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Suffredini G, Le L, Lee S, Gao WD, Robich MP, Aziz H, Kilic A, Lawton JS, Voegtline K, Olson S, Brown CH, Lima JAC, Das S, Dodd-O JM. The Impact of Silent Liver Disease on Hospital Length of Stay Following Isolated Coronary Artery Bypass Grafting Surgery. J Clin Med 2024; 13:3397. [PMID: 38929926 DOI: 10.3390/jcm13123397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/23/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Objectives: Risk assessment models for cardiac surgery do not distinguish between degrees of liver dysfunction. We have previously shown that preoperative liver stiffness is associated with hospital length of stay following cardiac surgery. The authors hypothesized that a liver stiffness measurement (LSM) ≥ 9.5 kPa would rule out a short hospital length of stay (LOS < 6 days) following isolated coronary artery bypass grafting (CABG) surgery. Methods: A prospective observational study of one hundred sixty-four adult patients undergoing non-emergent isolated CABG surgery at a single university hospital center. Preoperative liver stiffness measured by ultrasound elastography was obtained for each participant. Multivariate logistic regression models were used to assess the adjusted relationship between LSM and a short hospital stay. Results: We performed multivariate logistic regression models using short hospital LOS (<6 days) as the dependent variable. Independent variables included LSM (< 9.5 kPa, ≥ 9.5 kPa), age, sex, STS predicted morbidity and mortality, and baseline hemoglobin. After adjusting for included variables, LSM ≥ 9.5 kPa was associated with lower odds of early discharge as compared to LSM < 9.5 kPa (OR: 0.22, 95% CI: 0.06-0.84, p = 0.03). The ROC curve and resulting AUC of 0.76 (95% CI: 0.68-0.83) suggest the final multivariate model provides good discriminatory performance when predicting early discharge. Conclusions: A preoperative LSM ≥ 9.5 kPa ruled out a short length of stay in nearly 80% of patients when compared to patients with a LSM < 9.5 kPa. Preoperative liver stiffness may be a useful metric to incorporate into preoperative risk stratification.
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Affiliation(s)
- Giancarlo Suffredini
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Lan Le
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Seoho Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Wei Dong Gao
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michael P Robich
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Hamza Aziz
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ahmet Kilic
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jennifer S Lawton
- Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Kristin Voegtline
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Sarah Olson
- Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Charles Hugh Brown
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Joao A C Lima
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Samarjit Das
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jeffrey M Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Division of Cardiac Anesthesia, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
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Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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Tadege M, Tegegne AS, Dessie ZG. Post-surgery survival and associated factors for cardiac patients in Ethiopia: applications of machine learning, semi-parametric and parametric modelling. BMC Med Inform Decis Mak 2024; 24:91. [PMID: 38553701 PMCID: PMC10979627 DOI: 10.1186/s12911-024-02480-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/11/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Living in poverty, especially in low-income countries, are more affected by cardiovascular disease. Unlike the developed countries, it remains a significant cause of preventable heart disease in the Sub-Saharan region, including Ethiopia. According to the Ethiopian Ministry of Health statement, around 40,000 cardiac patients have been waiting for surgery in Ethiopia since September 2020. There is insufficient information about long-term cardiac patients' post-survival after cardiac surgery in Ethiopia. Therefore, the main objective of the current study was to determine the long-term post-cardiac surgery patients' survival status in Ethiopia. METHODS All patients attended from 2012 to 2023 throughout the country were included in the current study. The total number of participants was 1520 heart disease patients. The data collection procedure was conducted from February 2022- January 2023. Machine learning algorithms were applied. Gompertz regression was used also for the multivariable analysis report. RESULTS From possible machine learning models, random survival forest were preferred. It emphasizes, the most important variable for clinical prediction was SPO2, Age, time to surgery waiting time, and creatinine value and it accounts, 42.55%, 25.17%,11.82%, and 12.19% respectively. From the Gompertz regression, lower saturated oxygen, higher age, lower ejection fraction, short period of cardiac center stays after surgery, prolonged waiting time to surgery, and creating value were statistically significant predictors of death outcome for post-cardiac surgery patients' survival in Ethiopia. CONCLUSION Some of the risk factors for the death of post-cardiac surgery patients are identified in the current investigation. Particular attention should be given to patients with prolonged waiting times and aged patients. Since there were only two fully active cardiac centers in Ethiopia it is far from an adequate number of centers for more than 120 million population, therefore, the study highly recommended to increase the number of cardiac centers that serve as cardiac surgery in Ethiopia.
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Affiliation(s)
- Melaku Tadege
- College of Science, Bahir Dar University, Bahir Dar, Ethiopia.
- Department of Statistics, Injibara University, Injibara, Amhara, Ethiopia.
