EuroSCORE II with SYNTAX score to assess risks of coronary artery bypass grafting outcomes

Combination of the triglyceride-glucose index and EuroSCORE II improves the prediction of long-term adverse outcomes in patients undergoing coronary artery bypass grafting

AIMS

We aimed to investigate the independent and combined association of the triglyceride-glucose (TyG) index and EuroSCORE II with major adverse cardiovascular event (MACE) after coronary artery bypass grafting (CABG), and examine whether the addition of the TyG index improves the predictive performance of the EuroSCORE II.

MATERIALS AND METHODS

This study included 1013 patients who underwent CABG. The primary endpoint was MACE, which was defined as the composite of all-cause death, repeat coronary artery revascularisation, non-fatal myocardial infarction and non-fatal stroke. The patients were grouped by the TyG index and EuroSCORE II tertiles and the combination of these risk indicators.

RESULTS

During the follow-up, 211 individuals developed MACE. Elevated levels of the TyG index and EuroSCORE II were associated with an increased risk of MACE. The hazard ratio [95% confidence interval (CI)] was 3.66 (2.34-5.73) in patients with the highest tertile of the TyG index and EuroSCORE II. Compared with the EuroSCORE II alone, combining the TyG index with EuroSCORE II achieved a better predictive performance [C-statistic increased 0.032, p < 0.001; continuous net reclassification improvement (NRI) (95% CI): 0.364 (0.215-0.514), p < 0.001; integrated discrimination improvement (IDI) (95% CI): 0.015 (0.007-0.023), p < 0.001, Akaike's information criteria (AIC) and Bayesian information criterion (BIC) decreased, and the likelihood ratio test, p < 0.001].

CONCLUSIONS

The TyG index and EuroSCORE II are independently associated with poor prognosis. Furthermore, the TyG index is an important adjunct to the EuroSCORE II for improving risk stratification and guiding early intervention among post-CABG patients.

Midterm outcome of off-pump CABG for severe LV dysfunction-Does LV size and function predict their midterm outcome?

BACKGROUND

The superiority of surgical revascularization in ischemic cardiomyopathy is established beyond doubt, and off-pump CABG (OP-CABG) is a safe way of revascularization in this high-risk subset. Data on the effect of postoperative ventricular function and size on their midterm outcome is scarce.

MATERIALS AND METHODS

A retrospective study was done on 211 consecutive patients with severe LV dysfunction who underwent OP-CABG from January 2017 to December 2018. Data were collected from the institutional database. Their operative and midterm outcomes were statistically analyzed.

RESULTS

The mean age of the cohort was 58.4 ± 8.3 years. An average number of grafts was 3.1 ± 0.8 (cumulative intended number of grafts-3). Operative mortality was 10.9%. Preoperative NYHA class (p < .0001; OR, 19.72) and postoperative IABP insertion (p < .008; OR, 88.75) were independent predictors of operative mortality. The mean follow-up period was 3.14 ± 0.07 years, was 97.4% complete with cardiac mortality of 5.8%. Postoperative LVEF (p = .002; OR, 0.868) and LV dimensions (systole & diastole) (p = .013, OR = 1.182 and p = .036, OR = 1.184, respectively) were independent predictors of midterm mortality. Midterm major adverse cardiovascular event-free survival of operative survivors was 89%. There was no correlation between postoperative LV dimension and NYHA status(p > .05). Myocardial viability was not associated with early (p = .17) or midterm mortality (p = .676).

CONCLUSION

OP-CABG can achieve complete revascularization in patients with severe LV dysfunction with good midterm outcomes, albeit with high early operative mortality. Postoperative change in LV dimension and EF are predictors of midterm mortality.

