Neuropsychologic and quality-of-life outcomes after coronary artery bypass surgery with and without cardiopulmonary bypass: a prospective randomized trial

Impact of Clinical and Sociodemographic Factors on Quality of Life Following Coronary Artery Bypass Grafting: A Mixed-Methods Study

INTRODUCTION

Coronary artery bypass grafting (CABG) is an essential surgical management modality for patients with coronary artery disease. Health-related quality of life (HRQoL) has become important because of the significant decrease in the mortality rate associated with CABG. We aimed to explore the factors that affect the quality of life after CABG.

METHODS

This study used a descriptive correlational design to assess the determinants of HRQoL using the 36-item Short Form Health Survey questionnaire (SF-36). Patients who underwent CABG at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia, between March 2015 and December 2021 were enrolled in this study. Overall, 275 participants were eligible for our study, of which 84 were found to be valid for analysis. Phone contacts were made directly with the patient after briefly explaining the study. Scores and clinical data were investigated using multivariable linear regression analysis.

RESULTS

Subscales of role limitations due to physical issues had the lowest mean scores, followed by vitality and general health (57.4 ± 44.7; 60.4 ± 25.6; 64.1 ± 22.6), respectively. However, social functioning (78.9 ± 29.0) and pain (75.1 ± 29.9) had the highest scores of all subscales. A history of congestive heart failure (CHF) was independently associated with lower scores for physical role limitations (p = 0.021), vitality (p = 0.001), general health (p< 0.001), and mental health (p = 0.011). Lower mental health scores were also predicted by being a widow (p = 0.030), whereas lower general health scores were predicted by being unemployed (p = 0.001) and having a peripheral vascular disease (PVD) (p = 0.043). Additionally, the development of postoperative complications was an independent predictor of lower physical functioning (p = 0.028) and vitality (p = 0.043). Regarding the number of grafts, cardiopulmonary bypass, and cross-clamp time, no significant impact was found on any of the SF-36 subscales (p> 0.05).

CONCLUSION

The postoperative decline in HRQoL was attributed to comorbidities such as CHF and PVD, postoperative complications including bleeding and wound infection, as well as unemployment and widowed status. Therefore, choosing the appropriate patients for surgery and post-discharge follow-up may enhance HRQoL.

Impact of preoperative physical activity and depressive symptoms on post-cardiac surgical outcomes

Objective

To determine the independent and combined impact of preoperative physical activity and depressive symptoms with hospital length of stay (HLOS), and postoperative re-hospitalization and mortality in cardiac surgery patients.

Methods

A cohort study including 405 elective and in-house urgent cardiac surgery patients were analyzed preoperatively. Physical activity was assessed with the International Physical Activity Questionnaire to categorize patients as active and inactive. The Patient Health Questionnaire-9 was used to evaluate preoperative depressive symptoms and categorize patients as depressed and not depressed. Patients were separated into four groups: 1) Not depressed/active (n = 209), 2) Depressed/active (n = 48), 3) Not depressed/inactive (n = 101), and 4) Depressed/inactive (n = 47). Administrative data captured re-hospitalization and mortality data, and were combined into a composite endpoint. Models adjusted for demographics, comorbidities, and cardiac surgery type. Multiple imputation was used to impute missing values.

Results

Preoperative physical activity behavior and depression were not associated with HLOS examined in isolation or when analyzed by the physical activity/depressive symptom groups. Physical inactivity (HR: 1.60, 95% CI 1.05 to 2.42; p = 0.03), but not depressive symptoms, was independently associated with the composite outcome. Freedom from the composite outcome were 76.1%, 87.5%, 68.0%, and 61.7% in the Not depressed/active, Depressed/active, Not depressed/inactive, and Depressed/inactive groups, respectively (P = 0.02). The Active/Depressed group had a lower risk of the composite outcome (HR: 0.35 95% CI 0.14 to 0.89; p = 0.03) compared to the other physical activity/depression groups.

Conclusion

Preoperative physical activity appears to be more important than depressive symptoms on short-term postoperative re-hospitalization and mortality.

Prevalence of depression and its associated factors in patients post-coronary artery bypass graft surgery

This research aimed to determine the depression level and its correlation experienced by post-coronary artery bypass graft patients after being discharged from cardiac intensive care units. A cross-sectional design was employed for assessing variables. The Self-rating Depression Scale, as proposed by Zung, was used by the researchers on a convenience sample of Jordanian patients (N = 143) who were approached soon after their discharge from the targeted units. The results suggested that the level of depression among Jordanian patients was relatively high (M = 62.7, SD = 5.6). Moreover, depression was significantly higher among female, unmarried and unemployed patients. Patients who received their information about coronary artery bypass graft surgery from nurses had a lower level of depression. Age, length of stay in the cardiac intensive care unit and hospital type significantly predicted the level of depression. The research concluded that the post-coronary artery bypass graft patients who experienced an early onset depression required more attention to highlight the importance of supportive interventions.