- Regional Data Management Center for Health (RDMC), Amhara Public Health Institute (APHI), Bahir Dar, Ethiopia.
| | | | - Zelalem G Dessie
- College of Science, Bahir Dar University, Bahir Dar, Ethiopia
- School of Mathematics, Statistics and Computer Science, University of KwaZulu- Natal, Durban, South Africa
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Harik L, Habib RH, Dimagli A, Rahouma M, Perezgrovas-Olaria R, Jr Soletti G, Alzghari T, An KR, Rong LQ, Sandner S, Bairey-Merz CN, Redfors B, Girardi L, Gaudino M. Intraoperative Anemia Mediates Sex Disparity in Operative Mortality After Coronary Artery Bypass Grafting. J Am Coll Cardiol 2024; 83:918-928. [PMID: 38418006 DOI: 10.1016/j.jacc.2023.12.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Women undergoing coronary artery bypass grafting (CABG) have higher operative mortality than men. OBJECTIVES The purpose of this study was to evaluate the relationship between intraoperative anemia (nadir intraoperative hematocrit), CABG operative mortality, and sex. METHODS This was a cohort study of 1,434,225 isolated primary CABG patients (344,357 women) from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2022). The primary outcome was operative mortality. The attributable risk (AR) (the risk-adjusted strength of the association of female sex with CABG outcomes) for the primary outcome was calculated. Causal mediation analysis derived the total effect of female sex on operative mortality risk and the proportion of that effect mediated by intraoperative anemia. RESULTS Women had lower median nadir intraoperative hematocrit (22.0% [Q1-Q3: 20.0%-25.0%] vs 27.0% [Q1-Q3: 24.0%-30.0%], standardized mean difference 97.0%) than men. Women had higher operative mortality than men (2.8% vs 1.7%; P < 0.001; adjusted OR: 1.36; 95% CI: 1.30-1.41). The AR of female sex for operative mortality was 1.21 (95% CI: 1.17-1.24). After adjusting for nadir intraoperative hematocrit, AR was reduced by 43% (1.12; 95% CI: 1.09-1.16). Intraoperative anemia mediated 38.5% of the increased mortality risk associated with female sex (95% CI: 32.3%-44.7%). Spline regression showed a stronger association between operative mortality and nadir intraoperative hematocrit at hematocrit values <22.0% (P < 0.001). CONCLUSIONS The association of female sex with increased CABG operative mortality is mediated to a large extent by intraoperative anemia. Avoiding nadir intraoperative hematocrit values below 22.0% may reduce sex differences in CABG operative mortality.
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Affiliation(s)
- Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Robert H Habib
- The Society of Thoracic Surgeons Research and Analytic Center, Chicago, Illinois, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | | | - Giovanni Jr Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Talal Alzghari
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Kevin R An
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Lisa Q Rong
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - C Noel Bairey-Merz
- Barbara Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Leonard Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
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Vervoort D, Sud M, Zeis TM, Haouzi AA, An KR, Rocha R, Eikelboom R, Fremes SE, Tamis-Holland JE. Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines. Can J Cardiol 2024; 40:275-289. [PMID: 38181974 DOI: 10.1016/j.cjca.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/31/2023] [Accepted: 11/07/2023] [Indexed: 01/07/2024] Open
Abstract
The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.
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Affiliation(s)
- Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Maneesh Sud
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Tessa M Zeis
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alice A Haouzi
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rodolfo Rocha
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Rachel Eikelboom
- Division of Cardiac Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Stephen E Fremes
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Barron LK, Moon MR. Medical Therapy After CABG: the Known Knowns, the Known Unknowns, and the Unknown Unknowns. Cardiovasc Drugs Ther 2024; 38:141-149. [PMID: 36881214 DOI: 10.1007/s10557-023-07444-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE Medical therapies play a central role in secondary prevention after surgical revascularization. While coronary artery bypass grafting is the most definitive treatment for ischemic heart disease, progression of atherosclerotic disease in native coronary arteries and bypass grafts result in recurrent adverse ischemic events. The aim of this review is to summarize the recent evidence regarding current therapies in secondary prevention of adverse cardiovascular outcomes after CABG and review the existing recommendations as they pertain to the CABG subpopulations. RECENT FINDINGS There are many pharmacologic interventions recommended for secondary prevention in patients after coronary artery bypass grafting. Most of these recommendations are based on secondary outcomes from trials which include but did not focus on surgical patients as a cohort. Even those designed with CABG in mind lack the technical and demographic scope to provide universal recommendations for all CABG patients. CONCLUSION Recommendations for medical therapy after surgical revascularization are chiefly based on large-scale randomized controlled trials and meta-analyses. Much of what is known about medical management after surgical revascularization results from trials comparing surgical to non-surgical approaches and important characteristics of the operative patients are omitted. These omissions create a group of patients who are relatively heterogenous making solid recommendations elusive. While advances in pharmacologic therapies are clearly adding to the armamentarium of options for secondary prevention, knowing what patients benefit most from each therapeutic option remains challenging and a personalized approach is still required.
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Affiliation(s)
- Lauren K Barron
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Heart Institute, Houston, TX, USA.
