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Stroo JF, van Steenbergen GJ, van Straten AH, Houterman S, Soliman-Hamad MA. Long-term Outcome of Reexploration for Bleeding After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00377-4. [PMID: 37353424 DOI: 10.1053/j.jvca.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVES This study aimed to determine the influence of reexploration for bleeding and blood product requirement after coronary artery bypass grafting (CABG) on long-term mortality. DESIGN A retrospective cohort study. SETTING A single-center institution. PARTICIPANTS All patients who underwent CABG between January 1998 and December 2019 were included. INTERVENTIONS The parameters were analyzed to assess the association between reexploration for bleeding and long-term mortality. MEASUREMENTS AND MAIN RESULTS The primary endpoint was all-cause mortality up to the end of follow-up (June 1, 2021). The secondary endpoints were 30-day mortality, duration of admission, blood product transfusion, postoperative use of an intra-aortic balloon pump, deep sternal wound infection, myocardial infarction, and neurologic complications. The Cox proportional hazards model was used to assess the association between reexploration and blood product use and all-cause mortality. Median follow-up was 9.7 years (IQR 5.1-14.6). In total, 576 out of 21,346 (2.7%) patients were reexplored for bleeding. Thirty-day mortality was 6.2% v 1.6% for the reexplored versus not reexplored patients. Reexploration for bleeding was not significantly correlated with long-term mortality (hazard ratio [HR] 1.029; pΒ =Β 0.068). On the other hand, blood product transfusion (HRΒ =Β 1.135; p < 0.001), and in particular, packed red blood cell (pRBC) transfusion (HRΒ =Β 1.139; p < 0.001), was significantly associated with higher long-term mortality. After multivariate Cox regression using β₯5 pRBC transfused as a cut-off point, reexploration for bleeding was not significantly associated with long-term mortality (HR 0.982; pΒ =Β 0.813). Receiving β₯5 pRBCs was significantly associated with higher long-term mortality (HR 1.249; p < 0.001). CONCLUSION Reexploration for bleeding was significantly associated with higher 30-day mortality but not with long-term mortality. Poorer long-term mortality was attributed to patient characteristics and higher use of postoperative blood products.
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Affiliation(s)
- Jasmijn F Stroo
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Albert Hm van Straten
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | - Saskia Houterman
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, the Netherlands
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Ingrassia JJ, Mosleh W, Conner CM, Mather JF, Loya DS, Yaffee DW, Sutton TS, Takata ET, McMahon SR, Hashim SW, McKay RG. Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 46:44-51. [PMID: 35961855 DOI: 10.1016/j.carrev.2022.08.005] [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] [Received: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion β₯5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.
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Affiliation(s)
- Joseph J Ingrassia
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Chad M Conner
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - David W Yaffee
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA.
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Dyas AR, Zhuang Y, Meguid RA, Henderson WG, Madsen HJ, Bronsert MR, Colborn KL. Development and validation of a model for surveillance of postoperative bleeding complications using structured electronic health records data. Surgery 2022; 172:1728-1732. [PMID: 36150923 PMCID: PMC10204070 DOI: 10.1016/j.surg.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/01/2022] [Accepted: 08/22/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Postoperative bleeding complications surveillance is done primarily through manual chart review. The purpose of this study was to develop and validate a detection model for postoperative bleeding complications using structured electronic health records data. METHODS Patients who underwent operations at 1 of 5 hospitals within our local health system between 2013 and 2019 and whose complications were reported by the American College of Surgeons National Surgical Quality Improvement Program were included. Electronic health records data were linked to American College of Surgeons National Surgical Quality Improvement Program data using personal health identifiers. Electronic health records predictors included diagnosis codes mapped to PheCodes, procedure names, and medications within 30 days after surgery. We defined bleeding events as the transfusion of red blood cell components within 30 days after surgery. The knockoff filter and the lasso were used to develop a model in a training set of operations from January 2013 to March 2017. Performance of each model was tested in a held-out data set of patients who underwent operations from March 2017 to OctoberΒ 2019. RESULTS A total of 30,639 patients were included; 1,112 patients (3.6%) had a bleeding event. Eight predictor variables were selected by the knockoff filter. When applied to the test set, specificity was 94%, sensitivity was 94%, area under the curve was 0.97, and accuracy was 93%. Calibration was consistent in lower predicted risk patients, whereas the model slightly overpredicted risk in high-risk patients. CONCLUSION We created a parsimonious, accurate model for identifying patients with bleeding complications. This model can be used to augment manual chart review for surveillance and reporting of perioperative bleeding complications, enabling inclusion of all surgeries in quality improvement efforts.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO.
