Long-term survival of patients with pulmonary disease undergoing coronary artery bypass surgery

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Sex differences in long-term survival after total arterial coronary artery bypass grafting

OBJECTIVES

It is uncertain if the evidence on improved long-term survival of total arterial coronary artery bypass grafting applies to female patients. This study aims to compare the long-term survival outcomes of using total arterial revascularization (TAR) versus at least 1 saphenous vein graft separately for men and women.

METHODS

This retrospective analysis of the Australian and New Zealand Society of Cardiac-Thoracic Surgical Database had administrative linkage to the National Death Index. We identified all patients undergoing primary isolated coronary bypass from June 2001 to January 2020 inclusive. Following sex stratification, propensity score matching with 36 variables and Cox proportional hazard regression were used to facilitate adjusted comparisons. A Cox interaction-term analysis was performed to investigate the impact of sex on TAR survival benefit. The primary outcome was all-cause mortality.

RESULTS

Of the 69 624 eligible patients receiving at least 2 grafts, 13 019 (18.7%) were female patients. Matching generated 14 951 male and 3530 female pairs. Compared to vein-dependent procedures, TAR was associated with significantly reduced incidence of long-term all-cause mortality for both male (hazard ratio, 0.86; 95% confidence interval, 0.81-0.91; P < 0.001) and female (hazard ratio, 0.82; 95% confidence interval, 0.73-0.91; P < 0.001) cohorts. Interaction-term analysis indicated no significant subgroup effect from sex (P = 0.573) on the survival advantage of TAR. The treatment effect provided by TAR remained significant across most sex-stratified disease subgroups.

CONCLUSIONS

TAR, when compared to the use of at least 1 saphenous vein graft, provides comparable superior long-term survival outcomes in both females and males.

Impact of preheart transplant spirometry and DCLO measurement on post-transplant pulmonary outcomes

BACKGROUND

Pulmonary function tests (PFT) are a frequent component of heart transplant evaluation. In cardiac surgery abnormal PFTs, especially reduced DLCO, have been associated with poor outcomes. We sought to evaluate the impact of pretransplant PFTs on post-transplant pulmonary outcomes and patient survival.

METHODS

Among the 652 adult heart transplant recipients between January 1, 2010 and July 31, 2021, 462 had PFTs and constituted the patient cohort. Obstructive ventilatory defects (OVD), restrictive ventilatory defects (RVD), and reduced DLCO were defined according to established criteria. The primary outcome was the combined endpoint of a post-transplant pulmonary complication defined as reintubation, postoperative pneumonia, prolonged intubation, or tracheostomy. Secondary outcomes included 90-day all-cause mortality, length of stay, and the odds of individual pulmonary complications. Kaplan-Meier survival analysis, multivariable Cox proportional-hazards regression, and multivariable logistic regression were performed to compare outcomes between the groups.

RESULTS

Patients with severe OVD (OR 1.48, 95% CI 1.18-5.23, p = 0.02) or severely reduced DLCO (OR 1.95, 95% CI 1.19-3.20, p = 0.008) had increased odds of post-transplant pulmonary complications. Following multivariable adjustment, severe OVD (aOR 2.67, 95% CI 1.15-6.19, p = 0.02) and severely reduced DLCO (aOR 1.79, 95% CI 1.05-3.04) remained strongly associated with post-transplant pulmonary complications. Patients with any degree of extrinsic RVD, moderate or less OVD, or moderately reduced DLCO or less did not have increased odds of post-transplant pulmonary complications. Ninety-day post-transplant survival was significantly reduced for both severe OVD (97.2% vs 86.5%, p = 0.04) and severely reduced DLCO (97.3% vs 90.4%, p = 0.004). Post-transplant ICU and hospital length of stay were nominally longer for both groups as well.

CONCLUSIONS

Severe OVD or severely reduced DLCO on preheart transplant PFTs were associated with increased odds of post-transplant pulmonary complications and early mortality.

The impact of chronic obstructive pulmonary disease on the prognosis outcomes of patients with percutaneous coronary intervention or coronary artery bypass grafting: A meta-analysis

BACKGROUND

Coronary artery disease (CAD) is one of the main types of cardiovascular disease and is characterized by myocardial ischemia as a result of narrowing of the coronary arteries.