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Heart Institute, Houston, TX, USA
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Li R, Huddleston S. Development of Comorbidity Index for in-hospital mortality for patients who underwent coronary artery revascularization. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:678-685. [PMID: 37987738 DOI: 10.23736/s0021-9509.23.12833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
BACKGROUND For myocardial revascularization, coronary artery bypass grafting (CAGB) and percutaneous coronary intervention (PCI) are two common modalities but with high in-hospital mortality. A Comorbidity Index is useful to predict mortality or can be used with other covariates to develop point-scoring systems. This study aimed to develop specific comorbidity indices for patients who underwent coronary artery revascularization. METHODS Patients who underwent CABG or PCI were identified in the National Inpatient Sample database between Q4 2015-2020. Patients of age <40 were excluded for congenital heart defects. Patients were randomly sampled into experimental (70%) and validation (30%) groups. Thirty-eight Elixhauser comorbidities were identified and included in multivariable regression to discriminate in-hospital mortality. Weight for each comorbidity was assigned and single indices, Li CABG Mortality Index (LCMI) and Li PCI Mortality Index (LPMI), were developed. RESULTS Mortality discrimination by LCMI approached adequacy (c-statistic=0.691, 95% CI=0.682-0.701) and was comparable to multivariable regression with comorbidities (c-statistic=0.685, 95% CI=0.675-0.694). LCMI discrimination performed significantly better than Elixhauser Comorbidity Index (ECI) (c-statistic=0.621, 95% CI=0.611-0.631) and can be further improved by adjusting age (c-statistic=0.721, 95% CI=0.712-0.730). All models were well-calibrated (Brier score=0.021-0.022). LPMI moderately discriminated in-hospital mortality (c-statistic=0.666, 95% CI=0.660-0.672) and performed significantly better than ECI (c-statistic=0.610, 95% CI=0.604-0.616). LPMI performed better than the all-comorbidity multivariable regression (c-statistic=0.658, 95% CI=0.652-0.663). After age adjustment, LPMI discrimination was significantly increased and was approaching adequacy (c-statistic=0.695, 95% CI=0.690-0.701). All models were well-calibrated (Brier score=0.025-0.026). CONCLUSIONS LCMI and LPMI effectively discriminated and predicted in-hospital mortality. These indices were validated and performed superior to ECI. These indices can standardize comorbidity measurement as alternatives to ECI to help replicate and compare results across studies.
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Affiliation(s)
- Renxi Li
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA -
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA -
| | - Stephen Huddleston
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Penton A, Lin J, Kolde G, DeJong M, Blecha M. Investigation of Combined Carotid Endarterectomy and Coronary Artery Bypass Graft Surgery Outcomes and Adverse Event Risk Factors in the Vascular Quality Initiative. Vasc Endovascular Surg 2023; 57:884-900. [PMID: 37303074 PMCID: PMC10756645 DOI: 10.1177/15385744231183741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate outcomes of simultaneous CEA and CABG utilizing the Vascular Quality Initiative (VQI). Additionally, we seek to investigate risks for both perioperative and long-term mortality and adverse neurological outcomes. METHODS All carotid endarterectomies in the VQI between January 2003 and May 2022 were queried. We identified 171,816 CEA in the database. We extracted 2 cohorts from these CEA. The first group was patients who underwent simultaneous carotid endarterectomy (CEA) and coronary artery bypass (CABG) (N = 3137). The second group encompassed patients who underwent CABG or percutaneous coronary artery angioplasty/stent within 5 years of ultimately undergoing CEA (N = 27,387). We investigated the following outcomes in a multivariable fashion: 1. Risks for mortality in long term follow-up for both cohorts combined; 2. Risks for ischemic event in the cerebral hemisphere ipsilateral to the CEA site after index hospital admission in follow up for both cohorts combined. Tertiary outcomes are also investigated in the manuscript. RESULTS On multivariable analysis, patients undergoing simultaneous combined CEA and CABG had equivalent long-term survival to patients who underwent coronary revascularization within 5 years of ultimately undergoing CEA. Five-year survival is noted to be 84.5% vs 86% with a Cox regression non-significant P-value (.203). Significant multivariable risks for reduced long term survival (P < .03 for all) included: advancing age (HR 2.48/year); smoking history (HR 1.26); Diabetes (HR 1.33); history of CHF (HR 1.66); history of COPD (HR 1.54); baseline renal insufficiency at the time of surgery (HR 1.30); anemia (HR1.64); lack of preoperative aspirin (HR 1.12); and lack of preoperative statin (HR 1.32); lack of patch placement at CEA site (HR 1.16); perioperative MI (HR 2.04); perioperative CHF (1.66); perioperative dysrhythmia (HR 1.36); cerebral reperfusion injury (HR 2.23); perioperative ischemic neurological event (HR 2.48); and lack of statin at discharge (HR 2.04). Amongst patients with documented neurological status in follow up, combined CEA and CABG had over 99% freedom from ischemic cerebral event ipsilateral to the CEA site after discharge. CONCLUSIONS Combined CEA and CABG provides excellent long-term mortality prevention in patients with co-existing severe coronary and carotid atherosclerosis. Simultaneous CEA and CABG provides equivalent stroke prevention and long-term survival to both a cohort of patients undergoing coronary revascularization within 5 years of CEA and patients undergoing isolated CEA or CABG in the literature. The two most impactful modifiable risk factors towards long-term stroke and mortality prevention for patients undergoing simultaneous CEA-CABG are patch placement at CEA site and adherence to statin medication therapy.