Early and Mid-Term Outcomes of Patients Undergoing Coronary Artery Bypass Grafting in Ischemic Cardiomyopathy

Background Many observational studies and trials have shown that coronary artery bypass grafting improves the survival in patients with ischemic cardiomyopathy. However, these results are based on data generated from developed countries. Poor socioeconomic statuses, lack of uniformity in healthcare delivery, differences in risk profile, and affordability to access optimal health care are some factors that make the conclusions from these studies irrelevant to patients from India. Methods and Results One-hundred and sixty-two patients with severe left ventricular dysfunction (ejection fraction ≤35%) who underwent coronary artery bypass grafting from 2009 to 2017 were enrolled for this study. Mean age of the study population was 58.67±9.70 years. Operative mortality was 11.62%. Thirty day/in-house composite outcome of stroke and perioperative myocardial infarction were 5.8%. The percentage of survival for 1 year was 86.6%, and 5-year survival was 79.9%. Five-year event-free survival was 49.3%. The mean ejection fraction improved from 30.7±4.08% (range 18-35) to 39.9±8.3% (range 24-60). Lack of improvement of left ventricular function was a strong predictor of late mortality (hazard ratio, 21.41; CI 4.33-105.95). Even though there was a trend towards better early outcome in off-pump CABG , the 5-year survival rates were similar in off-pump and on-pump group (73.4% and 78.9%, respectively; P value 0.356). Conclusions We showed that coronary artery bypass grafting in ischemic cardiomyopathy was associated with high early composite outcomes. However, the 5-year survival rates were good. Lack of improvement of left ventricular function was a strong predictor of late mortality.

Activation of Interleukin-1 Beta in Arterialized Vein Grafts and the Influence of the -511C/T IL-1β Gene Polymorphism

The interleukin-1 family is associated with innate immunity and inflammation. The latter has been linked to the genesis of cardiovascular diseases. We, therefore, investigated whether interleukin-1 beta (IL-1β) is activated during arterialization of vein grafts. First, we examined the activation of IL-1β using the rat arterialized jugular vein serially sampled for up to 90 days. IL-1β expression increased 18 times on day 1 in the arterialized rat jugular vein and remained five times above nonarterialized vein levels for up to 90 days. Similarly, IL-1β expression increased early (1-5 days) in human vein graft autopsy samples compared with late phases (1-4 years). Activation was also detected in ex vivo arterialized human saphenous veins. Upon stratification of the results, we uncovered a T allele promoter attenuating effect in IL-1β activation in response to hemodynamic stress. Altogether, the results show that IL-1β is activated during arterialization of vein grafts in rats and humans, and this response is modulated by -511C/T IL-1β gene polymorphism. It is tempting to speculate that the activation of IL-1β, and consequently local inflammation, modulates early vascular remodeling and that the gene polymorphism may be useful in predicting outcomes or assisting in interventions.

Is SYNTAX Score Predictive of Atrial Fibrillation after On-Pump Coronary Artery Bypass Graft Surgery?

Background and Objectives

The relationship of synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score and development of atrial fibrillation (AF) after coronary artery bypass surgery (CABG) has not been studied. Therefore, we assessed the relationship between the SYNTAX score and development of AF after CABG (POAF).

Subjects and Methods

The medical records of consecutive patients, who underwent CABG surgery from January 2013 to September 2015, were retrospectively reviewed for the development of AF in the postoperative period. SYNTAX score, clinical and echocardiographic parameters were evaluated. The independent variables for the development of POAF were defined and their predictive values were measured.

Results

The study group consisted of 106 patients, of which 36 (34%) developed POAF. Age, hypertension, stroke, chronic obstructive pulmonary disease (COPD), heart failure (HF), diabetes mellitus (DM), left atrial diameter, neutrophil/lymphocyte ratio, platelet large cell ratio, creatinine, blood urea nitrogen and SYNTAX score were identified as important variables for the development of POAF. However, in logistic regression analysis COPD (OR=19.313, 95% CI=2.416-154.407, p=0.005), HF (OR=28.362, 95% CI=2.034-395.515, p=0.013), SYNTAX score (OR=0.863, 95% CI=0.757-0.983, p=0.026), and DM (OR=20.770, 95% CI=3.791-113.799, p<0.001) appeared as independent variables predicting the development of POAF. In receiver operation characteristic analysis, SYNTAX score (≥22.25) (AUC=0.777, 95% CI=0.676-0.877, p<0.001) was one of the strongest predictors for the development of POAF.

