall OPCAB patients and in the younger group of patients.
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Affiliation(s)
- Guodong Zhang
- Cardiac Surgery Department, Peking University People's Hospital, Bejing, China
| | - Qing Gao
- Cardiac Surgery Department, Peking University People's Hospital, Bejing, China
| | - Shenglong Chen
- Cardiac Surgery Department, Peking University People's Hospital, Bejing, China
| | - Yu Chen
- Cardiac Surgery Department, Peking University People's Hospital, Bejing, China
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Budworth L, Prestwich A, Lawton R, Kotzé A, Kellar I. Preoperative Interventions for Alcohol and Other Recreational Substance Use: A Systematic Review and Meta-Analysis. Front Psychol 2019; 10:34. [PMID: 30778307 PMCID: PMC6369879 DOI: 10.3389/fpsyg.2019.00034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/08/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Preoperative alcohol and other recreational substance use (ORSU) may catalyze perioperative complications. Accordingly, interventions aiming to reduce preoperative substance use are warranted. Methods: Studies investigating interventions to reduce alcohol and/or ORSU in elective surgery patients were identified from: Cochrane Library; MEDLINE; PSYCINFO; EMBASE; and CINAHL. In both narrative summaries of results and random effects meta-analyses, effects of interventions on perioperative alcohol/ORSU, complications, mortality and length of stay were assessed. Primary Results: Nine studies (n = 903) were included. Seven used behavioral interventions only, two provided disulfiram in addition. Pooled analyses found small effects on alcohol use (d: 0.34; 0.05-0.64), though two trials using disulfiram (0.71; 0.36-1.07) were superior to two using behavioral interventions (0.45; -0.49-1.39). No significant pooled effects were found for perioperative complications, length of hospital stay or mortality in studies solely targeting alcohol/ORSU. Too few interventions targeting ORSU (n = 1) were located to form conclusions regarding their efficacy. Studies were generally at high risk-of-bias and heterogeneous. Conclusions: Preoperative interventions were beneficial in reducing substance use in some instances, but more high-quality studies targeting alcohol/ORSU specifically are needed. The literature to date does not suggest that such interventions can reduce postoperative morbidity, length of hospital stay or mortality. Limitations in the literature are outlined and recommendations for future studies are suggested.
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Affiliation(s)
- Luke Budworth
- School of Psychology, University of Leeds, Leeds, United Kingdom.,Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, United Kingdom
| | - Andrew Prestwich
- School of Psychology, University of Leeds, Leeds, United Kingdom
| | - Rebecca Lawton
- School of Psychology, University of Leeds, Leeds, United Kingdom.,Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, United Kingdom
| | - Alwyn Kotzé
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Ian Kellar
- School of Psychology, University of Leeds, Leeds, United Kingdom
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11
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Lung-diffusing capacity for carbon monoxide predicts early complications after cardiac surgery. Surg Today 2019; 49:571-579. [PMID: 30706238 PMCID: PMC6584223 DOI: 10.1007/s00595-019-1770-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Preoperative pulmonary dysfunction has been associated with increased operative mortality and morbidity after cardiac surgery. This study aimed to determine whether values for the diffusing capacity of the lung for carbon monoxide (DLCO) could predict postoperative complications after cardiac surgery. METHODS This study included 408 consecutive patients who underwent cardiac surgery between June 2008 and December 2015. DLCO was routinely determined in all patients. A reduced DLCO was clinically defined as %DLCO < 70%. %DLCO was calculated as DLCO divided by the predicted DLCO. The association between %DLCO and in-hospital mortality was assessed, and independent predictors of complications were identified by a logistic regression analysis. RESULTS Among the 408 patients, 338 and 70 had %DLCO values of ≥ 70% and < 70%, respectively. Complications were associated with in-hospital mortality (P < 0.001), but not %DLCO (P = 0.275). A multivariate logistic regression analysis with propensity score matching identified reduced DLCO as an independent predictor of complications (OR, 3.270; 95%CI, 1.356-7.882; P = 0.008). CONCLUSIONS %DLCO is a powerful predictor of postoperative complications. The preoperative DLCO values might provide information that can be used to accurately predict the prognosis after cardiac surgery. CLINICAL TRIAL REGISTRATION NUMBER UMIN000029985.
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12
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Chen JO, Liu JF, Liu YQ, Chen YM, Tu ML, Yu HR, Lin MC, Lin CC, Liu SF. Effectiveness of a perioperative pulmonary rehabilitation program following coronary artery bypass graft surgery in patients with and without COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:1591-1597. [PMID: 29805258 PMCID: PMC5960241 DOI: 10.2147/copd.s157967] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose It is unclear whether the effectiveness of pulmonary rehabilitation program (PRP) after cardiac surgery differs between patients with and without COPD. This study aimed to compare the effectiveness of PRP between patients with and without COPD undergoing coronary artery bypass graft (CABG) surgery. Patients and methods We retrospectively included patients who underwent CABG surgery and received 3-week PRP from January 2009 to December 2013. We excluded patients who underwent emergency surgery, had an unstable hemodynamic status, were ventilator dependent or did not complete the PRP. Demographics, muscle strength, degree of dyspnea, pulmonary function and postoperative complications were compared. Results Seventy-eight patients were enrolled (COPD group, n=40; non-COPD group, n=38). Maximal inspiratory pressure (MIP; −34.52 cmH2O vs −43.25 cmH2O, P<0.01; −34.67 cmH2O vs −48.18 cmH2O, P<0.01), maximal expiratory pressure (MEP; 32.15 cmH2O vs 46.05 cmH2O, P<0.01; 37.78 cmH2O vs 45.72 cmH2O, P<0.01) and respiratory rate (RR; 20.65 breath/minute vs 17.02 breath/minute, P<0.01; 20.65 breath/minute vs 17.34 breath/minute, P<0.01) in COPD and non-COPD groups, respectively, showed significant improvement, but were not significantly different between the two groups. Forced vital capacity (FVC; 0.85 L vs 1.25 L, P<0.01), forced expiratory volume in 1 second (FEV1; 0.75 L vs 1.08 L, P<0.01), peak expiratory flow (PEF; 0.99 L vs 1.79 L, P<0.01) and forced expiratory flow between 25% and 75% of vital capacity (FEF25–75; 0.68 L vs 1.15 L, P<0.01) showed significant improvement between postoperative Days 1 and 14 in the COPD group. FVC (1.11 L vs 1.36 L, P<0.05), FEV1 (96 L vs 1.09 L, P<0.05) and FEF25–75 (1.03 L vs 1.26 L, P<0.05) were significantly improved in the non-COPD group. However, only PEF (80.8% vs 10.1%, P<0.01) and FEF25–75 (67.6% vs 22.3%, P<0.05) were more significantly improved in the COPD group than in the non-COPD group. Conclusion PRP significantly improved respiratory muscle strength and lung function in patients with and without COPD who underwent CABG surgery. However, PRP is more effective in improving PEF and FEF25–75 in COPD patients.