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Affiliation(s)
- Ashley Penton
- Department of Sugery, Loyola University Medical Center, Maywood, IL, USA
| | - Jonathan Lin
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Grant Kolde
- Loyola University Chicago Stritch School of Medicine, Maywood, IL, USA
| | - Matthew DeJong
- Department of Sugery, Loyola University Medical Center, Maywood, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Maywood, IL, USA
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Saemann L, Wernstedt L, Pohl S, Stiller M, Willsch J, Hofmann B, Veres G, Simm A, Szabó G. Impact of Age on Endothelial Function of Saphenous Vein Grafts in Coronary Artery Bypass Grafting. J Clin Med 2023; 12:5454. [PMID: 37685521 PMCID: PMC10487541 DOI: 10.3390/jcm12175454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/17/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND An intact and functionally preserved endothelial layer in the graft is crucial for myocardial perfusion and graft patency after coronary artery bypass grafting (CABG). We hypothesized that old age is a risk factor for decreased endothelial function of bypass grafts. Thus, we investigated the impact of age in patients treated with CABG on endothelial function in saphenous vein grafts. METHODS We mounted the saphenous vein graft segments of CABG patients < 70 (n = 33) and ≥70 (n = 40) years of age in organ bath chambers and exposed them to potassium chloride (KCl) and phenylephrine (PE) to test the receptor-independent and -dependent contractility, followed by exposure to acetylcholine (ACh) and sodium nitroprusside (SNP) to test the endothelial-dependent and -independent relaxation. RESULTS The maximal contraction induced by KCl (2.3 ± 1.8 vs. 1.8 ± 2 g) was stronger in patients ≥ 70 years of age. The relative contraction induced by PE in % of KCl (167 ± 64 vs. 163 ± 59%) was similar between groups. Patients aged < 70 years showed a higher endothelial-dependent relaxation induced by acetylcholine than patients ≥ 70 years (51 ± 27 vs. 42 ± 18%). The relaxation induced by SNP was similar between both groups. CONCLUSIONS The endothelial function of saphenous vein bypass grafts decreases during aging. Thus, age should be considered when improving graft maintenance.
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Affiliation(s)
- Lars Saemann
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Lena Wernstedt
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Sabine Pohl
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Markus Stiller
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Jan Willsch
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Britt Hofmann
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Gábor Veres
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Andreas Simm
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
| | - Gábor Szabó
- Department of Cardiac Surgery, University Hospital Halle, Ernst-Grube-Straße 40, 06120 Halle (Saale), Germany (G.V.); (A.S.); (G.S.)
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Cacciatore S, Spadafora L, Bernardi M, Galli M, Betti M, Perone F, Nicolaio G, Marzetti E, Martone AM, Landi F, Asher E, Banach M, Hanon O, Biondi-Zoccai G, Sabouret P. Management of Coronary Artery Disease in Older Adults: Recent Advances and Gaps in Evidence. J Clin Med 2023; 12:5233. [PMID: 37629275 PMCID: PMC10455820 DOI: 10.3390/jcm12165233] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Coronary artery disease (CAD) is highly prevalent in older adults, yet its management remains challenging. Treatment choices are made complex by the frailty burden of older patients, a high prevalence of comorbidities and body composition abnormalities (e.g., sarcopenia), the complexity of coronary anatomy, and the frequent presence of multivessel disease, as well as the coexistence of major ischemic and bleeding risk factors. Recent randomized clinical trials and epidemiological studies have provided new data on optimal management of complex patients with CAD. However, frail older adults are still underrepresented in the literature. This narrative review aims to highlight the importance of assessing frailty as an aid to guide therapeutic decision-making and tailor CAD management to the specific needs of older adults, taking into account age-related pharmacokinetic and pharmacodynamic changes, polypharmacy, and potential drug interactions. We also discuss gaps in the evidence and offer perspectives on how best in the future to optimize the global strategy of CAD management in older adults.
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Affiliation(s)
- Stefano Cacciatore
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00186 Rome, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy
| | - Matteo Betti
- University of Milan, 20122, Milan, Italy
- Monzino IRCCS Cardiological Center, 20137 Milan, Italy
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic “Villa delle Magnolie”, 81020 Castel Morrone, Caserta, Italy
| | - Giulia Nicolaio
- Department of Experimental and Clinical Medicine and Geriatrics, University of Florence, Azienda Ospedaliero Universitaria Careggi, Largo Giovanni Alessandro Brambilla 3, 50134 Florence, Italy
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Anna Maria Martone
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Francesco Landi
- Department of Geriatrics, Orthopedics and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy
- Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Elad Asher
- The Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, P.O. Box 12271, Jerusalem 9112102, Israel
| | - Maciej Banach
- Department of Preventive Cardiology, Polish Mother’s Memorial Hospital Research Institute (PMMHRI), Medical University of Lodz (MUL), 93-338 Lodz, Poland
| | - Olivier Hanon
- Assistance Publique Hôpitaux de Paris, Geriatric Department, Broca Hospital, University of Paris Cité, 54–56 Rue Pascal, 75013 Paris, France
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Corso della Repubblica 79, 04100 Latina, Italy
- Mediterranea Cardiocentro, Via Orazio 2, 80122 Naples, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, ACTION-Group, Sorbonne University, 47–83 Bd de l’Hôpital, 75013 Paris, France
- Department of Cardiology, National College of French Cardiologists, 13 Rue Niépce, 75014 Paris, France
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11
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Sadeghi R. Coronary Artery Bypass Grafting in advance aged patients. ARYA ATHEROSCLEROSIS 2023; 19:37-45. [PMID: 38881996 PMCID: PMC11179009 DOI: 10.48305/arya.2023.41535.2884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/20/2023] [Indexed: 06/18/2024]
Abstract
INTRODUCTION This study aimed to assess the impact of coronary artery bypass grafting (CABG) on outcomes in elderly patients compared to younger patients. METHOD An observational case-control study was conducted involving 535 patients, divided into two groups: older adults (≥75 years) and younger adults (<75 years). All patients underwent CABG following a similar protocol. The primary endpoints focused on early post-procedure outcomes, including in-hospital mortality and the duration of ICU or hospital stay. Patients were followed up for six months, and secondary study endpoints included long-term mortality, left ventricular ejection fraction, re-hospitalization rates, and repeated revascularization. RESULTS 535 patients who underwent CABG were enrolled in this study. The smoking habit was significantly higher among younger adults (38.2% vs. 12.5%, P=0.001). Hypertension was more prevalent among older adults than younger adults (75% vs. 60%, P=0.044). LDL cholesterol serum levels were higher among younger adult patients (94.9±32.5 vs. 80.9±32.9, P=0.028). In-hospital death was not significantly different between younger and older adults (2.8% vs. 5.0%, P=0.34). Mortality in the six-month follow-up was non-significantly higher in the elderly (2.1% vs. 8.1%, P=0.06).A significant proportion of patients in both groups (46.9% in younger patients vs. 40% in older ones, P=0.40) received dual antiplatelet therapy (DAPT) prior to CABG due to a recent myocardial infarction and receipt of a new stent, but without increased major bleeding in both groups. CONCLUSION CABG should be considered a viable treatment option for elderly patients with acceptable operative risk in current clinical practice.