OBJECTIVE

To evaluate the impact of chronic obstructive pulmonary disease (COPD) on outcomes in patients with CAD treated by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Library for observational studies and post-hoc analyses of randomized controlled trials published before Jan 20, 2022, in English. Adjusted odds ratios (ORs), risk ratios (RRs), and hazard ratios (HRs) for short-term outcomes (in-hospital and 30-day all-cause mortality) and long-term outcomes (all-cause mortality, cardiac death, major adverse cardiac events) were extracted or transformed.

RESULTS

Nineteen studies were included. The risk of short-term all-cause mortality was significantly higher in patients with COPD than in those without COPD (RR 1.42, 95% CI 1.05-1.93), as were the risks of long-term all-cause mortality (RR 1.68, 95% CI 1.50-1.88) and long-term cardiac mortality (HR 1.84, 95% CI 1.41-2.41). There was no significant between-group difference in the long-term revascularization rate (HR 1.01, 95% CI 0.99-1.04) or in short-term and long-term stroke rates (OR 0.89, 95% CI 0.58-1.37 and HR 1.38, 95% CI 0.97-1.95). Operation significantly affected heterogeneity and combined results for long-term mortality (CABG, HR 1.32, 95% CI 1.04-1.66; PCI, HR 1.84, 95% CI 1.58-2.13).

CONCLUSIONS

COPD was independently associated with poor outcomes after PCI or CABG after adjustment for confounders.

Surgical site wound infection, and other postoperative problems after coronary artery bypass grafting in subjects with chronic obstructive pulmonary disease: A meta-analysis

We performed a meta-analysis to evaluate the effect of chronic obstructive pulmonary disease on surgical site wound infection, and other postoperative problems after coronary artery bypass grafting. A systematic literature search up to April 2022 was performed and 37 444 subjects with coronary artery bypass grafting at the baseline of the studies; 4320 of them were with the chronic obstructive pulmonary disease, and 33 124 were without chronic obstructive pulmonary disease. Odds ratio (OR), and mean difference (MD) with 95% confidence intervals (CIs) were calculated to assess the effect of chronic obstructive pulmonary disease on surgical site wound infection, and other postoperative problems after coronary artery bypass grafting using the dichotomous, and contentious methods with a random or fixed-effect model. The chronic obstructive pulmonary disease subjects had a significantly higher surgical site wound infection (OR, 1.27; 95% CI, 1.01-1.60, P = 0.04), respiratory failure (OR, 1.84; 95% CI, 1.55-2.18, P < 0.001), mortality (OR, 1.61; 95% CI, 1.37-1.89, P < 0.001), pneumonia (OR, 2.30; 95% CI, 1.97-2.68, P < 0.001), pleural effusion (OR, 1.78; 95% CI, 1.12-2.83, P = 0.02), stroke (OR, 1.99; 95% CI, 1.17-3.36, P = 0.01), and length of intensive care unit stay (MD, 0.73; 95% CI, 0.19-1.26, P = 0.008) after coronary artery bypass grafting compared with subjects without chronic obstructive pulmonary disease. However, chronic obstructive pulmonary disease subjects did not show any significant difference in length of hospital stay (MD, 0.83; 95% CI, -0.01 to 1.67, P = 0.05), and pneumothorax (OR, 1.59; 95% CI, 0.98-2.59, P = 0.06) after coronary artery bypass grafting compared with subjects without chronic obstructive pulmonary disease. The chronic obstructive pulmonary disease subjects had a significantly higher surgical site wound infection, respiratory failure, mortality, pneumonia, pleural effusion, stroke, and length of intensive care unit stay, and no significant difference in length of hospital stay, and pneumothorax after coronary artery bypass grafting compared with subjects without chronic obstructive pulmonary disease. The analysis of outcomes should be with caution because of the low sample size of 1 out of 11 studies in the meta-analysis and a low number of studies in certain comparisons.

Long-Term Outcomes for Chinese COPD Patients After PCI: A Propensity Score Matched, Double-Cohort Study

Objectives

The aim of this study was to analyze long-term outcomes of Chinese coronary artery disease (CAD) patients with (and without) chronic obstructive pulmonary disease (COPD) after percutaneous coronary intervention (PCI).