| | - Yaxu Zhuang
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Helen J Madsen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
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Senage T, Gerrard C, Moorjani N, Jenkins DP, Ali JM. Early postoperative bleeding impacts long-term survival following first-time on-pump coronary artery bypass grafting. J Thorac Dis 2021; 13:5670-5682. [PMID: 34795917 PMCID: PMC8575859 DOI: 10.21037/jtd-21-1241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022]
Abstract
Background Significant bleeding following cardiac surgery is a recognised complication, associated with a requirement for re-exploration and blood transfusion, both associated with increased morbidity and early mortality. The aim of this study was to examine the impact of the volume of early postoperative bleeding on long-term survival for patients undergoing coronary artery bypass grafting (CABG). Methods A retrospective analysis was performed of patients undergoing first-time isolated CABG at a single centre between January 2003 and April 2013, conditional from 30-day survival. Results Six thousand two hundred and sixty-five patients were analysed, with a mean Logistic EuroSCORE of 4.9%. The mean age was 67.8 years. Median follow-up was 11.5 years. The overall 10- and 15-year survival was 70.6% and 51.9% respectively. Following surgery, 4.6% (n=291) required return to theatre for re-exploration, and 43.6% (n=2,733) received at least one red cell transfusion. In multivariable analysis, the strongest correlates of mortality were age, smoking history, BMI, COPD, renal impairment, preoperative left ventricular function and preoperative haemoglobin (Hb) level. Twelve-hour blood loss was an additional predictor of inferior long-term survival. Five-year survival was 89.6% for patients with <500 mL blood loss, 86.8% for 500β1,000 mL and 83.8% for >1,000 mL. Re-exploration and receiving blood transfusion were not associated with reduced long-term survival. Conclusions Significant 12-hour blood loss is associated with inferior long-term survival following CABG. This observation supports efforts aimed at improving intra-operative haemostasis and aggressive management of patients with early signs of bleeding.
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Affiliation(s)
- Thomas Senage
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK.,SPHERE (MethodS in Patient-Centred Outcomes and Health Research), University of Nantes, Nantes, France
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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5
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Pearse BL, Keogh S, Rickard CM, Fung YL. Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model. BMC Health Serv Res 2021; 21:550. [PMID: 34090421 PMCID: PMC8178922 DOI: 10.1186/s12913-021-06269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Bleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units. Methods We used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour. Results Seventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice. Conclusion Using a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06269-8.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia. .,Departments of Surgery, Anaesthesia and Critical Care, The Prince Charles Hospital, Sippy Downs, QLD, Australia. .,School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia.
| | - Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Yoke L Fung
- School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia
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Qureshi SH, Ruel M. Commentary: A Long-Lasting Complication: Re-exploration for Bleeding and Its Negative Correlation With Long-Term Survival. Semin Thorac Cardiovasc Surg 2021; 33:776-777. [PMID: 33600978 DOI: 10.1053/j.semtcvs.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Saqib H Qureshi
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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7
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Fazmin IT, Ali JM. Re-exploration and bleeding rates after cardiac surgery can be reduced-The utility of a checklist. J Card Surg 2020; 36:417-419. [PMID: 33135219 DOI: 10.1111/jocs.15142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 11/28/2022]
Affiliation(s)
| | - Jason M Ali
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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8
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Ali JM, Gerrard C, Clayton J, Moorjani N. Hemostasis Checklist Reduces Bleeding and Blood Product Consumption After Cardiac Surgery. Ann Thorac Surg 2020; 111:1570-1577. [PMID: 32956672 DOI: 10.1016/j.athoracsur.2020.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 05/23/2020] [Accepted: 07/07/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Considerable mediastinal bleeding is a recognized complication after cardiac surgery and may require reexploration and blood product transfusion, both of which are associated with inferior clinical outcomes with greater morbidity and mortality. The aim of this study was to develop a hemostasis checklist, with the intention of reducing mediastinal bleeding after cardiac surgery. METHODS A hemostasis checklist was developed with multidisciplinary collaboration. It contains 2 components: a series of surgical sites and factors affecting coagulation status. The checklist is performed at a time-out before sternal wire insertion. Analysis compared outcomes for patients undergoing cardiac surgery in the 1 year before and 2 years after implementation. RESULTS A total of 5542 patients underwent surgery during the study. After we implemented the checklist, there was a significant reduction in the reexploration rate (3.5% versus 1.9%; P < .001) and the proportion of patients bleeding greater than 1 L in 12 hours (6.1% versus 2.8%; P < .001). There was a major reduction in consumption of blood products, saving $430,513. There was progressive improvement in the second year after implementation. Checklist implementation was also associated with reduced intensive care unit and hospital length of stay, adding to the financial benefit. CONCLUSIONS Implementation of a simple and quickly performed hemostasis checklist has had a sustained impact over the 2 years after implementation, reducing the incidence of noteworthy mediastinal bleeding and reexploration, which has resulted in a major reduction in blood product consumption. Together, these have resulted in an associated reduction in intensive care unit and hospital length of stay, and a considerable financial savings. This highlights that perioperative bleeding is a preventable complication.