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Affiliation(s)
- Roxana Sadeghi
- Prevention of Cardiovascular Disease Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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12
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Li R. Development of Comorbidity Index for In-hospital Mortality for Patients Underwent Coronary Artery Revascularization. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.08.23288311. [PMID: 37090644 PMCID: PMC10120802 DOI: 10.1101/2023.04.08.23288311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Background For myocardial revascularization, coronary artery bypass grafting (CAGB) and percutaneous coronary intervention (PCI) are two common modalities but with high in-hospital mortality. A comorbidity index is useful to predict mortality or can be used with other covariates to develop point-scoring systems. This study aimed to develop specific comorbidity indices for patients who underwent coronary artery revascularization. Methods Patients who underwent CABG or PCI were identified in the National Inpatient Sample database between Q4 2015-2020. Patients of age<40 were excluded for congenital heart defects. Patients were randomly sampled into experimental (70%) and validation (30%) groups. Thirty-eight Elixhauser comorbidities were identified and included in multivariable regression to predict in-hospital mortality. Weight for each comorbidity was assigned and single indices, Li CABG Mortality Index (LCMI) and Li PCI Mortality Index (LPMI), were developed. Results Mortality prediction by LCMI approached adequacy ( c -statistic=0.691, 95% CI=0.682-0.701) and was comparable to multivariable regression with comorbidities ( c -statistic=0.685, 95% CI=0.675-0.694). LCMI prediction performed significantly better than Elixhauser Comorbidity Index (ECI) ( c -statistic=0.621, 95% CI=0.611-0.631) and can be further improved by adjusting age ( c -statistic=0.721, 95% CI=0.712-0.730). LPMI moderately predicted in-hospital mortality ( c -statistic=0.666, 95% CI=0.660-0.672) and performed significantly better than ECI ( c -statistic=0.610, 95% CI=0.604-0.616). LPMI performed better than the all-comorbidity multivariable regression ( c -statistic=0.658, 95% CI=0.652-0.663). After age adjustment, LPMI prediction was significantly increased and was approaching adequacy ( c -statistic=0.695, 95% CI=0.690-0.701). Conclusions LCMI and LPMI effectively predicted in-hospital mortality. These indices were validated and performed superior to ECI. The adjustment of age increased their predictive power to adequacy, implicating potential clinical application.
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13
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Ren J, Royse C, Srivastav N, Lu O, Royse A. Long-Term Survival of Multiple Versus Single Arterial Coronary Bypass Grafting in Elderly Patients. J Clin Med 2023; 12:jcm12072594. [PMID: 37048677 PMCID: PMC10094898 DOI: 10.3390/jcm12072594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Multiple arterial grafting (MAG) utilizes more than one arterial graft with any additional grafts being saphenous vein grafts (SVG). It remains an infrequently used coronary surgical revascularization technique, especially in elderly patients. Our study aims to evaluate the age-related association with the relative outcomes of multiple versus single arterial grafting (SAG). The Australian and New Zealand national registry was used to identify adult patients undergoing primary isolated CABG with at least two grafts. Exclusion criteria included reoperations, concomitant or previous cardiac surgery, and the absence of arterial grafting. Propensity score matching was used to match patient groups. The primary outcome was all-cause late mortality and the secondary outcomes were 30-day mortality and 30-day hospital readmission. We selected 69,624 eligible patients with a mean (standard deviation) age of 65.0 (10.2) years old. Matching between MAG and SAG generated 16,882 pairs of patients < 70 years old and 10,921 pairs of patients ≥ 70 years old. At a median [interquartile range] follow-up duration of 5.9 [3.2–9.6] years, MAG was associated with significantly reduced mortality compared to SAG (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.68–0.78; p < 0.001) in the younger subgroup as well as the elderly subgroup (HR, 0.84; 95% CI, 0.79–0.88; p < 0.001). In conclusion, MAG offers a survival benefit over SAG, in both younger and elderly patients.