Background

Chronic obstructive pulmonary disease is a chronic condition which often develops in conjunction with CAD. PCI is a core therapy for CAD, although we still need to understand CAD-COPD outcomes and to identify factors that influence prognoses, across ethnicities.

Methods

This double-cohort study involved 12,343 Chinese CAD patients who received PCI. Baseline characteristics were collected in two independent, specialty centers. Propensity-score matching was performed to control confounding factors, using a nearest neighbor matching method within a 0.02 caliper and on a propensity score scale of 0.1 for each center. Comorbid CAD-COPD cases were compared to non-COPD patients in terms of major adverse cardiac events (MACEs).

Results

Patients with COPD were generally older than those without COPD (65.4 ± 9.2 vs. 58.2 ± 10.3, p < 0.001). There were no significant differences in the end points between COPD and non-COPD groups after PCI (All p > 0.05); however, the incidence of MACEs increased after 450 days. Further subgroup analysis suggests that COPD is approximately four times more prevalent among those aged over 75 years (HR, 3.818; 95%CI, 1.10–13.29; p = 0.027) and those aged below 55 years (HR = 4.254; 95% CI, 1.55–11.72; p = 0.003).

Conclusion

Having COPD does not appear to have a significant impact on CAD outcomes 2 years after PCI, and beyond. However, an increasing number of MACEs was observed after 450 days, which suggests that there may be a double-stage effect of COPD on PCI prognosis. There is a need for focused comorbidity management, specifically for those aged below 55 years and above 75 years.

Impact of chronic obstructive pulmonary disease on 10-year mortality after percutaneous coronary intervention and bypass surgery for complex coronary artery disease: insights from the SYNTAX Extended Survival study

Aims

To evaluate the impact of chronic obstructive pulmonary disease (COPD) on 10-year all-cause death and the treatment effect of CABG versus PCI on 10-year all-cause death in patients with three-vessel disease (3VD) and/or left main coronary artery disease (LMCAD) and COPD.

Methods

Patients were stratified according to COPD status and compared with regard to clinical outcomes. Ten-year all-cause death was examined according to the presence of COPD and the revascularization strategy.

Results

COPD status was available for all randomized 1800 patients, of whom, 154 had COPD (8.6%) at the time of randomization. Regardless of the revascularization strategy, patients with COPD had a higher risk of 10-year all-cause death, compared with those without COPD (43.1% vs. 24.9%; hazard ratio [HR]: 2.03; 95% confidence interval [CI]: 1.56–2.64; p < 0.001). Among patients with COPD, CABG appeared to have a slightly lower risk of 10-year all-cause death compared with PCI (42.3% vs. 43.9%; HR: 0.96; 95% CI: 0.59–1.56, p = 0.858), whereas among those without COPD, CABG had a significantly lower risk of 10-year all-cause death (22.7% vs. 27.1%; HR: 0.81; 95% CI: 0.67–0.99, p = 0.041). There was no significant differential treatment effect of CABG versus PCI on 10-year all-cause death between patients with and without COPD (p_interaction = 0.544).

Conclusions

COPD was associated with a higher risk of 10-year all-cause death after revascularization for complex coronary artery disease. The presence of COPD did not significantly modify the beneficial effect of CABG versus PCI on 10-year all-cause death.

Trial registration: SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050

Graphic abstract

Short-term and long-term impact of diagnosed and undiagnosed chronic obstructive pulmonary disease on coronary artery bypass grafting surgery

OBJECTIVES

This study sought to compare clinical outcomes between three categories of patients: non-chronic obstructive pulmonary disease (COPD), diagnosed COPD and undiagnosed COPD in coronary artery bypass grafting surgery.

METHODS

A single-centred retrospective study from January 2010 to December 2019. Primary outcomes were postoperative complications, length of ITU admission and in-hospital staying. Secondary outcomes were reintervention rate, in-hospital and long-term mortality.

RESULTS

A total of 4020 patients were analysed and divided into three cohorts: non-COPD (group A) (74.55%, n=2997), diagnosed COPD (group B) (14.78%, n=594) and undiagnosed COPD (group C) (10.67%, n=429). The rate of respiratory complications was noted in this order: group B>group C>group A (p 0.00000002). Periooperative acute kidney injury and wound complications were higher in group B (p 0.0004 and p 0.03, respectively). Prolonged in-hospital staying (days) resulted in group B (p 0.0009). Finally, long-term mortality was statistically higher in group B and C compared with group A (p 0.0004). No difference in long-term mortality was noted in relation to the expected FEV1% in group B (p 0.29) and group C (p 0.82).