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Affiliation(s)
- Jui-O Chen
- Department of Nursing, Tajen University, Pingtung, Taiwan.,College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jui-Fang Liu
- Department of Nursing, Tajen University, Pingtung, Taiwan.,Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Respiratory Care, Chang Gung University of Science and Technology, Taoyuan, Taiwan.,Department of Education, National Kaohsiung Normal University, Kaohsiung, Taiwan
| | - Yu-Qi Liu
- Department of Intensive Care unit, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Yu-Mu Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mei-Lien Tu
- Respiratory Care, Chang Gung University of Science and Technology, Taoyuan, Taiwan
| | - Hong-Ren Yu
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Meng-Chih Lin
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chiu-Chu Lin
- College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Feng Liu
- Department of Respiratory Therapy, Kaohsiung Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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13
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Gaulton TG, Neuman MD. Association Between Obesity, Age, and Functional Decline in Survivors of Cardiac Surgery. J Am Geriatr Soc 2018; 66:127-132. [PMID: 29114877 PMCID: PMC5777886 DOI: 10.1111/jgs.15160] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/OBJECTIVES Little is known about the effect of obesity on functional decline after cardiac surgery, especially in elderly adults. Our goal was to determine the association between obesity and functional decline in the 2 years after cardiac surgery and the interaction between obesity and age. DESIGN Retrospective cohort study. SETTING The Health and Retirement Study, 2004-2014. PARTICIPANTS U.S. adults aged 50 and older who indicated having cardiac surgery and had a body mass index (BMI) of 18.5 kg/m2 or greater (N = 1,731). MEASUREMENTS BMI was classified as normal or overweight (18.5-29.9 kg/m2 ) and obese (≥30 kg/m2 ). Primary outcome was decline in ability to perform an activity of daily living (ADL) after surgery. RESULTS Respondents had a median age of 71, 59.3% were female, and 34.3% were obese. Obese respondents had a higher incidence of ADL decline (22.4%) than those who were not obese (17.1%) (P = .007). In the multivariable analysis of our full cohort, obesity was not associated with ADL decline (odds ratio (OR)=1.20, 95% confidence interval (CI)=0.90-1.59, P = .21) after cardiac surgery, although obese respondents aged 50 to 79 had greater odds of ADL decline (OR=1.45, 95% CI=1.06-2.00, P = .02). Obese respondents aged 80 and older had nonstatistically significantly lower odds of ADL decline (OR=0.61, 95% CI=0.30-1.24, P = .18) compared to non-obese respondents. CONCLUSION The association between obesity and postoperative functional decline in survivors of cardiac surgery differed according to age. Additional research is needed to identify interventions to improve outcomes in groups of older adults in whom obesity may increase the risk of postoperative functional decline.
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Affiliation(s)
- Timothy G Gaulton
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark D Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, Pennsylvania
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El-Essawi A, Breitenbach I, Haupt B, Brouwer R, Baraki H, Harringer W. Impact of minimally invasive extracorporeal circuits on octogenarians undergoing coronary artery bypass grafting. Have we been looking in the wrong direction? Eur J Cardiothorac Surg 2017; 52:1175-1181. [PMID: 28582490 DOI: 10.1093/ejcts/ezx156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/23/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Minimally invasive extracorporeal circuits (MiECCs) aim at the preservation of physiologic reserves, the impact of which is expected to be most evident in patients in whom these are depleted. In this context, octogenarians present a subpopulation of specific interest. METHODS Based on the type of the utilized ECC, we performed a retrospective comparison between all octogenarians (n = 324) who received a primary coronary artery bypass in our institution from 2003 until 2010. RESULTS An MiECC was used in 52% of patients. Preoperative variables showed that the MiECC patients were older (83 ± 2 vs 82 ± 2 years; P = 0.001), had higher incidence of renal dysfunction (8% vs 3%; P = 0.04), moderately reduced left ventricular function (43 vs 33%; P = 0.07) and lower incidence of unstable angina (20% vs 28%; P = 0.06). To overcome these differences, a propensity score matching was performed and yielded 126 matched pairs of patients. The overall transfusion of packed red blood cells (2.3 ± 2.3 vs 3.4 ± 3.2 units per patint; P = <0.001), the rate of low cardiac output (0% vs 6%; P = 0.01) and the 30-day postoperative mortality (2.4% vs 9.5%; P = 0.02) were all in favour of the MiECC group in the matched patient population. CONCLUSIONS The MiECC concept has shown its benefits regarding both morbidity and mortality in this high-risk patient population. We believe that this beneficial effect finds its reason in a better preservation of physiologic reserves that are essential for a positive outcome in this patient group.
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Affiliation(s)
- Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Benjamin Haupt
- Academy of Perfusion, German Heart Centre Berlin, Berlin, Germany
| | - Rene Brouwer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Hassina Baraki
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
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15
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De Santo LS, Romano G, Mango E, Iorio F, Savarese L, Numis F, Zebele C. Age and blood transfusion: relationship and prognostic implications in cardiac surgery. J Thorac Dis 2017; 9:3719-3727. [PMID: 29268379 DOI: 10.21037/jtd.2017.08.126] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Red blood cell (RBC) transfusion is a well-known predictor of acute kidney injury (AKI) and death after cardiac surgery. This study aimed to define the relationship between age and the need for RBC. Methods Study population included 1,765 consecutive patients undergoing on-pump procedures from 2013 to 2015. The relationship between RBC transfusion and both survival and AKI, and any interaction with age was estimated. A propensity score for the likelihood to receive RBC transfusion was calculated using multivariate logistic regression analysis to adjust for the effect of confounding factors. A logistic estimation curve was developed to investigate the interaction between this score and age. Results Patients receiving RBC transfusions had more comorbidities irrespective of age. Elderly patients underwent transfusion more often than younger patients with a 1.3-fold increase in the relative risk for transfusion. Age did not independently predict the need for RBC. AKI and mortality rates were significantly higher in transfused subsets irrespective of age. Conclusions Comorbidity profile and not age per se confers an increased risk of transfusion.
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Affiliation(s)
- Luca Salvatore De Santo
- Division of Cardiac Surgery, University of Foggia, Foggia, Italy.,Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
| | - Gianpaolo Romano
- Department of Cardiovascular Surgery and Transplants, V. Monaldi Hospital, Naples, Italy
| | - Emilio Mango
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
| | - Francesco Iorio
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
| | - Leonardo Savarese
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
| | - Flora Numis
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
| | - Carlo Zebele
- Division of Cardiac Surgery, Casa di Cura Montevergine, GVM Care and Research, Mercogliano, Avellino, Italy
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16
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Dunckley M, Ellard D, Quinn T, Barlow J. Recovery after coronary artery bypass grafting: Patients’ and health professionals’ views of the hospital experience. Eur J Cardiovasc Nurs 2016; 6:200-7. [PMID: 17092777 DOI: 10.1016/j.ejcnurse.2006.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Revised: 07/10/2006] [Accepted: 09/18/2006] [Indexed: 12/01/2022]
Abstract
Background Increasing access to revascularisation procedures is a key aspect of a National Service Framework. Coronary artery bypass grafting (CABG) is effective in relieving symptoms and reducing mortality but some patients do not report an improved quality of life or experience a good recovery. Aims To describe the recovery trajectory after CABG and identify facilitators and barriers to recovery. Methods Semi-structured interviews were conducted with 11 patients who had previously undergone elective, isolated, first-time CABG and with 10 health professionals experienced in caring for these patients. Results Thematic analysis identified the following themes: definition and timeline of recovery, preparation for surgery including information provision, attitude to surgery and confidence in staff, clinical factors and the in-patient experience. The key finding is the different recovery trajectory between patients with severe versus mild pre-operative symptoms; patients with few pre-CABG symptoms reported a much longer recovery time. Conclusions This study has provided insights into the barriers and facilitators to recovery after CABG and the processes involved. Findings have indicated areas where health professionals can intervene to aid patients’ long-term recovery and thereby maximise the benefits of CABG.
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Affiliation(s)
- Maria Dunckley
- Interdisciplinary Research Centre in Health, Faculty of Health and Life sciences, Coventry University, Priory Street, Coventry, UK.