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14
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Impact of gender on mid-term prognosis of patients undergoing coronary artery bypass grafting. PLoS One 2023; 18:e0279030. [PMID: 36862681 PMCID: PMC9980750 DOI: 10.1371/journal.pone.0279030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/29/2022] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVES We evaluated the impact of sex on mid-term prognosis in patients who underwent coronary artery bypass grafting (CABG). Data on gender differences in current management or clinical outcomes after CABG are controversial, and there have been limited data focusing on them. METHODS This was a retrospective and prospective, single-center, observational study. Between January 2001 and December 2017, 6613 patients who underwent CABG were enrolled from an institutional registry of Samsung Medical Center, Seoul, Korea (Clinicaltrials.gov, NCT03870815) and divided into two groups according to sex (female group, n = 1679 vs. male group, n = 4934). The primary outcome was cardiovascular death or myocardial infarction (MI) at 5 years. Propensity score matching analysis was performed to reduce confounding factors. RESULTS During a mean follow-up duration of 54 months, a total of 252 cardiovascular death or MIs occurred (female, 78 [7.5%] vs. male, 174 [5.7%]). Multivariate analysis revealed no significant difference in the incidence of cardiovascular death or MI at 5 years between female and male groups (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.78 to 1.41; p = 0.735). After propensity score matching, the incidence of cardiovascular death or MI was still similar between the two groups (HR 1.08; 95% CI 0.76 to 1.54; p = 0.666). The similarity of long-term outcomes between the two groups was consistent across various subgroups. There was also no significant difference in the risk of 5-year cardiovascular death or MI between males and females according to age (pre- and postmenopausal status) (p for interaction = 0.437). CONCLUSIONS After adjusting for baseline differences, sex does not appear to influence long-term risk of cardiovascular death or MI in patients undergoing CABG. CLINICAL TRIALS.GOV NUMBER NCT03870815.
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15
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Behnoush AH, Khalaji A, Rezaee M, Momtahen S, Mansourian S, Bagheri J, Masoudkabir F, Hosseini K. Machine learning-based prediction of 1-year mortality in hypertensive patients undergoing coronary revascularization surgery. Clin Cardiol 2023; 46:269-278. [PMID: 36588391 PMCID: PMC10018097 DOI: 10.1002/clc.23963] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Machine learning (ML) has shown promising results in all fields of medicine, including preventive cardiology. Hypertensive patients are at higher risk of mortality after coronary artery bypass graft (CABG) surgery; thus, we aimed to design and evaluate five ML models to predict 1-year mortality among hypertensive patients who underwent CABG. HYOTHESIS ML algorithms can significantly improve mortality prediction after CABG. METHODS Tehran Heart Center's CABG data registry was used to extract several baseline and peri-procedural characteristics and mortality data. The best features were chosen using random forest (RF) feature selection algorithm. Five ML models were developed to predict 1-year mortality: logistic regression (LR), RF, artificial neural network (ANN), extreme gradient boosting (XGB), and naïve Bayes (NB). The area under the curve (AUC), sensitivity, and specificity were used to evaluate the models. RESULTS Among the 8,493 hypertensive patients who underwent CABG (mean age of 68.27 ± 9.27 years), 303 died in the first year. Eleven features were selected as the best predictors, among which total ventilation hours and ejection fraction were the leading ones. LR showed the best prediction ability with an AUC of 0.82, while the least AUC was for the NB model (0.79). Among the subgroups, the highest AUC for LR model was for two age range groups (50-59 and 80-89 years), overweight, diabetic, and smoker subgroups of hypertensive patients. CONCLUSIONS All ML models had excellent performance in predicting 1-year mortality among CABG hypertension patients, while LR was the best regarding AUC. These models can help clinicians assess the risk of mortality in specific subgroups at higher risk (such as hypertensive ones).
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Affiliation(s)
- Amir Hossein Behnoush
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirmohammad Khalaji
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Malihe Rezaee
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahram Momtahen
- Department of Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Mansourian
- Department of Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jamshid Bagheri
- Department of Surgery, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farzad Masoudkabir
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.,Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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Zhang RJZ, Yu XY, Wang J, Lv J, Yu MH, Wang L, Liu ZG. Comparison of in-hospital outcomes after coronary artery bypass graft surgery in elders and younger patients: a multicenter retrospective study. J Cardiothorac Surg 2023; 18:53. [PMID: 36726146 PMCID: PMC9893615 DOI: 10.1186/s13019-023-02163-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/24/2023] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES We aimed to identify in-hospital outcomes in young (≤ 65 years) and old (> 65 years) patients after coronary artery bypass grafting (CABG) by analyzing the effect of age on adverse events after on-pump or off-pump CABG. METHODS Patients older than 65 years were defined as older patients and others were defined as younger patients. The qualitative data were compared by chi-square or Fisher's exact tests. The quantitative data were compared by the two-sample independent t-test or Mann-Whitney U test. Multifactor binary logistic regression was used to control for confounders and to investigate the effect of age on dichotomous outcome variables such as death. RESULTS In the on-pump CABG population, the postoperative in-hospital mortality, the incidence of postoperative symptomatic cerebral infarction (POSCI) and postoperative atrial fibrillation (POAF) was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with postoperative in-hospital mortality (OR = 2.370, P value = 0.031), POSCI (OR = 5.033, P value = 0.013), and POAF (OR = 1.499, P value < 0.001). In the off-pump CABG population, the incidence of POAF was higher in older patients than in younger patients (P value < 0.05), and age > 65 years was associated with POAF (OR = 1.392, P value = 0.011). CONCLUSION In-hospital outcomes after CABG are strongly influenced by age. In on-pump CABG, the risk of postoperative death, POSCI, and POAF was higher in older patients, and in off-pump CABG, the risk of POAF was higher in older patients.