Off-pump coronary artery bypass grafting improves short-term outcomes in high-risk patients compared with on-pump coronary artery bypass grafting: Meta-analysis

OBJECTIVES

To assess the benefits and risks of off-pump coronary artery bypass (OPCAB) versus coronary artery bypass grafting (CABG) through a meta-analysis of randomized controlled trials (RCTs), and to investigate the relationship between outcomes and patient risk profile.

METHODS

PubMed, Embase, the Cumulative Index of Nursing and Allied Health Literature, Scopus, Web of Science, Cochrane Library, and major conference proceedings databases were searched for RCTs comparing OPCAB and CABG and reporting short-term (≤ 30 days) outcomes. Endpoints assessed were all-cause mortality, myocardial infarction (MI), and cerebral stroke.

RESULTS

The meta-analysis included 100 studies, with a total of 19,192 subjects. There was no difference between the 2 techniques with respect to all-cause mortality and MI (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.71-1.09; P = .25; I(2) = 0% and OR, 0.90; 95% CI, 0.77-1.05; P = .19; I(2) = 0%, respectively). OPCAB was associated with a significant 28% reduction in the odds of cerebral stroke (OR, 0.72; 95% CI, 0.56-0.92; P = .009; I(2) = 0%). A significant relationship between patient risk profile and benefits from OPCAB was found in terms of all-cause mortality (P < .01), MI (P < .01), and cerebral stroke (P < .01).

CONCLUSIONS

OPCAB is associated with a significant reduction in the odds of cerebral stroke compared with conventional CABG. In addition, benefits of OPCAB in terms of death, MI, and cerebral stroke are significantly related to patient risk profile, suggesting that OPCAB should be strongly considered in high-risk patients.

The Impact of Stress Hormones on Post-traumatic Stress Disorders Symptoms and Memory in Cardiac Surgery Patients

The relationship and interactions between stress hormones and post-traumatic stress disorder (PTSD) are well established from both animal and human research studies. This interaction is especially important in the post-operative phase of cardiac surgery where the development of PTSD symptoms will result in increased morbidity and mortality and prolong length of stay for critically ill cardiac surgery patients. Cardiopulmonary bypass itself will independently result in massive inflammation response and release of stress hormones in the perioperative period. Glucocorticoid may reduce this response and result in reduction of PTSD symptom clusters and therefore improve health outcome. In this review, we plan to conduct a systemic review and analysis of the literatures on this topic.

Cognitive dysfunction after off-pump versus on-pump coronary artery bypass surgery: a meta-analysis

OBJECTIVE

A meta-analysis to compare the incidence of postoperative cognitive dysfunction (POCD) following off-pump coronary artery bypass grafting (OPCAB) versus after conventional coronary artery bypass grafting (CABG).

METHODS

A systematic search of the Medline(®), EMBASE(®) and Cochrane Library databases was performed to identify randomized controlled trials published until the end of November 2011. Data were analysed using RevMan version 5.0 software.

RESULTS

The literature search identified 13 randomized controlled trials which included a total of 2326 cases. Meta-analysis found that the incidence of POCD was significantly higher following CABG than after OPCAB during the perioperative period (1-2 weeks) and at 3 months postsurgery. There were no significant between-group differences at 6 or 12 months postsurgery.

CONCLUSIONS

Compared with CABG, OPCAB was found to be associated with a reduced incidence of early-stage POCD. Caution must be taken when interpreting these findings because of limitations in the available data.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsychological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.

Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease

BACKGROUND

Coronary artery bypass grafting (CABG) is performed both without and with cardiopulmonary bypass, referred to as off-pump and on-pump CABG respectively. However, the preferable technique is unclear.

OBJECTIVES

To assess the benefits and harms of off-pump versus on-pump CABG in patients with ischaemic heart disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 1, 2011), MEDLINE (OVID, 1950 to February 2011), EMBASE (OVID, 1980 to February 2011), Science Citation Index Expanded on ISI Web of Science (1970 to February 2011) and CINAHL (EBSCOhost, 1981 to February 2011) on 2 February 2011. No language restrictions were applied.

SELECTION CRITERIA

Randomised clinical trials of off-pump versus on-pump CABG irrespective of language, publication status and blinding were selected for inclusion.

DATA COLLECTION AND ANALYSIS

For statistical analysis of dichotomous data risk ratio (RR) and for continuous data mean difference (MD) with 95% confidence intervals (CI) were used. Trial sequential analysis (TSA) was used for analysis to assess the risk of random error due to sparse data and to multiple updating of accumulating data.

MAIN RESULTS

Eighty-six trials (10,716 participants) were included. Ten trials (4,950 participants) were considered to be low risk of bias. Pooled analysis of all trials showed that off-pump CABG increased all-cause mortality compared with on-pump CABG (189/5,180 (3.7%) versus 160/5144 (3.1%); RR 1.24, 95% CI 1.01 to 1.53; P =.04). In the trials at low risk of bias the effect was more pronounced (154/2,485 (6.2%) versus 113/2,465 (4.6%), RR 1.35,95% CI 1.07 to 1.70; P =.01). TSA showed that the risk of random error on the result was unlikely. Off-pump CABG resulted in fewer distal anastomoses (MD -0.28; 95% CI -0.40 to -0.16, P <.00001). No significant differences in myocardial infarction, stroke, renal insufficiency, or coronary re-intervention were observed. Off-pump CABG reduced post-operative atrial fibrillation compared with on-pump CABG, however, in trials at low risk of bias, the estimated effect was not significantly different.