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17
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Almashrafi A, Elmontsri M, Aylin P. Systematic review of factors influencing length of stay in ICU after adult cardiac surgery. BMC Health Serv Res 2016; 16:318. [PMID: 27473872 PMCID: PMC4966741 DOI: 10.1186/s12913-016-1591-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 07/27/2016] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) care is associated with costly and often scarce resources. In many parts of the world, ICUs are being perceived as major bottlenecks limiting downstream services such as operating theatres. There are many clinical, surgical and contextual factors that influence length of stay. Knowing these factors can facilitate resource planning. However, the extent at which this knowledge is put into practice remains unclear. The aim of this systematic review was to identify factors that impact the duration of ICU stay after cardiac surgery and to explore evidence on the link between understanding these factors and patient and resource management. METHODS We conducted electronic searches of Embase, PubMed, ISI Web of Knowledge, Medline and Google Scholar, and reference lists for eligible studies. RESULTS Twenty-nine papers fulfilled inclusion criteria. We recognised two types of objectives for identifying influential factors of ICU length of stay (LOS) among the reviewed studies. These were general descriptions of predictors and prediction of prolonged ICU stay through statistical models. Among studies with prediction models, only two studies have reported their implementation. Factors most commonly associated with increased ICU LOS included increased age, atrial fibrillation/ arrhythmia, chronic obstructive pulmonary disease (COPD), low ejection fraction, renal failure/ dysfunction and non-elective surgery status. CONCLUSION Cardiac ICUs are major bottlenecks in many hospitals around the world. Efforts to optimise resources should be linked to patient and surgical characteristics. More research is needed to integrate patient and surgical factors into ICU resource planning.
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Affiliation(s)
- Ahmed Almashrafi
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstans Road, London, W6 8RP UK
| | - Mustafa Elmontsri
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstans Road, London, W6 8RP UK
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, Charing Cross Campus, Reynolds Building, St Dunstans Road, London, W6 8RP UK
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18
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Almashrafi A, Alsabti H, Mukaddirov M, Balan B, Aylin P. Factors associated with prolonged length of stay following cardiac surgery in a major referral hospital in Oman: a retrospective observational study. BMJ Open 2016; 6:e010764. [PMID: 27279475 PMCID: PMC4908878 DOI: 10.1136/bmjopen-2015-010764] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Two objectives were set for this study. The first was to identify factors influencing prolonged postoperative length of stay (LOS) following cardiac surgery. The second was to devise a predictive model for prolonged LOS in the cardiac intensive care unit (CICU) based on preoperative factors available at admission and to compare it against two existing cardiac stratification systems. DESIGN Observational retrospective study. SETTINGS A tertiary hospital in Oman. PARTICIPANTS All adult patients who underwent cardiac surgery at a major referral hospital in Oman between 2009 and 2013. RESULTS 30.5% of the patients had prolonged LOS (≥11 days) after surgery, while 17% experienced prolonged ICU LOS (≥5 days). Factors that were identified to prolong CICU LOS were non-elective surgery, current congestive heart failure (CHF), renal failure, combined coronary artery bypass graft (CABG) and valve surgery, and other non-isolated valve or CABG surgery. Patients were divided into three groups based on their scores. The probabilities of prolonged CICU LOS were 11%, 26% and 28% for group 1, 2 and 3, respectively. The predictive model had an area under the curve of 0.75. Factors associated with prolonged overall postoperative LOS included the body mass index, the type of surgery, cardiopulmonary bypass machine use, packed red blood cells use, non-elective surgery and number of complications. The latter was the most important determinant of postoperative LOS. CONCLUSIONS Patient management can be tailored for individual patient based on their treatments and personal attributes to optimise resource allocation. Moreover, a simple predictive score system to enable identification of patients at risk of prolonged CICU stay can be developed using data that are routinely collected by most hospitals.
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Affiliation(s)
- Ahmed Almashrafi
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Hilal Alsabti
- Cardiothoracic Surgery Division, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Mirdavron Mukaddirov
- Cardiothoracic Surgery Division, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Baskaran Balan
- Cardiothoracic Surgery Division, Department of Surgery, Sultan Qaboos University Hospital, Muscat, Oman
| | - Paul Aylin
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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19
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population: A Scientific Statement From the American Heart Association, American College of Cardiology, and American Geriatrics Society. J Am Coll Cardiol 2016; 67:2419-2440. [PMID: 27079335 DOI: 10.1016/j.jacc.2016.03.004] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The incidence and prevalence of most cardiovascular disorders increase with age, and cardiovascular disease is the leading cause of death and major disability in adults ≥75 years of age; however, despite the large impact of cardiovascular disease on quality of life, morbidity, and mortality in older adults, patients aged ≥75 years have been markedly underrepresented in most major cardiovascular trials, and virtually all trials have excluded older patients with complex comorbidities, significant physical or cognitive disabilities, frailty, or residence in a nursing home or assisted living facility. As a result, current guidelines are unable to provide evidence-based recommendations for diagnosis and treatment of older patients typical of those encountered in routine clinical practice. The objectives of this scientific statement are to summarize current guideline recommendations as they apply to older adults, identify critical gaps in knowledge that preclude informed evidence-based decision making, and recommend future research to close existing knowledge gaps. To achieve these objectives, we conducted a detailed review of current American College of Cardiology/American Heart Association and American Stroke Association guidelines to identify content and recommendations that explicitly targeted older patients. We found that there is a pervasive lack of evidence to guide clinical decision making in older patients with cardiovascular disease, as well as a paucity of data on the impact of diagnostic and therapeutic interventions on key outcomes that are particularly important to older patients, such as quality of life, physical function, and maintenance of independence. Accordingly, there is a critical need for a multitude of large population-based studies and clinical trials that include a broad spectrum of older patients representative of those seen in clinical practice and that incorporate relevant outcomes important to older patients in the study design. The results of these studies will provide the foundation for future evidence-based guidelines applicable to older patients, thereby enhancing patient-centered evidence-based care of older people with cardiovascular disease in the United States and around the world.
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20
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Rich MW, Chyun DA, Skolnick AH, Alexander KP, Forman DE, Kitzman DW, Maurer MS, McClurken JB, Resnick BM, Shen WK, Tirschwell DL. Knowledge Gaps in Cardiovascular Care of the Older Adult Population. Circulation 2016; 133:2103-22. [DOI: 10.1161/cir.0000000000000380] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Carr BM, Romeiser J, Ruan J, Gupta S, Seifert FC, Zhu W, Shroyer AL. Long-Term Post-CABG Survival: Performance of Clinical Risk Models Versus Actuarial Predictions. J Card Surg 2016; 31:23-30. [PMID: 26543019 PMCID: PMC4738429 DOI: 10.1111/jocs.12665] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND/AIM Clinical risk models are commonly used to predict short-term coronary artery bypass grafting (CABG) mortality but are less commonly used to predict long-term mortality. The added value of long-term mortality clinical risk models over traditional actuarial models has not been evaluated. To address this, the predictive performance of a long-term clinical risk model was compared with that of an actuarial model to identify the clinical variable(s) most responsible for any differences observed. METHODS Long-term mortality for 1028 CABG patients was estimated using the Hannan New York State clinical risk model and an actuarial model (based on age, gender, and race/ethnicity). Vital status was assessed using the Social Security Death Index. Observed/expected (O/E) ratios were calculated, and the models' predictive performances were compared using a nested c-index approach. Linear regression analyses identified the subgroup of risk factors driving the differences observed. RESULTS Mortality rates were 3%, 9%, and 17% at one-, three-, and five years, respectively (median follow-up: five years). The clinical risk model provided more accurate predictions. Greater divergence between model estimates occurred with increasing long-term mortality risk, with baseline renal dysfunction identified as a particularly important driver of these differences. CONCLUSIONS Long-term mortality clinical risk models provide enhanced predictive power compared to actuarial models. Using the Hannan risk model, a patient's long-term mortality risk can be accurately assessed and subgroups of higher-risk patients can be identified for enhanced follow-up care. More research appears warranted to refine long-term CABG clinical risk models.