CONCLUSIONS

In CABG surgery, COPD is a well-known independent risk factor for morbidity. Patients with preoperative spirometry results indicative of COPD result in the same outcomes of known patients with COPD. As a result of that, greater value should be given to the preoperative spirometry in the EuroSCORE. Finally, the expected FEV1% appears not be a predictor for long-term survival.

Impact of chronic obstructive pulmonary disease on prognosis after percutaneous coronary intervention and bypass surgery for left main coronary artery disease: an analysis from the EXCEL trial

OBJECTIVES

Percutaneous coronary intervention (PCI) is often favoured over coronary artery bypass grafting (CABG) surgery for revascularization in patients with chronic obstructive pulmonary disease (COPD). We studied whether COPD affected clinical outcomes according to revascularization in the Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization (EXCEL) trial, in which PCI with everolimus-eluting stents was non-inferior to CABG for the treatment of patients with left main coronary artery disease and low or intermediate SYNTAX scores.

METHODS

Patients with a history of COPD were propensity score matched to those without COPD. Outcomes at 30 days and 3 years in both groups were compared in patients randomized to PCI versus CABG.

RESULTS

COPD status was available for 1901 of 1905 randomized patients (99.8%), 148 of whom had COPD (7.8%). Propensity score matching yielded 135 patients with COPD and 675 patients without COPD. Patients with COPD had higher 3-year rates of the primary composite end point of death, myocardial infarction or stroke (31.7% vs 14.5%, P < 0.0001), death (17.1% vs 7.5%, P = 0.0005) and myocardial infarction (18.3% vs 7.3%, P < 0.0001), but not stroke (3.3% vs 2.9%, P = 0.84). There were no statistically significant interactions in the relative risks of PCI versus CABG for the primary composite end point in patients with and without COPD at 30 days [hazard ratio (HR) 0.39, 95% confidence interval (CI) 0.12-1.21 vs HR 0.55, 95% CI 0.29-1.06; Pinteraction = 0.61] or at 3 years (HR 0.85, 95% CI 0.46-1.56 vs HR 1.28, 95% CI 0.84-1.94; Pinteraction = 0.27).

CONCLUSIONS

In the EXCEL trial, COPD was independently associated with poor prognosis after left main coronary artery disease revascularization. The relative risks of PCI versus CABG at 30 days and 3 years were consistent in patients with and without COPD.

CLINICAL TRIAL REGISTRATION NUMBER

http://www.clinicaltrials.gov; NCT01205776.

Postoperative Delirium in Patients with Chronic Obstructive Pulmonary Disease after Coronary Artery Bypass Grafting

Background and Objectives: The incidence of postoperative delirium (POD) in patients with chronic obstructive pulmonary disease (COPD) is unclear. It seems that postoperative respiratory problems that may occur in COPD patients, including prolonged mechanical ventilation or respiratory-tract infections, may contribute to the development of delirium. The aim of the study was to identify a relationship between COPD and the occurrence of delirium after cardiac surgery and the impact of these combined disorders on postoperative mortality. Materials and Methods: We performed an analysis of data collected from 4151 patients undergoing isolated coronary artery bypass grafting (CABG) in a tertiary cardiac-surgery center between 2012 and 2018. We included patients with a clinical diagnosis of COPD according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The primary endpoint was postoperative delirium; Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) was used for delirium assessment. Results: Final analysis included 283 patients with COPD, out of which 65 (22.97%) were diagnosed with POD. Delirious COPD patients had longer intubation time (p = 0.007), more often required reintubation (p = 0.019), had significantly higher levels of C-reactive protein (CRP) three days after surgery (p = 0.009) and were more often diagnosed with pneumonia (p < 0.001). The CRP rise on day three correlated positively with the occurrence of postoperative pneumonia (r = 0.335, p = 0.005). The probability of survival after CABG was significantly lower in COPD patients with delirium (p < 0.001). Conclusions: The results of this study confirmed the relationship between chronic obstructive pulmonary disease and the incidence of delirium after cardiac surgery. The probability of survival in COPD patients undergoing CABG who developed postoperative delirium was significantly decreased.