AUTHORS' CONCLUSIONS

Our systematic review did not demonstrate any significant benefit of off-pump compared with on-pump CABG regarding mortality, stroke, or myocardial infarction. In contrast, we observed better long-term survival in the group of patients undergoing on-pump CABG with the use of cardiopulmonary bypass and cardioplegic arrest. Based on the current evidence, on-pump CABG should continue to be the standard surgical treatment. However, off-pump CABG may be acceptable when there are contraindications for cannulation of the aorta and cardiopulmonary bypass. Further randomised clinical trials should address the optimal treatment in such patients.

Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review

Post-operative cognitive dysfunction (POCD) is a decline in cognitive function from pre-operative levels, which has been frequently described after cardiac surgery. The purpose of this study was to examine the variability in the measurement and definitions for POCD using the framework of a 1995 Consensus Statement on measurement of POCD. Electronic medical literature databases were searched for the intersection of the search terms 'thoracic surgery' and 'cognition, dementia, and neuropsychological test.' Abstracts were reviewed independently by two reviewers. English articles with >50 participants published since 1995 that performed pre-operative and post-operative psychometric testing in patients undergoing cardiac surgery were reviewed. Data relevant to the measurement and definition of POCD were abstracted and compared with the recommendations of the Consensus Statement. Sixty-two studies of POCD in patients undergoing cardiac surgery were identified. Of these studies, the recommended neuropsychological tests were carried out in less than half of the studies. The cognitive domains measured most frequently were attention (n=56; 93%) and memory (n=57; 95%); motor skills were measured less frequently (n=36; 60%). Additionally, less than half of the studies examined anxiety and depression, performed neurological exam, or accounted for learning. Four definitions of POCD emerged: per cent decline (n=15), standard deviation decline (n=14), factor analysis (n=13), and analysis of performance on individual tests (n=12). There is marked variability in the measurement and definition of POCD. This heterogeneity may impede progress by reducing the ability to compare studies on the causes and treatment of POCD.

Neuropsychological function 5 years after cardiac surgery and the effect of psychological distress

Research has shown conflicting results with regard to the influence of depression and anxiety on neuropsychological performance following coronary artery bypass graft (CABG) surgery. Notably, the independent effects of depression and anxiety have not been examined among CABG candidates in the longer term where it is has been suggested that these patients show marked cognitive deterioration. A neuropsychological test battery and measures of psychological distress were completed by 86 CABG patients and 50 nonsurgical control participants at baseline and 6 months, whereas 75 patients and 36 controls, respectively, completed a 5-year follow-up. In CABG patients, cognitive and affective depressive symptoms were independently associated with lower and worse performance on the Boston Naming Test, Purdue Peg Board, and Digit Symbol Coding 6 months after surgery, whereas at 5-year follow-up an effect for Digit Symbol persisted, and an association was also observed for the Trail Making Test (TMT). On average, CABG patients performed worse on TMT and Digit Symbol at 6 months, whereas at 5-year follow-up their performance was worse on short-term delayed verbal recall. The results among the CABG patients did not show a consistent pattern of association between psychological distress and those neuropsychological domains that were on average significantly lower than a nonsurgical control group. The results here also support the use of nonbiased statistical methodology to document dysfunction among heterogeneous cognitive domains after CABG surgery.

Negative emotions and quality of life six months after cardiac surgery: the dominant role of depression not anxiety symptoms

The specific syndromal aspects of depression and anxiety have not been explored in relation to changes in health related quality of life (HRQOL) after cardiac surgery. The purpose of this study was to examine the impact of general stress, depression and anxiety on HRQOL after coronary artery bypass graft (CABG) surgery. Utilizing a tripartite conceptual model of depression and anxiety, it was hypothesized that general stress symptoms, rather than unique depressive or anxiogenic symptoms, would be associated with lower HRQOL 6 months after CABG surgery. Elective CABG patients (n=226) completed baseline and postoperative self-report measures of negative emotions and HRQOL, and 193 patients completed these measures at 6-month follow-up. Multiple linear regression analyses and logit link analyses were performed to test the hypothesis. Elevated depression symptoms before and after surgery showed an association with lower and worse HRQOL for vitality and social role functioning and physical and general health. This study adds to previous research by outlining discrete associations between specific HRQOL domains, and is perhaps the first to test a theoretical model of depression and anxiety in relation to cardiac CABG patients' perceptions of HRQOL. These findings encourage further research on negative emotions and HRQOL in cardiac surgery patients and the practical implications of these findings are discussed.