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Affiliation(s)
- Ren-Jian-Zhi Zhang
- grid.506261.60000 0001 0706 7839Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 61, Third Avenue, TEDA, Tianjin, China
| | - Xin-Yi Yu
- grid.506261.60000 0001 0706 7839Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 61, Third Avenue, TEDA, Tianjin, China
| | - Jing Wang
- grid.412633.10000 0004 1799 0733Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian Lv
- Department of Cardiovascular Surgery, Nanyang Central Hospital, Nanyang, China
| | - Ming-Huan Yu
- grid.506261.60000 0001 0706 7839Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 61, Third Avenue, TEDA, Tianjin, China
| | - Li Wang
- grid.412633.10000 0004 1799 0733Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhi-Gang Liu
- grid.506261.60000 0001 0706 7839Department of Cardiovascular Surgery, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 61, Third Avenue, TEDA, Tianjin, China
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17
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Widyastuti Y, Boom CE, A Parmana IM, Kurniawaty J, Jufan AY, Hanafy DA, Videm V. Validation in Indonesia of two published scores for mortality prediction after cardiac surgery. Ann Card Anaesth 2023; 26:23-28. [PMID: 36722584 PMCID: PMC9997462 DOI: 10.4103/aca.aca_297_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Introduction No mortality risk prediction model has previously been validated for cardiac surgery in Indonesia. This study aimed at validating the EuroSCORE II and Age Creatinine Ejection Fraction (ACEF) score as predictors for in-hospital mortality after cardiac surgery a in tertiary center, and if necessary, to recalibrate the EuroSCORE II model to our population. Methods This study was a single-center observational study from prospectively collected data on adult patients undergoing cardiac surgery from January 2006 to December 2011 (n = 1833). EuroSCORE II and ACEF scores were calculated for all patients to predict in-hospital mortality. Discrimination was assessed using the area under the curve (AUC) with a 95% confidence interval. Calibration was assessed with the Hosmer-Lemeshow test (HL test). Multivariable analysis was performed to recalibrate the EuroSCORE II; variables with P < 0.2 entered the final model. Results The in-hospital mortality rate was 3.8%, which was underestimated by the EuroSCORE II (2.1%) and the ACEF score (2.4%). EuroSCORE II (AUC 0.774 (0.714-0.834)) showed good discrimination, whereas the ACEF score (AUC 0.638 [0.561-0.718]) showed poor discrimination. The differences in AUC were significant (P = 0.002). Both scores were poorly calibrated (EuroSCORE II: HL test P < 0.001, ACEF score: HL test P < 0.001) and underestimated mortality in all risk groups. After recalibration, EuroSCORE II showed good discrimination (AUC 0.776 [0.714- 0.840]) and calibration (HL test P = 0.79). Conclusions EuroSCORE II and the ACEF score were unsuitable for risk prediction of in-hospital mortality after cardiac surgery in our center. Following recalibration, the calibration of the EuroSCORE II was greatly improved.
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Affiliation(s)
- Yunita Widyastuti
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Cindy E Boom
- Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - I Made A Parmana
- Department of Anesthesiology and Intensive Care, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Juni Kurniawaty
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Akhmad Y Jufan
- Department of Anesthesiology and Intensive Therapy, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Dudy A Hanafy
- Department of Cardiothoracic Surgery, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Vibeke Videm
- Department of Clinical and Molecular Medicine, NTNU - Norwegian University of Science and Technology; Department of Immunology and Transfusion Medicine, St. Olavs University Hospital, Trondheim, Norway
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18
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Elzanaty AM, Khalil M, Meenakshisundaram C, Alharbi A, Patel N, Maraey A, Zafarullah F, Elgendy IY, Eltahawy E. Outcomes of Coronary Artery Bypass Grafting in Patients With Previous Mediastinal Radiation. Am J Cardiol 2023; 186:80-86. [PMID: 36356429 DOI: 10.1016/j.amjcard.2022.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/25/2022] [Accepted: 10/08/2022] [Indexed: 11/09/2022]
Abstract
Studies have shown that patients with radiation therapy-associated coronary artery disease tend to have worse outcomes with percutaneous revascularization. Previous irradiation has been linked with future internal mammary artery graft disease. Studies investigating the outcomes of coronary artery bypass surgery (CABG) among patients with previous radiation are limited. The Nationwide Readmission Database for the years 2016 to 2019 was queried for hospitalizations with CABG and history of mediastinal radiation. Complex samples multivariable logistic and linear regression models were used to determine the association between the history of mediastinal radiation and in-hospital mortality, 90 days all-cause unplanned readmission rates, and acute coronary syndrome readmission rates. A total of 533,702 hospitalizations (2,070 in the irradiation history group and 531,632 in the control group) were included in this analysis. Patients with radiation therapy history were less likely to have traditional coronary artery disease risk factors and more likely to have associated valvular disease. Patients with a history of irradiation had similar in-hospital mortality and 90-day readmission risk at the expense of higher hospitalizations costs (β coefficient: $2,764; p = 0.005). They had a higher likelihood of readmission with acute coronary syndrome within 90 days (adjusted odds ratio 1.67, p = 0.02). In a conclusion, a history of mediastinal irradiation is not associated with increased rates of short-term mortality or increased all-cause readmission risk after CABG. However, it may be associated with increased acute coronary syndrome readmission rates.