Conclusion

The SYNTAX score level was independently associated with the development of AF after CABG.

SYNTAX score predicts postoperative atrial fibrillation in patients undergoing on-pump isolated coronary artery bypass grafting surgery

Objective:

Atrial fibrillation (AF) is the most common arrhythmia following coronary artery by-pass graft surgery (CABG). The value of SYNTAX score to predict postoperative atrial fibrillation (PoAF) has not been clearly addressed. We aimed to evaluate this relationship in patients undergoing isolated CABG.

Methods:

This study was designed as a single-center, non-randomized, observational, prospective study. Ninety-four patients undergoing isolated on-pump CABG, who had sinus rhythm and were older than 18 years, were enrolled. Demographic characteristics of the patients were recorded; SYNTAX score was calculated preoperatively for each patient. The univariate and multivariate logistic regression analysis were used to determine for predictors of PoAF.

Results:

The median SYNTAX score of the enrolled patients was 21, (56–5). PoAF was observed in 31 (33.3%) patients. Univariate logistic regression showed that age, chronic obstructive pulmonary disease (COPD), red blood cell distribution width (RDW), urea, initial troponin I, peak postoperative troponin I, interventricular septum, left atrial diameter, and SYNTAX score were significantly associated with the frequency of PoAF following CABG. An independent association was identified with age [b 0.088, p:0.023, OR: 1.092, 95% CI (1.012–1.179)], COPD [(b: 2.222, p:0.003, OR: 9.228, 95% CI (2.150–39.602)], and SYNTAX score [(b: 0.130, p:0.002, OR: 1.139, 95% CI (1.050–1.235)].

Conclusion:

This study showed that a higher SYNTAX score was related to more frequent PoAF in patients undergoing isolated on-pump CABG.

Risk Stratification in Off-Pump Coronary Artery Bypass (OPCAB) Surgery—Role of EuroSCORE II

OBJECTIVES

To evaluate the EuroSCORE II for risk stratification in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.

DESIGN

A retrospective observational study.

SETTING

Two tertiary care hospitals.

PARTICIPANTS

Participants were 1,211 patients undergoing OPCAB surgery.

INTERVENTIONS

No interventions were implemented.

MEASUREMENTS AND MAIN RESULTS

The EuroSCORE II estimated the operative risk for each patient. The calibration of the scoring system was assessed using the Hosmer Lemeshow test, and the discriminative capacity was estimated with area under receiver operating characteristic curves. The incidence, patient characteristics, causes of intraoperative conversion to on-pump coronary artery bypass (ONCAB), and outcome were studied. The all-cause in-hospital mortality was 2.39%. Predicted mortality with the EuroSCORE II was 2.03±1.63. Using the Hosmer Lemeshow test, a C statistic of 8.066 (p = 0.472) was obtained, indicating satisfactory model fit. The calculated area under the receiver operating characteristic curve was 0.706 (p = 0.0002), indicating good discriminatory power. Emergency intraoperative conversion to ONCAB occurred in 6.53% of patients. The mortality in the ONCAB group was significantly higher compared with patients who underwent successful OPCAB surgery (15.18% v 1.5%, p<0.0001). On multiple regression analysis with conversion to ONCAB as the endpoint, associated factors were patients with a higher EuroSCORE II (odds ratio = 1.13, confidence interval = 1.03-1.27) and more-than-trivial mitral regurgitation (odds ratio = 1.84, confidence interval = 1.07-3.06). Net reclassification improvement of 0.714 (p<0.0001) was obtained when on-pump conversion was added to the EuroSCORE II.

CONCLUSIONS

The EuroSCORE II has satisfactory calibration and discrimination power to predict mortality after OPCAB surgery. Intraoperative conversion to ONCAB is a major complication of OPCAB surgery. A higher EuroSCORE II also predicts higher probability of conversion to ONCAB.