The burden of chronic obstructive pulmonary disease in open heart surgery-a retrospective cohort analysis of postoperative complications: STROBE compliant

Chronic obstructive pulmonary disease (COPD) has a major impact on mortality and morbidity in patients undergoing cardiac surgery. Mortality risk increases by 50% in patients who were re-intubated or required prolonged mechanical ventilation after the operation. The aim of this study was to assess the impact of COPD on the prediction of postoperative complications and outcome including intensive care unit (ICU) and hospital stay, postoperative morbidity and mortality in patients undergoing all types of cardiac surgery.We performed a retrospective cohort analysis of prospectively collected data from a tertiary cardiac surgery department of a university hospital between 2014 and 2016. We divided patients undergoing cardiac surgery into 2 sub-groups - the first - with a clinical diagnosis of COPD (n = 198) and the second comprised all other non-COPD patients (n = 2980).Among patients with COPD a longer intubation time (P = .039), longer ICU stay (P < .001) and longer hospitalization time (P = .006) was noted as compared with non-COPD patients. Patients with COPD required reintubation more often than non-COPD patients, reintubation occurring twice, 19 (9.60%) versus 144 (4.83%) P = .002, reintubation occurring 3 or more times, 7 (3.54%) versus 34 (1.14%) P = .006. Mortality within 30 days after surgery was higher in patients with pulmonary problems before surgery (P = .003). Multivariable logistic regression analysis corrected for interfering variables showed an increased risk of postoperative bronchoconstriction (odds ratio [OR] = 4.40, P = .002), respiratory failure (OR = 1.67, P = .018), atrial fibrillation (OR = 1.45, P = .023), and use of hemofiltration (OR = 1.60, P = .029) for patients with COPD.Patients with COPD undergoing all types of cardiac surgery are at increased risk of respiratory complications and mortality. The occurrence of COPD was associated with longer ICU and hospital stay. In COPD patients, undergoing cardiac surgery, treatment strategies aimed at preventing reintubation and early weaning mechanical ventilation must be employed to reduce postoperative complications.

Postoperative outcomes of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting surgery: A meta-analysis

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a frequent comorbid disease in patients undergoing coronary artery bypass grafting (CABG) surgery, with an incidence ranging from 4% to 20.5%. Conventionally, COPD was recognized as a surgical contraindication to CABG. Because of the recent improvements in surgical techniques, anesthesia, and postoperative management, CABG has been performed more commonly in patients with COPD. However, studies have shown the various effects of COPD on postoperative morbidity and mortality after CABG, and this remains to be well defined.

OBJECTIVES

To compare the postoperative outcomes after CABG between patients with and those without COPD.

METHODS

A systematic search was conducted in the Cochrane Library, PubMed, EmBase, and Ovid databases (until May 10, 2018). Studies comparing perioperative results and mortality outcomes after CABG between patients with and those without COPD were evaluated independently by 2 reviewers to identify the potentially eligible studies. Review Manager and STATA software were used for statistical analyses.

RESULTS

No significant difference in the mortality rates were found between patients with and those without COPD. COPD was associated with a higher respiratory failure rate (odds ratio [OR] = 4.01; 95% CI: 1.19-13.51, P = .03; P <.001 for heterogeneity), higher pneumonia rate (OR = 2.92; 95% CI: 2.37-3.60, P <.00001; P = .73 for heterogeneity), higher stroke rate (OR = 2.91; 95% CI: 1.37-6.18, P = .005; P = .60 for heterogeneity), higher renal failure rate (OR = 1.60; 95% CI: 1.30-1.97, P <.00001; P = .19 for heterogeneity), and higher wound infection rate (OR = 2.16; 95% CI: 1.21-3.88, P = .01; P = .53 for heterogeneity) after CABG.

CONCLUSIONS

Patients with COPD were at higher risks for developing postoperative morbidities, particularly pneumonia, respiratory failure, stroke, renal failure, and wound infection. Although COPD was not associated with a higher risk of mortality, caution should be taken when a patient with COPD is indicated for CABG, considering the higher odds of postoperative complications involving the respiratory system and others.