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Affiliation(s)
- Brendan M Carr
- Department of Surgery, Stony Brook Medicine, Stony Brook University, Stony Brook, New York
| | - Jamie Romeiser
- Department of Surgery, Stony Brook Medicine, Stony Brook University, Stony Brook, New York
| | - Joyce Ruan
- Department of Applied Mathematics and Statistics, College of Engineering and Applied Sciences, Stony Brook University, Stony Brook, New York
| | - Sandeep Gupta
- Department of Surgery, Stony Brook Medicine, Stony Brook University, Stony Brook, New York
| | - Frank C Seifert
- Department of Surgery, Stony Brook Medicine, Stony Brook University, Stony Brook, New York
| | - Wei Zhu
- Department of Applied Mathematics and Statistics, College of Engineering and Applied Sciences, Stony Brook University, Stony Brook, New York
| | - A Laurie Shroyer
- Department of Surgery, Stony Brook Medicine, Stony Brook University, Stony Brook, New York
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22
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Prognosis of patients in a medical intensive care unit. North Clin Istanb 2015; 2:189-195. [PMID: 28058366 PMCID: PMC5175105 DOI: 10.14744/nci.2015.79188] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 12/29/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the demographic characteristics of critically ill patients and to determine intensive care unit (ICU) mortality and its predictors. METHODS This study was undertaken in the Istanbul Medeniyet University Göztepe Training and Research Hospital Medical ICU. Between May 2012 and January 2013, 111 patients (53 female, 58 male; mean age, 73.79±14.73, mean length of ICU length stay, 9.1±10.7; prevalence of geriatric patients, 77.5%) were admitted to the ICU. The common indications for ICU admission, prevalence of mechanical ventilation support, hematological and biochemical parameters and their effects on mortality were assessed. RESULTS The common indications for ICU admission were hemodynamic instability (48.6%), respiratory failure (27.9%) and sepsis (15.3%). Hypertension (46.8%) was the most common comorbidity. Prevalance rates of heart failure and diabetes mellitus were 32.4% and 25.2% respectively. Mortality rate was 52.3% in all patients. Approximately 80% of all deaths was observed within the first fifteen-day. In additon, mortality rate (85.7%) was prominent within patients in need of the mechanical ventilation support. Mechanical ventilation requirement, increased ferritin and vitamin B12 levels were independent risk factors for mortality in critically ill patients (p<0.01, for all). CONCLUSION Mortality rate was higher in medical ICU. Herein, increased prevalence of geriatric population, concomitant comorbidities and mechanical ventilation requirements may play role.
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Singh AK, Maslow AD, Machan JT, Fingleton JG, Feng WC, Schwartz C, Rotenberg FA, Bert AA. Long-term survival after use of internal thoracic artery in octogenarians is gender related. J Thorac Cardiovasc Surg 2015; 150:891-9. [DOI: 10.1016/j.jtcvs.2015.07.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 07/01/2015] [Accepted: 07/18/2015] [Indexed: 11/30/2022]
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Early and long-term results of cardiosurgical treatment of coronary artery disease and aortic stenosis in patients over 80 years old. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 11:246-51. [PMID: 26336430 PMCID: PMC4283889 DOI: 10.5114/kitp.2014.45671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 12/23/2013] [Accepted: 06/09/2014] [Indexed: 11/21/2022]
Abstract
Background In recent years, patients over 80 years of age have been a growing group of individuals referred to cardiac surgeons. They pose a serious challenge and usually require a multidisciplinary approach. Aim The aim of this study was to evaluate the early and late outcomes of cardiosurgical treatment of patients over 80 years of age suffering from coronary artery disease and aortic stenosis. Material and methods The study involved 96 patients aged over 80 years treated between January, 2004 and December, 2012. The mortality and morbidity in the early postoperative period, as well as throughout the follow-up period, were analyzed. Results The majority of patients underwent isolated coronary artery bypass grafting (CABG) (58.3%; Group I), while 29.2% of them underwent an isolated aortic valve replacement (AVR) (Group II). Combined procedures (CABG + AVR) were carried out in 12.5% of patients (Group III). The mean operational risk calculated according to the logistic EuroSCORE was 11.6%, 11.9%, and 9.5%, respectively in Group I, Group II and in Group III. In the early postoperative period, 4 patients died (all from Group I). The 30-day mortality rate was 4.2% and the morbidity rate was 56.3%. During the post-discharge follow-up period that lasted from 1 to 100 months, 4 patients died (2 from Group I and 2 from Group III). The 2-year probability of survival was 91.9 ± 3.0%. During the last follow-up clinical assessment, half of the patients were asymptomatic. Conclusions The perioperative mortality of the patients is acceptably and markedly lower than that predicted by the logistic EuroSCORE calculator. However, the complication rate, particularly in the early postoperative period, is relatively high.
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25
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Titinger DP, Lisboa LAF, Matrangolo BLR, Dallan LRP, Dallan LAO, Trindade EM, Eckl I, Kalil Filho R, Mejía OAV, Jatene FB. Cardiac surgery costs according to the preoperative risk in the Brazilian public health system. Arq Bras Cardiol 2015; 105:130-8. [PMID: 26107813 PMCID: PMC4559121 DOI: 10.5935/abc.20150068] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Heart surgery has developed with increasing patient complexity. OBJECTIVE To assess the use of resources and real costs stratified by risk factors of patients submitted to surgical cardiac procedures and to compare them with the values reimbursed by the Brazilian Unified Health System (SUS). METHOD All cardiac surgery procedures performed between January and July 2013 in a tertiary referral center were analyzed. Demographic and clinical data allowed the calculation of the value reimbursed by the Brazilian SUS. Patients were stratified as low, intermediate and high-risk categories according to the EuroSCORE. Clinical outcomes, use of resources and costs (real costs versus SUS) were compared between established risk groups. RESULTS Postoperative mortality rates of low, intermediate and high-risk EuroSCORE risk strata showed a significant linear positive correlation (EuroSCORE: 3.8%, 10%, and 25%; p < 0.0001), as well as occurrence of any postoperative complication EuroSCORE: 13.7%, 20.7%, and 30.8%, respectively; p = 0.006). Accordingly, length-of-stay increased from 20.9 days to 24.8 and 29.2 days (p < 0.001). The real cost was parallel to increased resource use according to EuroSCORE risk strata (R$ 27.116,00 ± R$ 13.928,00 versus R$ 34.854,00 ± R$ 27.814,00 versus R$ 43.234,00 ± R$ 26.009,00, respectively; p < 0.001). SUS reimbursement also increased (R$ 14.306,00 ± R$ 4.571,00 versus R$ 16.217,00 ± R$ 7.298,00 versus R$ 19.548,00 ± R$935,00; p < 0.001). However, as the EuroSCORE increased, there was significant difference (p < 0.0001) between the real cost increasing slope and the SUS reimbursement elevation per EuroSCORE risk strata. CONCLUSION Higher EuroSCORE was related to higher postoperative mortality, complications, length of stay, and costs. Although SUS reimbursement increased according to risk, it was not proportional to real costs.
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Affiliation(s)
| | | | | | | | | | | | - Ivone Eckl
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, BR
| | - Roberto Kalil Filho
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, BR
| | | | - Fabio Biscegli Jatene
- Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, BR
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Quarterman C, Kirmani BH, Al-Rawi O. Critical care admissions in a cardiothoracic hospital: Mortality in patients aged over 80 years. J Intensive Care Soc 2015; 16:109-113. [PMID: 28979392 DOI: 10.1177/1751143715569963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cardiac surgery is increasingly performed on patients aged 80 years and over. Previous studies have shown an associated longer length of hospital stay and higher morbidity and mortality. Our aim was to establish whether an increased mortality was demonstrated in patients aged over 80 undergoing surgery in our centre, and the impact of age upon critical care and hospital stay, and 30-day and 6-month survival. METHODS Over a 12-month period, 2042 critical care episodes were examined collectively and divided into those undergoing thoracic and cardiac surgery. Propensity matching of 216 patients who underwent cardiac surgery was performed for parameters including Acute Physiology And Chronic Health Evaluation (APACHE) II and Intensive Care National Audit and Research Centre score. RESULTS Of the admissions studied, 1784 were of patients under 80 years of age, and 258 over 80. Thirty-day mortality of those aged over 80 was significantly higher (8.9% vs. 3.8%, p < 0.0001), although the number of days of each level of organ support and total duration of critical care stay was not significantly different. Propensity matching of cardiac surgery patients indicated a longer length of hospital stay in those aged over 80, but no significant difference in length of critical care stay or mortality at six months. CONCLUSIONS As previously demonstrated, we found an increased mortality in the older patient group. Following propensity matching, there was no significant difference in 30-day or 6-month mortality. Older patients must be fitter than their younger peers to compensate for the effects of age on APACHE II score. Even when this is taken into consideration, cardiothoracic operations appear to be safe in patients aged over 80.