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Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom.
| | - Caroline Gerrard
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - James Clayton
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, United Kingdom
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Patel K, Adalti S, Runwal S, Singh R, Ananthanarayanan C, Doshi C, Pandya H. Reβexploration after offβpump coronary artery bypass grafting: Incidence, risk factors, and impact of timing. J Card Surg 2020; 35:3062-3069. [DOI: 10.1111/jocs.14986] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Kartik Patel
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Sudhir Adalti
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Shreyas Runwal
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Rahul Singh
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | | | - Chirag Doshi
- Department of Cardiovascular and Thoracic Surgery U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
| | - Himani Pandya
- Department of Research U. N. Mehta Institute of Cardiology and Research Center Ahmedabad India
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Tiwari KK, Wadhawa V, Jawarkar M, Rathod D, Shah M, Manek P, Doshi C. Total arterial multivessels minimal invasive direct coronary artery bypass grafting via left minithoracotomy. Gen Thorac Cardiovasc Surg 2020; 69:8-13. [PMID: 32588292 DOI: 10.1007/s11748-020-01412-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Minimal Invasive Direct Coronary Artery Bypass Surgery (MIDCAB) is becoming popular and an important armamentarium for cardiac surgeons. We aimed to evaluate the result of MIDCAB total arterial revascularization. METHODS We have evaluated 216 patients who underwent MIDCAB multivessel total arterial revascularization through a left anterolateral mini thoracotomy. LIMA harvested in every patient, RIMA or radial artery used as second conduit. LIMA-RIMA Y or LIMA-RADIAL Y was made to accomplish multivessels total arterial revascularization. Post-operative graft patency was evaluated in all patients by CT coronary angiography at 6Β months following discharge. RESULTS Mean age of patients was 52.5βΒ±β9.8Β years. Average number of anastomosis performed were 2.34βΒ±β0.75. Multivessels total arterial CABG was accomplished in all individuals. There was no mortality or deep wound infection. Re-exploration was done in two patients for bleeding. In one patient emergency CPB was required. Average ICU and hospital stay was 1.52βΒ±β0.77 and 4.92βΒ±β1.46Β days, respectively. Patients were mobilized earlier due to less pain. Wound healing of anterolateral thoracotomy was faster. In the follow up CT angiography 100% of the LIMA grafts were patent. CONCLUSIONS Multivessels total arterial MIDCAB can be accomplished safely in selected individuals. RIMA can be harvested in long standing diabetic patients with no concern for sternal wound healing. MIDCAB patients experience better cosmetics and early return to daily activities.
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Affiliation(s)
- Kaushal K Tiwari
- Department of Cardio Thoracic and Vascular Surgery, ADK Hospital Pvt. Ltd, Male, Maldives
| | - Vivek Wadhawa
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India.
| | - Manish Jawarkar
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India
| | - Divyesh Rathod
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India
| | - Mausam Shah
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India
| | - Pratik Manek
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India
| | - Chirag Doshi
- Department of Cardio Thoracic and Vascular Surgery, U.N.Mehta Institute of Cardiology and Research Center, Civil Hospital Campus, Asarwa, Ahmedabad, 380016, Gujarat, India
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11
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Ali JM, Kovzel M, McPhilimey E, Colah S, De Silva R, Moorjani N. Minimally invasive extracorporeal circulation is a cost-effective alternative to conventional extracorporeal circulation for coronary artery bypass grafting: propensity matched analysis. Perfusion 2020; 36:154-160. [PMID: 32522075 DOI: 10.1177/0267659120929180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Minimally invasive extracorporeal circulation has developed with the aim of reducing the impact of the adverse effects associated with conventional extracorporeal circulation. The aim of this study was to compare outcomes for patients undergoing coronary artery bypass grafting using minimally invasive extracorporeal circulation with those performed using conventional extracorporeal circulation. METHODS A retrospective analysis was performed of patients undergoing minimally invasive extracorporeal circulation coronary artery bypass grafting at a single centre. 