Chronic obstructive pulmonary disease severity influences outcomes after off-pump coronary artery bypass

OBJECTIVE

To analyze the impact and severity of chronic obstructive pulmonary disease (COPD) on pulmonary function and postoperative clinical outcome based on the Global Initiative for Obstructive Lung Disease criteria in patients undergoing off-pump coronary artery bypass grafting (CABG).

METHODS

Patients were allocated into 3 groups according to presence and severity of COPD: no or mild COPD (n = 144); moderate COPD (n = 77); and severe COPD (n = 30). Spirometry values were obtained preoperatively and on postoperative days (PODs) 2 and 5. The incidences of pneumonia and reintubation, time of mechanical ventilation, and length of postoperative hospital stay were recorded.

RESULTS

Significant impairment in pulmonary function was observed in all groups on PODs 2 and 5 (P < .001). However, postoperative pulmonary dysfunction was significantly higher in the moderate and severe COPD groups compared with the no or mild COPD group (P < .05). On multivariable analysis, severe COPD was associated with an elevated risk for composite outcomes (odds ratio, 1.37; 95% confidence interval, 1.20-1.57; P < .001). A preoperative forced expiratory volume in 1 second (FEV₁) <50% of the predicted value was associated with poor outcome. A significant negative correlation was found between FEV₁ at POD 5 and postoperative length of stay (r = -0.5; P < .001).

CONCLUSIONS

More severe COPD was associated with greater impairment in pulmonary function and worse clinical outcomes after off-pump CABG surgery. A preoperative FEV₁ <50% of predicted value appears to be an important predictor of postoperative complications.

Determinants of Health-Related Quality of Life 1 Year after Pulmonary Thromboendarterectomy

BACKGROUND

Pulmonary thromboendarterectomy (PTE) is a recognized treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH), with good long-term hemodynamic results. The aim of this study was to test the hypothesis that the dynamics of health-related quality of life (QoL), 1 year after PTE, depend both on the clinical determinants associated with the underlying disease and the adverse events occurring in the early postoperative period.

METHODS

This prospective cohort study included 136 patients with CTEPH. All patients before and after PTE (1-year follow-up) were examined in terms of QoL, by using the Short Form 36 Health Survey Questionnaire.

RESULTS

One year after PTE, a significant improvement in the QoL of patients was observed in all subscales of the Short Form 36 Health Survey Questionnaire, except in the general health scale. Multivariate analysis showed that the predictors adversely affecting the dynamics of QoL after PTE were the presence of comorbidities (such as chronic obstructive pulmonary disease [COPD] and coronary artery disease) and early postoperative complications (specific ones for this category of patients are residual pulmonary hypertension and neurological complications, and nonspecific ones are atrial fibrillation and heart failure).

CONCLUSIONS

The determinants that affect the dynamics of QoL 1 year after PTE in patients with CTEPH were the presence of comorbidities (COPD and coronary artery disease) and adverse events in the early postoperative period (residual pulmonary hypertension, neurological complications, atrial fibrillation, and heart failure).

ANMCO/GICR-IACPR/SICI-GISE Consensus Document: the clinical management of chronic ischaemic cardiomyopathy

Stable coronary artery disease (CAD) is a clinical entity of great epidemiological importance. It is becoming increasingly common due to the longer life expectancy, being strictly related to age and to advances in diagnostic techniques and pharmacological and non-pharmacological interventions. Stable CAD encompasses a variety of clinical and anatomic presentations, making the identification of its clinical and anatomical features challenging. Therapeutic interventions should be defined on an individual basis according to the patient's risk profile. To this aim, management flow charts have been reviewed based on sustainability and appropriateness derived from recent evidence. Special emphasis has been placed on non-pharmacological interventions, stressing the importance of lifestyle changes, including smoking cessation, regular physical activity, and diet. Adherence to therapy as an emerging risk factor is also discussed.

Prevalence and Implications of Abnormal Respiratory Patterns in Cardiac Surgery: A Prospective Cohort Study

OBJECTIVE

To investigate the prevalence and impact of abnormal respiratory patterns in cardiac surgery patients.

DESIGN

Prospective cohort study.

SETTING

Tertiary hospital.