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Affiliation(s)
- Clare Quarterman
- Department of Critical Care and Anaesthesia, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Bilal H Kirmani
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Omar Al-Rawi
- Department of Critical Care and Anaesthesia, Liverpool Heart and Chest Hospital, Liverpool, UK
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Wang W, Bagshaw SM, Norris CM, Zibdawi R, Zibdawi M, MacArthur R. Association between older age and outcome after cardiac surgery: a population-based cohort study. J Cardiothorac Surg 2014; 9:177. [PMID: 25761494 PMCID: PMC4255435 DOI: 10.1186/s13019-014-0177-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 10/30/2014] [Indexed: 11/29/2022] Open
Abstract
Objective Octogenarians (aged ≥ 80 years) are increasingly being referred for cardiac surgery. We aimed to describe the morbidity, mortality, and health services utilization of octogenarians undergoing elective cardiac surgery. Methods Retrospective population-based cohort study of adult patients receiving elective cardiac surgery between January 1 2004 and December 31 2009. Primary exposure was age ≥80 years. Outcomes were 30-day, 1- and 5-year mortality, post-operative complications, and ICU/hospital lengths of stay. Multi-variable logistic and Cox regression analyses were used to explore the association between older age and outcome. Results Of 6,843 patients receiving cardiac surgery, 544 (7.9%) were octogenarians. There was an increasing trend in the proportion of octogenarians undergoing surgery during the study period (0.3% per year, P = 0.073). Octogenarians were more likely to have combined procedures (valve plus coronary artery bypass or multiple valves) compared with younger strata (p < 0.001). Crude 30-day, 1-year and 5-year mortality for octogenarians were 3.7%, 10.8% and 29.0%, respectively. Compared to younger strata, octogenarians had higher adjusted 30-day (OR 4.83, 95%CI 1.30-17.92; P = 0.018) and 1-year mortality (OR 4.92; 95% CI, 2.32-10.46. P<0.001). Post-operative complications were more likely among octogenarians. Octogenarians had longer post-operative stays in ICU and hospital, and higher rates of ICU readmission (P < 0.001 for all). After multi-variable adjustment, age ≧ 80 years was an independent predictor of death at 30-days and 1 year. Conclusions Octogenarians are increasingly referred for elective cardiac surgery with more combined procedures. Compared to younger patients, octogenarians have a higher risk of post-operative complications, consume greater resources, and have worse but acceptable short and long-term survival. Electronic supplementary material The online version of this article (doi:10.1186/s13019-014-0177-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wei Wang
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Sean M Bagshaw
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. .,Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. .,Division of Critical Care Medicine, Clinical Sciences Building, 2-124E, 8440 - 112 Street, Edmonton, Alberta, T6G 2B7, Canada.
| | - Colleen M Norris
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. .,Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada. .,Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada.
| | - Rami Zibdawi
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Mohamad Zibdawi
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. .,Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Roderick MacArthur
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
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Fellahi JL, Brossier D, Dechanet F, Fischer MO, Saplacan V, Gérard JL, Hanouz JL. Early goal-directed therapy based on endotracheal bioimpedance cardiography: a prospective, randomized controlled study in coronary surgery. J Clin Monit Comput 2014; 29:351-8. [PMID: 25380955 DOI: 10.1007/s10877-014-9611-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/27/2014] [Indexed: 01/01/2023]
Abstract
The objective was to compare the impact of an early goal-directed hemodynamic therapy based on cardiac output monitoring (Endotracheal Cardiac Output Monitor, ECOM) with a standard of care on postoperative outcome following coronary surgery. This prospective, controlled, parallel-arm trial randomized 100 elective primary coronary artery bypass grafting patients to a study group (ECOM; n = 50) or a control group (control; n = 50). In the ECOM group, hemodynamic therapy was guided by respiratory stroke volume variation and cardiac index given by the ECOM system. A standard of care was used in the control. Goal-directed therapy was started immediately after induction of anesthesia and continued until arrival in the intensive care unit (ICU). The primary endpoint was the time when patients fulfilled discharge criteria from hospital (possible hospital discharge). Secondary endpoints were the hospital discharge, the time to reach extubation, the length of stay in ICU, the number of major adverse cardiac events, and in-hospital mortality. Patients in the ECOM group received more often fluid loading and dobutamine. The time to reach extubation was reduced in the ECOM group: 510 min [360-1,110] versus 570 min [320-1,520], P = 0.005. No significant differences were found between both groups for possible hospital discharge [Hazard Ratio = 0.96 (95 % CI 0.64-1.45)] and hospital discharge [Hazard Ratio = 1.20 (95 % CI 0.79-1.81)]. A mini-invasive early goal-directed hemodynamic therapy based on ECOM can reduce the time to reach extubation but fails to significantly reduce the length of stay in hospital and the rate of major cardiac morbidity.
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Affiliation(s)
- Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Hospices Civils de Lyon, 28 avenue du Doyen Lépine, 69677, Lyon-Bron Cedex, France,
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Afshar AH, Virk N, Porhomayon J, Pourafkari L, Dosluoglu HH, Nader ND. The validity of the VA surgical risk tool in predicting postoperative mortality among octogenarians. Am J Surg 2014; 209:274-9. [PMID: 25457253 DOI: 10.1016/j.amjsurg.2014.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 06/26/2014] [Accepted: 07/15/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND To examine the validity of Veterans Affair-VA risk assessment tool in predicting the perioperative and overall mortality among octogenarians. METHODS This is a single-institution retrospective observational study, in which the clinical information of 1,618 octogenarians were extracted from the VA Surgical Quality Improvement Program database. VA risk assessment tool and ASA classification were used to predict the probability of postoperative mortality and morbidity. Multiple risk groups were compared for mortality using multiple logistic regressions. RESULTS There were 570 survivors and 1,048 nonsurvivors. VA risk tool strongly predicted perioperative 30-day mortality in receiver operator characteristic curve analysis (area under the curve: .82 ± .02). The power of this tool, while acceptable, was less in predicting overall mortality (area under the curve: .68 ± .01). Age, dialysis, a history of congestive heart failure, functional status, transfusion, and weight loss were also associated with increased rate of death within 30 days. CONCLUSIONS VA risk tool predicted both perioperative and overall mortality. Relatively strong power of this tool in predicting overall mortality may be unique to this age group because of their advanced age.
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Affiliation(s)
- Ata H Afshar
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Navyugjit Virk
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | - Jahan Porhomayon
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA; VAWestern NY Healthcare System, Anesthesiology Services, Buffalo, NY
| | - Leili Pourafkari
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA
| | | | - Nader D Nader
- Department of Anesthesiology, University at Buffalo, Buffalo, NY, USA; VAWestern NY Healthcare System, Anesthesiology Services, Buffalo, NY.
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Adams PD, Ritz J, Kather R, Patton P, Jordan J, Mooney R, Horst HM, Rubinfeld I. The differential effects of surgical harm in elderly populations. Does the adage: "they tolerate the operation, but not the complications" hold true? Am J Surg 2014; 208:656-62. [PMID: 24929708 DOI: 10.1016/j.amjsurg.2014.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/19/2014] [Accepted: 03/04/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Elderly patients are thought to tolerate surgical complications poorly because of low physiologic reserve. The purpose of the study was to evaluate the differential effects of surgical harm in patients over 80 years old. METHODS Three years of data from a harm-reduction campaign were used to identify inpatient surgeries performed on patients older than 50. The rates of harm, death, cost, and length of stay (LOS) were analyzed using SPSS 21 (IBM, New York, NY). RESULTS A total of 22,710 patients were identified. Rates of harm and mortality increased with increasing age. Harmed patients over age 80 had increased mortality (9.5% vs 7%), but lower cost, intensive care unit days, and LOS versus those aged 50 to 80. Linear regression showed increased cost with harm ($24,000) and decreased cost with age above 80 (-$7,000). CONCLUSIONS In the elderly surgical population, there is more harm and harm events are associated with higher mortality rates, but less additional cost and LOS. Differing goals or aggressiveness of care may explain cost avoidance in the elderly.