2:1 propensity matching was performed to identify control patients undergoing conventional extracorporeal circulation coronary artery bypass grafting. Outcomes were compared using univariate analysis. RESULTS A total of 354 patients were included in the study, with 118 patients undergoing minimally invasive extracorporeal circulation coronary artery bypass grafting. Patients were well matched on baseline characteristics. The mean logistic EuroSCORE was 3.95βΒ±β4.20. Operative times (3.31βΒ±β1.52 vs. 3.56βΒ±β0.73, pβ=β0.03) were significantly shorter in minimally invasive extracorporeal circulation cases. Patients who underwent surgery with minimally invasive extracorporeal circulation had significantly less 12-hour blood loss (322.3βΒ±β13.2βmL vs. 380.8βΒ±β15.2βmL, pβ<β0.01). Correspondingly, a significantly lower proportion of patients were transfused (25.8% vs. 36%, pβ=β0.04), and the mean number of red blood cells transfused was lower (0.45βΒ±β0.95 vs. 0.97βΒ±β2.13, pβ=β0.01). Similarly, the number of coagulation products administered was lower (0.161βΒ±β0.05 vs. 0.40βΒ±β0.09, pβ=β0.05). There was a significantly lower incidence of acute kidney injury (11.0% vs. 19.9%, pβ=β0.03). Minimally invasive extracorporeal circulation was associated with a Β£679.50 cost saving per patient. DISCUSSION Minimally invasive extracorporeal circulation for coronary artery bypass grafting is associated with a reduced requirement for blood transfusion, reduced incidence of acute kidney injury and a significant cost saving. Minimally invasive extracorporeal circulation should be considered as an adjunct for all patients undergoing coronary artery bypass grafting.
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Affiliation(s)
- Jason M Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Maksym Kovzel
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Eve McPhilimey
- Department of Clinical Perfusion, Royal Papworth Hospital, Cambridge, UK
| | - Simon Colah
- Department of Clinical Perfusion, Royal Papworth Hospital, Cambridge, UK
| | - Ravi De Silva
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
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12
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Bai SJ, Zeng B, Zhang L, Huang Z. Autologous Platelet-Rich Plasmapheresis in Cardiovascular Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 34:1614-1621. [DOI: 10.1053/j.jvca.2019.07.129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/12/2019] [Accepted: 07/14/2019] [Indexed: 01/08/2023]
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13
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Pearse BL, Keogh S, Rickard CM, Faulke DJ, Smith I, Wall D, McDonald C, Fung YL. Bleeding Management Practices of Australian Cardiac Surgeons, Anesthesiologists and Perfusionists: A Cross-Sectional National Survey Incorporating the Theoretical Domains Framework (TDF) and COM-B Model. J Multidiscip Healthc 2020; 13:27-41. [PMID: 32021232 PMCID: PMC6970603 DOI: 10.2147/jmdh.s232888] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/11/2019] [Indexed: 12/18/2022] Open
Abstract
Purpose Excessive bleeding is an acknowledged consequence of cardiac surgery, occurring in up to 10% of adult patients. This clinically important complication leads to poorer patient outcomes. Clinical practice guidelines are available to support best practice however variability in bleeding management practice and related adverse outcomes still exist. This study had two objectives: 1) to gain insight into current bleeding management practice for adult cardiac surgery in Australia and how that compared to guidelines and literature; and 2) to understand perceived difficulties clinicians face implementing improvements in bleeding management. Methods A national cross-sectional questionnaire survey was utilized. Perspectives were sought from cardiac surgeons, cardiac anesthesiologists and perfusionists. Thirty-nine closed-ended questions focused on routine bleeding management practices to address pre and intra-operative care. One open-ended question was asked; βWhat would assist you to improve bleeding management with cardiac surgery patients?β Quantitative data were analysed with SPSS. Qualitative data were categorized into the domains of the Theoretical Domains Framework; the domains were then mapped to the COM-B model. Results Survey responses from 159 Anesthesiologists, 39 cardiac surgeons and 86 perfusionists were included (response rate 37%). Four of the recommendations queried in this survey were reported as routinely adhered to < 50% of the time, 9 queried recommendations were adhered to 51β75% of the time and 4 recommendations were routinely followed >76% of the time. Conclusion There is a wide variation in peri-operative bleeding management practice among cardiac anaesthesiologists, surgeons and perfusionists in Australian cardiac surgery units. Conceptualizing factors believed necessary to improve practice with the TDF and COM-B model found that bleeding management could be improved with a standardized approach including; point of care diagnostic assays, a bleeding management algorithm, access to concentrated coagulation factors, cardiac surgery specific bleeding management education, multidisciplinary team agreement and support, and an overarching national approach.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia.,Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Samantha Keogh
- School of Nursing and Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Daniel J Faulke
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Ian Smith
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Douglas Wall
- Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Yoke L Fung
- School of Health and Sports Sciences, University of Sunshine Coast, Sunshine Coast, QLD, Australia
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