PARTICIPANTS

Patients scheduled for elective coronary artery bypass graft surgery.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pulmonary function tests were performed in 454 patients before surgery. Abnormal respiratory patterns were defined as follows: obstructive (forced expiratory volume in 1 s [FEV₁]/forced vital capacity [FVC]<0.70), restrictive (FEV₁/FVC≥0.70 and FVC<80% of predicted), and mixed (FEV₁/FVC<0.70 and both FEV₁ and FVC<80% of predicted). Of the 31 patients with a history of chronic obstructive pulmonary disease, no abnormal respiratory pattern was confirmed in 5. Of the 423 patients without a history of lung disease, the authors newly identified 57 obstructive, 46 restrictive, and 4 mixed patterns. Therefore, lung disease was reclassified in 24.7% of cases. Independent predictors of obstructive pattern were age, male sex, history of smoking, and chronic obstructive pulmonary disease. Obstructive lung disease was associated with 16 hours or longer ventilation. A reduced FEV₁ was associated with a likelihood of atrial fibrillation (1-L decrement, odds ratio: 1.38, 95% confidence interval: 1.01-to-1.90, p = 0.04) and hospitalization time (regression coefficient: 1.23, 95% confidence interval: 0.54-to-1.91, p<0.001).

CONCLUSIONS

Abnormal respiratory patterns are common and often underdiagnosed in the cardiac surgery setting. Pulmonary function tests help reveal patients at risk of complications and may provide an opportunity for intervention.

Prevalence and burden of comorbidities in Chronic Obstructive Pulmonary Disease

The classical definition of Chronic Obstructive Pulmonary Disease (COPD) as a lung condition characterized by irreversible airway obstruction is outdated. The systemic involvement in patients with COPD, as well as the interactions between COPD and its comorbidities, justify the description of chronic systemic inflammatory syndrome. The pathogenesis of COPD is closely linked with aging, as well as with cardiovascular, endocrine, musculoskeletal, renal, and gastrointestinal pathologies, decreasing the quality of life of patients with COPD and, furthermore, complicating the management of the disease. The most frequently described comorbidities include skeletal muscle wasting, cachexia (loss of fat-free mass), lung cancer (small cell or non-small cell), pulmonary hypertension, ischemic heart disease, hyperlipidemia, congestive heart failure, normocytic anemia, diabetes, metabolic syndrome, osteoporosis, obstructive sleep apnea, depression, and arthritis. These complex interactions are based on chronic low-grade systemic inflammation, chronic hypoxia, and multiple common predisposing factors, and are currently under intense research. This review article is an overview of the comorbidities of COPD, as well as their interaction and influence on mutual disease progression, prognosis, and quality of life.

Chronic obstructive pulmonary disease and ischemic heart disease comorbidity: overview of mechanisms and clinical management

In the last few years, many studies focused their attention on the relationship between chronic obstructive pulmonary disease (COPD) and ischemic heart disease (IHD), showing that these diseases are mutually influenced. Many different biological processes such as hypoxia, systemic inflammation, endothelial dysfunction, heightened platelet reactivity, arterial stiffness and right ventricle modification interact in the development of the COPD-IHD comorbidity, which therefore deserves special attention in early diagnosis and treatment. Patients with COPD-IHD comorbidity have a worst outcome, when compared to patients with only COPD or only IHD. These patients showed a significant increase on risk of adverse events and of hospital readmissions for recurrent myocardial infarction, heart failure, coronary revascularization, and acute exacerbation of COPD. Taken together, these complications determine a significant increase in mortality. In most cases death occurs for cardiovascular cause, soon after an acute exacerbation of COPD or a cardiovascular adverse event. Recent data regarding incidence, mechanisms and prognosis of this comorbidity, along with the development of new drugs and interventional approaches may improve the management and long-term outcome of COPD-IHD patients. The aim of this review is to describe the current knowledge on COPD-IHD comorbidity. Particularly, we focused our attention on underlying pathological mechanisms and on all treatment and strategies that may improve and optimize the clinical management of COPD-IHD patients.

Assessing the risk of aortic valve replacement for severe aortic stenosis in the transcatheter valve era

Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as "high risk" or "inoperable" with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.