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Affiliation(s)
- Peter D Adams
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA.
| | - Jennifer Ritz
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Ryan Kather
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Pat Patton
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Jack Jordan
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Roberta Mooney
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | | | - Ilan Rubinfeld
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
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Anaortic Off-Pump Coronary Artery Bypass Grafting in the Elderly and Very Elderly. Heart Lung Circ 2013; 22:989-95. [DOI: 10.1016/j.hlc.2013.05.650] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 05/13/2013] [Accepted: 05/30/2013] [Indexed: 11/19/2022]
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Ettema RGA, Hoogendoorn ME, Kalkman CJ, Schuurmans MJ. Development of a nursing intervention to prepare frail older patients for cardiac surgery (the PREDOCS programme), following phase one of the guidelines of the Medical Research Council. Eur J Cardiovasc Nurs 2013; 13:494-505. [DOI: 10.1177/1474515113511715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In older patients undergoing elective cardiac surgery, the timely identification and preparation of patients at risk for frequent postoperative hospital complications provide opportunities to reduce the risk of these complications. Aims: We developed an evidence-based, multi-component nursing intervention (Prevention of Decline in Older Cardiac Surgery Patients; the PREDOCS programme) for application in the preadmission period to improve patients’ physical and psychosocial condition to reduce their risk of postoperative complications. This paper describes in detail the process used to design and develop this multi-component intervention. Methods: In a team of researchers, experts, cardiac surgeons, registered cardiac surgery nurses, and patients, the revised guidelines for developing and evaluating complex interventions of the Medical Research Council (MRC) were followed, including identifying existing evidence, identifying and developing theory and modelling the process and outcomes. Additionally, the criteria for reporting the development of complex interventions in healthcare (CReDECI) were followed. Results: The intervention is administered during a consultation by the nurse two to four weeks before the surgery procedure. The consultation includes three parts: a general part for all patients, a second part in which patients with an increased risk are identified, and a third part in which selected patients are informed about how to prepare themselves for the hospital admission to reduce their risk. Conclusions: Following the MRC guidelines, an extended, stepwise, multi-method procedure was used to develop the multi-component nursing intervention to prepare older patients for cardiac surgery, creating transparency in the assumed working mechanisms. Additionally, a detailed description of the intervention is provided.
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Affiliation(s)
- Roelof GA Ettema
- University of Applied Science Utrecht, Faculty of Health Care, The Netherlands
- University Medical Centre Utrecht, The Netherlands
| | | | | | - Marieke J Schuurmans
- University of Applied Science Utrecht, Faculty of Health Care, The Netherlands
- University Medical Centre Utrecht, The Netherlands
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Ettema RGA, Van Koeven H, Peelen LM, Kalkman CJ, Schuurmans MJ. Preadmission interventions to prevent postoperative complications in older cardiac surgery patients: a systematic review. Int J Nurs Stud 2013; 51:251-60. [PMID: 23796313 DOI: 10.1016/j.ijnurstu.2013.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 05/15/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE(S) The literature on postoperative complications in cardiac surgery patients shows high incidences of postoperative complications such as delirium, depression, pressure ulcer, infection, pulmonary complications and atrial fibrillation. These complications are associated with functional and cognitive decline and a decrease in the quality of life after discharge. Several studies attempted to prevent one or more postoperative complications by preoperative interventions. Here we provide a comprehensive overview of both single and multiple component preadmission interventions designed to prevent postoperative complications. METHODS We systematically reviewed the literature following the PRISMA statement guidelines. RESULTS Of 1335 initial citations, 31 were subjected to critical appraisal. Finally, 23 studies were included, of which we derived a list of interventions that can be applied in the preadmission period to effectively reduce postoperative depression, infection, pulmonary complications, atrial fibrillation, prolonged intensive care unit stay and hospital stay in older elective cardiac surgery patients. No high quality studies were found describing effective interventions to prevent postoperative delirium. We did not find studies specifically targeting the prevention of pressure ulcers in this patient population. CONCLUSIONS Multi-component approaches that include different single interventions have the strongest effect in preventing postoperative depression, pulmonary complications, prolonged intensive care unit stay and hospital stay. Postoperative infection can be best prevented by disinfection with chlorhexidine combined with immune-enhancing nutritional supplements. Atrial fibrillation might be prevented by ingestion of N-3 polyunsaturated fatty acids. High quality studies are urgently needed to evaluate preadmission preventive strategies to reduce postoperative delirium or pressure ulcers in older elective cardiac surgery patients.
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Affiliation(s)
- Roelof G A Ettema
- Nursing and Paramedical Care for People With Chronic Illnesses, University of Applied Science Utrecht, Faculty of Health Care, Bolognalaan 101, 3584 CJ Utrecht, The Netherlands; Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Heleen Van Koeven
- Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Center for Health Sciences and Primary Care, Department of Epidemiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Cor J Kalkman
- Professor of Anesthesiology, Division of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marieke J Schuurmans
- Nursing and Paramedical Care for People With Chronic Illnesses, University of Applied Science Utrecht, Faculty of Health Care, Bolognalaan 101, 3584 CJ Utrecht, The Netherlands; Professor of Nursing Science, Department of Rehabilitation, Nursing Science & Sports, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
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Rahmanian PB, Kröner A, Langebartels G, Özel O, Wippermann J, Wahlers T. Impact of major non-cardiac complications on outcome following cardiac surgery procedures: logistic regression analysis in a very recent patient cohort. Interact Cardiovasc Thorac Surg 2013; 17:319-26; discussion 326-7. [PMID: 23667066 DOI: 10.1093/icvts/ivt149] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES In this study, we sought to analyse the incidence of major non-cardiac complications and their impact on survival following cardiac surgery procedures in a contemporary patient cohort. We further determined independent predictors of perioperative mortality and created a logistic regression model for prediction of outcome after the occurrence of these complications. METHODS Prospectively collected data of 5318 consecutive adult patients (mean age 68.9±11.0 years; 29.3% [n=1559] female) undergoing cardiac surgery from January 2009 to May 2012 were retrospectively analysed. Outcome measures were six major non-cardiac complications including respiratory failure, dialysis-dependent renal failure, deep sternal wound infection (DSWI), cerebrovascular accident (CVA), gastrointestinal complications (GIC) and sepsis and their impact on perioperative mortality and hospital length of stay using multivariate regression models. The discriminatory power was evaluated by calculating the area under the receiver operating characteristic curves (C statistic). RESULTS A total of 1321 complications were observed in 846 (15.9%) patients: respiratory failure (n=432; 8.1%), dialysis-dependent renal failure (n=295; 5.5%), GIC (n=154; 2.9%), CVA (n=151; 2.8%), DSWI (n=146; 2.7%) and sepsis (n=143; 2.7%). Perioperative mortality was 17.0% in patients with at least one major non-cardiac complication and correlated with the number of complications (single, 9.7%; n=53/549; double, 24.0%; n=44/183; ≥3, 41.2%; n=47/114, P<0.001). Six preoperative and four postoperative independent predictors of operative mortality were identified (age (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.4), peripheral vascular disease (OR 2.6; 95% CI 1.6-4.2), pulmonary hypertension (OR 2.7; 95% CI 1.5-4.9), atrial fibrillation (OR 1.5; 95% CI 1.0-2.3), emergency (OR 5.0; 95% CI 3.4-7.2), other procedures than CABG (OR 1.5; 95% CI 1.0-2.1), postoperative dialysis (OR 4.0; 95% CI 2.6-6.1), sepsis (OR 3.4; 95% CI 2.0-5.6), respiratory failure (OR 3.2; 95% CI 2.2-4.9), GIC (OR 3.2; 95% CI 1.9-5.3)) and included in the logistic model, which accurately predicted outcome (C statistic, 0.892; 95% CI 0.868-0.916). Length of hospital stay was significantly increased according to the number of complications (single: median 15 (IQR 10-24) days, double: 16 (IQR 8-28) days, ≥3: 20 (IQR 13-39) days, P<0.001). CONCLUSIONS With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complications leading to increased length of stay and mortality, which is correlated to the number and severity of these complications. Our predictive model based on preoperative and postoperative variables allowed us to determine with accuracy the perioperative mortality in critically ill patients after cardiac surgery.
