Coronary Artery Bypass Grafting in Cardiogenic Shock: Decision-Making, Management Options, and Outcomes

Prognostic impact of preoperative atrial fibrillation in patients undergoing heart surgery in cardiogenic shock

Surgical intervention in the setting of cardiogenic shock (CS) is burdened with high mortality. Due to acute condition, detailed diagnoses and risk assessment is often precluded. Atrial fibrillation (AF) is a risk factor for perioperative complications and worse survival but little is known about AF patients operated in CS. Current analysis aimed to determine prognostic impact of preoperative AF in patients undergoing heart surgery in CS. We analyzed data from the Polish National Registry of Cardiac Surgery (KROK) Procedures. Between 2012 and 2021, 332,109 patients underwent cardiac surgery in 37 centers; 4852 (1.5%) patients presented with CS. Of those 624 (13%) patients had AF history. Cox proportional hazards models were used for computations. Propensity score (nearest neighbor) matching for the comparison of patients with and without AF was performed. Median follow-up was 4.6 years (max.10.0), mean age was 62 (± 15) years and 68% patients were men. Thirty-day mortality was 36% (1728 patients). The origin of CS included acute myocardial infarction (1751 patients, 36%), acute aortic dissection (1075 patients, 22%) and valvular dysfunction (610 patients, 13%). In an unadjusted analysis, patients with underlying AF had almost 20% higher mortality risk (HR 1.19, 95% CIs 1.06-1.34; P = 0.004). Propensity score matching returned 597 pairs with similar baseline characteristics; AF remained a significant prognostic factor for worse survival (HR 1.19, 95% CI 1.00-1.40; P = 0.045). Among patients with CS referred for cardiac surgery, history of AF was a significant risk factor for mortality. Role of concomitant AF ablation and/or left atrial appendage occlusion or more aggressive perioperative circulatory support should be addressed in the future.

Predictors of perioperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Background

Perioperative myocardial infarction (PMI) increases morbidity and mortality after off-pump coronary artery bypass grafting (CABG). The objective of the current study was to characterize patients with PMI after off-pump CABG and identify its predictors.

Results

We included 1181 patients who had off-pump CABG from 2010 to 2020; 59 patients (5%) had PMI. We compared patients with PMI to those without PMI. Patients with PMI were older (57 (25th–75th percentiles: 51–63) vs. 54 (48–60) years; P = 0.01) and had higher NYHA class (28 (47.46%) vs. 326 (29.06%): P = 0.01). The distal anastomosis time was longer in patients with PMI (28 (23–35) vs. 24 (16–30) min; P ˂ 0.001). Patients with PMI had higher postoperative low cardiac output (10 (18.18%) vs. 1 (0.1%): P ˂ 0.001), prolonged ventilation (12 (8–39) vs. 8 (6–10) h, P ˂ 0.001), ICU (71 (46–138) vs. 24 (23–42) h; P ˂ 0.001), and hospital stay (9 (6–15) vs. 7 (6–8) days; P ˂ 0.001). Mortality was significantly higher in patients with PMI (20 (33.9%) vs. 6 (0.53%); P ˂ 0.001). Older age (OR: 1.05 (95% CI: 1.01–1.1); P = 0.02), increased number of distal anastomoses (OR: 1.74 (95% CI: 1.20–2.50); P = 0.003), preoperative congestive heart failure (OR: 10.27 (95% CI: 2.58–40.95); P = 0.001), and thrombolysis within 24 h of surgery (OR: 15.34 (1.93–121.9); P = 0.01) were associated with increased PMI, while PMI was lower in male patients (OR: 0.42 (95% CI: 0.19–0.93); P = 0.03) and with higher body surface area (BSA) (OR: 0.08 (95% CI: 0.07–0.86); P = 0.04).

Conclusions

Post-off-pump CABG PMI was associated with increased morbidity and mortality. Risk factors for PMI were older age, lower BSA, females, increased distal anastomoses, preoperative heart failure, and thrombolysis.

Transparency, Public Reporting and a Culture of Change to Quality and Safety in Cardiac Surgery

Academic medical centers have a duty to serve as hospitals of last resort for advanced cardiac surgical care and therefore manage patients at elevated risk of post-operative morbidity and mortality. They must also meet state and professional quality targets devised to protect the public. The tension between these imperatives can be managed by a multi-dimensional quality improvement program which aims to manage risk, optimize outcomes and exclude futile operations. We here share our approach to this process, its impact on our institution and discuss pertinent issues relevant to institutions in a similar situation.