Virchow’s triad and intestinal ischemia post cardiac surgery

Background

Intestinal ischemia is associated with a very high mortality rate. We combined the principles of Virchow’s triad to produce preoperative and postoperative models for the development of intestinal ischemia.

Methods

A single institutional study was undertaken involving 18,325 consecutive patients from April 1997 to March 2012. Univariate and multivariate analysis was performed.

Results

Mortality was 87% in 91 patients who developed bowel ischemia. Multivariate logistic regression demonstrated that age, peripheral vascular disease, intraaortic balloon pump support, female sex, and preexisting renal failure were significant determinates of intestinal ischemia preoperatively. Logistic regression demonstrated that age, peripheral vascular disease, creatine kinase-MB level, reoperation for bleeding, and blood product usage were significant determinates of intestinal ischemia postoperatively.

Conclusions

Potentially remedial causes of intestinal ischemia include blood product usage, reoperation for bleeding, and creatine kinase-MB release. Age, female sex, peripheral vascular disease, intraaortic balloon pump usage, and preexisting renal failure are fixed risk factors. Despite the continuing trend of reduced blood product usage in the field of cardiac surgery, the increase in patients’ risk factors will mean that incidences of intestinal ischemia may increase in the future.

Long-term survival of non-smokers undergoing coronary artery bypass surgery

OBJECTIVES

We sought to investigate long-term survival of non-smokers undergoing coronary artery bypass surgery (CABG).

METHODS

A prospective database of consecutive patients was retrospectively analysed and cross correlated with the UK strategic tracking service to evaluate survival after primary CABG. Univariate, multivariate and a propensity analyses were performed.

RESULTS

We analysed 13 337 primary CABG procedures. Median follow-up was 7 years. Kaplan-Meier survival curves demonstrate that non-smokers have a significantly improved long-term survival compared with ex- and current smokers, P < 0.0001. Cox regression analysis identified smoking status, age, diabetes, ejection fraction (EF), body mass index, cerebrovascular disease, dialysis, left internal mammary artery (LIMA) non-usage, postoperative creatinine kinase muscle-brain isoenzyme (CKMB), radial artery usage, preoperative rhythm, forced vital capacity (FVC) and logistic EuroSCORE as significant risk factors determining long-term survival. Propensity matching resulted in 3575 non-smokers being matched 1:1, with ex-smokers. After matching, univariate analysis demonstrated the significantly worse long-term survival of ex-smokers compared with non-smokers, P < 0.0001. Cox regression analysis identified smoking status, age, postoperative CKMB, cerebrovascular disease, dialysis, diabetes, EF, FVC, LIMA non-usage, radial artery used, sinus rhythm and logistic EuroSCORE as significant risk factors determining long-term survival. Survival by smoking status plotted at the mean of the covariates, prepropensity matching, demonstrated that non-smokers had a significantly better long-term survival than ex-smokers, P < 0.0001; however, after propensity matching, non-smokers under 65 years of age had a significantly worse long-term survival compared with ex-smokers, P < 0.0001.

CONCLUSIONS

Non-smokers under the age of 65 years of age have significantly worse long-term survival compared with ex-smokers after risk factor adjustment. We speculate that this is because ex-smokers have had the causative factor, smoking, removed, but non-smokers have not.

The effect of race and chronic obstructive pulmonary disease on long-term survival after coronary artery bypass grafting

Background: Chronic obstructive pulmonary disease (COPD) is a known predictor of decreased long-term survival after coronary artery bypass grafting (CABG). Differences in survival by race have not been examined.

Methods: A retrospective cohort study was conducted of CABG patients between 2002 and 2011. Long-term survival was compared in patients with and without COPD and stratified by race. Hazard ratios (HR) and 95% confidence intervals (CI) were computed using a Cox regression model.

Results: A total of 984 (20%) patients had COPD (black n = 182; white n = 802) at the time of CABG (N = 4,801). The median follow-up for study participants was 4.4 years. COPD was observed to be a statistically significant predictor of decreased survival independent of race following CABG (no COPD: HR = 1.0; white COPD: adjusted HR = 1.9, 95% CI = 1.7–2.3; black COPD: adjusted HR = 1.6, 95% CI = 1.1–2.2).

Conclusion: Contrary to the expected increased risk of mortality among black COPD patients in the general population, a similar survival disadvantage was not observed in our CABG population.