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Affiliation(s)
- Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital Cologne, Cologne, Germany.
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Raja SG. Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes. Curr Cardiol Rev 2013; 8:26-36. [PMID: 22845813 PMCID: PMC3394105 DOI: 10.2174/157340312801215809] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 03/19/2012] [Accepted: 03/23/2012] [Indexed: 12/22/2022] Open
Abstract
The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, United Kingdom.
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Grothusen C, Attmann T, Friedrich C, Freitag-Wolf S, Haake N, Cremer J, Schöttler J. Predictors for long-term outcome and quality of life of patients after cardiac surgery with prolonged intensive care unit stay. Interv Med Appl Sci 2013; 5:3-9. [PMID: 24265881 DOI: 10.1556/imas.5.2013.1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2012] [Accepted: 11/26/2012] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study investigated factors determining the long-term outcome and quality of life of patients with a prolonged intensive care unit (ICU) stay after cardiac surgery. DESIGN A retrospective analysis was performed in 230 patients that had undergone cardiac surgery and suffered from a post-operative ICU stay of 7 or more days at our institution. Among 11 pre-, 13 intra-, and 14 post-operative variables, factors influencing 5-year outcome were identified by logistic regression analysis. Quality of life was determined using the Short Form-36 questionnaire. RESULTS In-hospital mortality was 12%. One hundred and eleven of 187 patients (59%) were alive after 5 years. Non-survivors were older (70 vs. 65 years, p = 0.005) and had a higher additive EuroSCORE (7 vs. 5, p = 0.034). Logistic regression identified pre-operative atrial fibrillation (AF), (28 vs. 10%, p = 0.003) as the strongest predictor for a 5-year outcome, followed by myocardial infarction (62 vs. 41%, p = 0.005), and prolonged mechanical ventilation (8 vs. 5 days, p = 0.036). Survivors did not show an impaired physical component summary SF-36 score (39 vs. 46, p = 0.737) or mental component summary score (55 vs. 55, p = 0.947) compared to an age-matched German Normative Sample. CONCLUSIONS Pre-operative AF proved to be the most important factor determining the 5-year outcome of patients with a prolonged ICU stay after cardiac surgery. Neither physical nor mental health appeared to be impaired in these patients.
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Aya HD, Cecconi M, Hamilton M, Rhodes A. Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2013; 110:510-7. [PMID: 23447502 DOI: 10.1093/bja/aet020] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Perioperative mortality after cardiac surgery has decreased in recent years although postoperative morbidity is still significant. Although there is evidence that perioperative goal-directed haemodynamic therapy (GDT) may reduce surgical mortality and morbidity in non-cardiac surgical patients, the data are less clear after cardiac surgery. The objective of this review is to perform a meta-analysis on the effects of perioperative GDT on mortality, morbidity, and length of hospital stay in cardiac surgical patients. METHODS We conducted a systematic review using Medline, EMBASE, and the Cochrane Controlled Clinical Trials Register. Additional sources were sought from experts. The inclusion criteria were randomized controlled trials, mortality reported as an outcome, pre-emptive haemodynamic intervention, and cardiac surgical population. Included studies were examined in full and subjected to quantifiable analysis, subgroup analysis, and sensitivity analysis where possible. Data synthesis was obtained by using odds ratio (OR) and mean difference (MD) for continuous data with 95% confidence interval (CI) utilizing a random-effects model. RESULTS From 4986 potential studies, 5 met all the inclusion criteria (699 patients). The quantitative analysis showed that the use of GDT reduced the postoperative complication rate (OR 0.33, 95% CI 0.15-0.73; P=0,006) and hospital length of stay (MD -2.44, 95% CI -4.03 to -0.84; P=0,003). There was no significant reduction in mortality. CONCLUSION The use of pre-emptive GDT in cardiac surgery reduces morbidity and hospital length of stay.
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Affiliation(s)
- H D Aya
- St George's Hospital NHS Trust and St George's University of London, London SW170QT, UK
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Lee J, Govindan S, Celi LA, Khabbaz KR, Subramaniam B. Customized Prediction of Short Length of Stay Following Elective Cardiac Surgery in Elderly Patients Using a Genetic Algorithm. ACTA ACUST UNITED AC 2013; 3:163-170. [PMID: 24482754 PMCID: PMC3904130 DOI: 10.4236/wjcs.2013.35034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective To develop a customized short LOS (<6 days) prediction model for geriatric patients receiving cardiac surgery, using local data and a computational feature selection algorithm. Design Utilization of a machine learning algorithm in a prospectively collected STS database consisting of patients who received cardiac surgery between January 2002 and June 2011. Setting Urban tertiary-care center. Participants Geriatric patients aged 70 years or older at the time of cardiac surgery. Interventions None. Measurements and Main Results Predefined morbidity and mortality events were collected from the STS database. 23 clinically relevant predictors were investigated for short LOS prediction with a genetic algorithm (GenAlg) in 1426 patients. Due to the absence of an STS model for their particular surgery type, STS risk scores were unavailable for 771 patients. STS prediction achieved an AUC of 0.629 while the GenAlg achieved AUCs of 0.573 (in those with STS scores) and 0.691 (in those without STS scores). Among the patients with STS scores, the GenAlg features significantly associated with shorter LOS were absence of congestive heart failure (CHF) (OR = 0.59, p = 0.04), aortic valve procedure (OR = 1.54, p = 0.04), and shorter cross clamp time (OR = 0.99, p = 0.004). In those without STS prediction, short LOS was significantly correlated with younger age (OR = 0.93, p < 0.001), absence of CHF (OR = 0.53, p = 0.007), no preoperative use of beta blockers (OR = 0.66, p = 0.03), and shorter cross clamp time (OR = 0.99, p < 0.001). Conclusion While the GenAlg-based models did not outperform STS prediction for patients with STS risk scores, our local-data-driven approach reliably predicted short LOS for cardiac surgery types that do not allow STS risk calculation. We advocate that each institution with sufficient observational data should build their own cardiac surgery risk models.
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Affiliation(s)
- Joon Lee
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada ; Harvard-MIT Division of Health Sciences and Technology, Cambridge, USA
| | | | - Leo A Celi
- Harvard-MIT Division of Health Sciences and Technology, Cambridge, USA ; Beth Israel Deaconess Medical Center, Boston, USA
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Limited Blood Transfusion Does Not Impact Survival in Octogenarians Undergoing Cardiac Operations. Ann Thorac Surg 2012; 94:2038-45. [DOI: 10.1016/j.athoracsur.2012.06.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2012] [Revised: 06/19/2012] [Accepted: 06/20/2012] [Indexed: 11/23/2022]
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Girerd N, Magne J, Rabilloud M, Charbonneau E, Mohamadi S, Pibarot P, Voisine P, Baillot R, Doyle D, Dumont E, Dagenais F, Mathieu P. The Impact of Complete Revascularization on Long-Term Survival Is Strongly Dependent on Age. Ann Thorac Surg 2012; 94:1166-72. [DOI: 10.1016/j.athoracsur.2012.05.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 10/28/2022]
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de Sousa VEC, de Oliveira Lopes MV, de Araujo TL, Rolim ILTP, do Nascimento RV, Oliveira TF. Clinical indicators of ineffective airway clearance for patients in the cardiac postoperative period. Eur J Cardiovasc Nurs 2012; 12:193-200. [DOI: 10.1177/1474515112443931] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Flynn BC, Silvay G. Value of Specialized Preanesthetic Clinic for Cardiac and Major Vascular Surgery Patients. ACTA ACUST UNITED AC 2012; 79:13-24. [DOI: 10.1002/msj.21293] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 575] [Impact Index Per Article: 44.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Nicolini F, Molardi A, Verdichizzo D, Gallazzi MC, Spaggiari I, Cocconcelli F, Budillon AM, Borrello B, Rivara D, Beghi C, Gherli T. Coronary artery surgery in octogenarians: evolving strategies for the improvement in early and late results. Heart Vessels 2011; 27:559-67. [PMID: 22045151 DOI: 10.1007/s00380-011-0198-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Accepted: 09/30/2011] [Indexed: 10/16/2022]
Abstract
The purpose of this study was to investigate retrospectively early and late outcomes of coronary artery bypass grafting (CABG) in a large series of octogenarians. We retrospectively reviewed the data of 241 octogenarian patients who underwent CABG between April 2002 and April 2009 at our institution. Mean age was 84.7 ± 1.8 years. Patients affected by concomitant coexistent organic aortic, mitral, or tricuspid valve disease were excluded from the study. Patients with functional secondary ischemic mitral incompetence were included in the study. The majority of the patients were male. Angina pectoris functional class III/IV accounted for 164 patients (68%). Left ventricular ejection fraction ≤35% was diagnosed in 38 patients (15.8%). Early mortality rate was 5.8% (14 patients). Causes of death were cardiac related in 10 patients. Preoperative independent predictors of in-hospital mortality obtained with multivariate analysis were extracardiac arteriopathy, New York Heart Association class III/IV, and previous percutaneous transluminal coronary angioplasty (PTCA). The overall mean follow-up was 41.6 ± 25.9 months (range 1-87.6 months). Among the 222 contacted survivors, there were 16 (7.2%) deaths during the follow-up. The actuarial survival was 91.9% at 1 year and 83.5% at 5 years. On multivariate analysis, time to late death was adversely affected by preoperative extracardiac arteriopathy and previous PTCA. Advanced age alone should not be a deterrent for CABG if it has been determined that the benefits outweigh the potential risk. A careful selection of optimal candidates, based on the evaluation of their systemic comorbidities, appears mandatory in order to obtain the greatest benefit for these high-risk patients.
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Affiliation(s)
- Francesco Nicolini
- Heart Surgery Section, University of Parma Medical School, Via A. Gramsci 14, 43100, Parma, Italy.
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Predicting prolonged intensive care unit stays in older cardiac surgery patients: a validation study. Intensive Care Med 2011; 37:1480-7. [PMID: 21805158 DOI: 10.1007/s00134-011-2314-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 05/24/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE In cardiac surgery prediction models identifying patients at risk of prolonged stay at the Intensive Care Unit (ICU) are used to optimize treatment and use of ICU resources. A recent systematic validation study of 14 of these models identified three models with a good predictive performance across patients of all ages. It is however unclear how these models perform in older patients, who nowadays form a considerable part of this patient population. The current study specifically validates the performance of these three models in older cardiac surgery patients and quantifies how their performance changes with increasing age of patients. METHODS The Parsonnet model, the EuroSCORE, and a model by Huijskes and colleagues were validated using prospectively collected data of 11,395 cardiac surgery patients. Performance of the models was described by discrimination (area under the ROC curve, AUC) and calibration. RESULTS For the Parsonnet model, the EuroSCORE and the Huijskes model discrimination clearly decreased with increasing age (AUCs of 0.76, 0.71 and 0.72 for ages 70-75 and 0.72, 0.70 and 0.72, respectively, for ages 75-80 and 0.68, 0.64 and 0.69, respectively, above 80 years). The models showed poor calibration in patients aged >70 (p values for fit of the models <0.006). CONCLUSIONS To optimize treatment and ICU resources, risk prediction for prolonged ICU stay after cardiac surgery using the existing models should be done with great care for older patients.
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Savci S, Degirmenci B, Saglam M, Arikan H, Inal-Ince D, Turan HN, Demircin M. Short-term effects of inspiratory muscle training in coronary artery bypass graft surgery: a randomized controlled trial. SCAND CARDIOVASC J 2011; 45:286-93. [PMID: 21793631 DOI: 10.3109/14017431.2011.595820] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To investigate the efficiency of inspiratory muscle training (IMT) on postoperative respiratory muscle strength, functional capacity, quality of life, and psychosocial status in patients with coronary artery bypass graft (CABG) surgery. DESIGN Forty-three patients undergoing CABG surgery were randomly assigned to the one of two groups. All subjects received usual care. In addition, subjects in the intervention group received IMT training pre- and postoperatively. Pulmonary function testing, six minute walk test (6MWT), quality of life and psychosocial parameters were assessed preoperatively and the fifth day after the surgery. RESULTS The mean inspiratory muscle strength increased from 82.64 cmH(2)O at baseline to 95.45 cmH(2)O five days postoperatively in the intervention group. The intervention group (319.55 ± 72.17 m before and 387.91 ± 65.69 m after surgery) covered further distance during the 6MWT than usual care (355.43 ± 56.08 m before and 357.69 ± 43.42 m after surgery). The improvement in quality of life was greater in the intervention group for the dimension of sleep. The anxiety scores were significantly lower in the intervention group than the usual care group. The length of intensive care unit stay was significantly shorter in the intervention group than the usual care group (p < 0.05). CONCLUSION IMT results in faster recovery of inspiratory muscle strength, functional capacity, intensive care unit stay, quality of life and psychosocial status after CABG.
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Affiliation(s)
- Sema Savci
- School of Physical Therapy and Rehabilitation, Dokuz Eylul University, Izmir, Turkey.
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Predicting Hospital Mortality and Analysis of Long-Term Survival After Major Noncardiac Complications in Cardiac Surgery Patients. Ann Thorac Surg 2010; 90:1221-9. [DOI: 10.1016/j.athoracsur.2010.05.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Revised: 05/03/2010] [Accepted: 05/06/2010] [Indexed: 11/20/2022]
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Maraschini A, Seccareccia F, D'Errigo P, Rosato S, Badoni G, Casali G, Musumeci F. Role of gender and age on early mortality after coronary artery bypass graft in different hospitals: data from a national administrative database. Interact Cardiovasc Thorac Surg 2010; 11:537-42. [PMID: 20709699 DOI: 10.1510/icvts.2010.233296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The aim of this study is to evaluate the effect of gender and age on outcome following coronary surgery in several hospitals enrolled in a national quality assessment program. Patients undergoing isolated coronary artery bypass graft (CABG) during 2003-2005 in Italy were included in the study (n=74,577). The outcome measure was 30-day in-hospital mortality. Comorbidities recorded during previous and current hospitalizations were used to define patients' health status and to build the adjustment model. The interaction term (gender*hospital) was introduced into the model to test the effect modification of gender; if present, gender specific models were analyzed to test the effect modification of age. A significant effect modification by gender was found in 39 hospitals; the adjusted odds ratios (AdjORs) showed significant increased risk for females (AdjORs ranging from 3.7 to 21.6). In three of these hospitals a significant increased risk was found for older age (AdjORs for elderly patients ranging from 8.1 to 14.6). Two hospitals showed a significant excess risk for patients ≥75 years (AdjORs=6.6 and 13.8). The technical aspects of surgery could account for the excess risk found in female patients; differences in the entire care process (intraoperative and postoperative management) could explain the variations in outcome among elderly patients.
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Affiliation(s)
- Alice Maraschini
- National Centre of Epidemiology, Surveillance and Health Promotion, Istituto Superiore di Sanità, Via Giano della Bella, 34, I-00161 Rome, Italy.
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