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Affiliation(s)
- Ahmed M Elzanaty
- Division of Cardiovascular Medicine and Department of Internal Medicine, University of Toledo, Toledo, Ohio.
| | - Mahmoud Khalil
- Department of Internal Medicine, Lincoln Medical Center, New York, New York
| | | | | | - Neha Patel
- Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Ahmed Maraey
- Department of Internal Medicine, University of North Dakota, Bismarck, North Dakota
| | - Fnu Zafarullah
- Division of Cardiovascular Medicine and Department of Internal Medicine, University of Toledo, Toledo, Ohio
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky
| | - Ehab Eltahawy
- Division of Cardiovascular Medicine and Department of Internal Medicine, University of Toledo, Toledo, Ohio
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Santana A, Mediano M, Kasal D. Physical performance tests and in-hospital outcomes in elective open chest heart surgery. IJC HEART & VASCULATURE 2022; 44:101164. [PMID: 36578300 PMCID: PMC9791027 DOI: 10.1016/j.ijcha.2022.101164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
Background Physical performance tests are essential for a comprehensive health assessment, and have been described as predictors of disability and muscle mass decline after open chest heart surgery (OHS). We evaluated the association between physical performance tests with clinical outcomes after OHS in younger and older patients. Moreover, the ability of physical performance tests and European System for Cardiac Operative Risk Evaluation (Euroscore II) to predict death was assessed. Methods Elective OHS patients were evaluated before surgery with handgrip strength (HGS), 30-s Chair-Stand Test (30sCST), and timed up and go test (TUGT). The outcomes were post-surgical complications, total length of stay (LOS), time to walk (TW), time in invasive mechanical ventilation (TIMV), and in-hospital mortality. Data were stratified between patients < 60 (younger) and ≥ 60 years old (older). Results A total of 166 patients were included in the study (older, n = 89). The only physical test associated with mortality in the adjusted models was HGS in older patients (p = 0.03). Among older patients, both Euroscore II (AUC = 0.77) and HGS (AUC = 0.80) demonstrated good ability to predict death. Combining HGS and Euroscore II did not increase accuracy for mortality prediction (AUC = 0.83). Conclusion HGS performance was comparable to a well-established surgical risk score in evaluating in-hospital mortality after OHS, only in older patients. Functional testing before OHS could be a tool to improve risk stratification in these patients. Future intervention studies aiming to improve functional capacity before elective OHS can further clarify the impact of physical fitness in surgical recovery.
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Affiliation(s)
- Abisai Santana
- National Institute of Cardiology, Ministry of Health, Rio de Janeiro, Brazil
| | - Mauro Mediano
- National Institute of Cardiology, Ministry of Health, Rio de Janeiro, Brazil
| | - Daniel Kasal
- National Institute of Cardiology, Ministry of Health, Rio de Janeiro, Brazil,State University of Rio de Janeiro, Internal Medicine Department, Brazil,Corresponding author at: Rua das Laranjeiras 374, 22240-006 Rio de Janeiro, Brazil.
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20
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A Practical Approach to Left Main Coronary Artery Disease. J Am Coll Cardiol 2022; 80:2119-2134. [DOI: 10.1016/j.jacc.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 11/22/2022]
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21
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Machado RJ, Saraiva FA, Mancio J, Sousa P, Cerqueira RJ, Barros AS, Lourenço AP, Leite-Moreira AF. A systematic review and meta-analysis of randomized controlled studies comparing off-pump versus on-pump coronary artery bypass grafting in the elderly. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 63:60-68. [PMID: 34792312 DOI: 10.23736/s0021-9509.21.12012-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIM Comparison of short and mid-term outcomes between off-pump CABG (OPCAB) and on-pump CABG (ONCAB) in patients older than 65 throughout a meta-analysis of randomized clinical trials (RCTs). EVIDENCE ACQUISITION A literature search was conducted using 3 databases. RCTs reporting mortality outcomes of OPCAB versus ONCAB among the elderly were included. Data on myocardial infarction, stroke, re-revascularization, renal failure and composite endpoints after CABG were also collected. Random effects models were used to compute statistical combined measures and 95% confidence intervals (CI). EVIDENCE SYNTHESIS Five RCTs encompassing 6221 patients were included (3105 OPCAB and 3116 ONCAB). There were no significant differences on mid-term mortality (pooled HR: 1.02, 95%CI: 0.89-1.17, p=0.80) and composite endpoint incidence (pooled HR: 0.98, 95%CI: 0.88-1.09, p=0.72) between OPCAB and ONCAB. At 30-day, there were no differences in mortality, myocardial infarction, stroke and renal complications. The need for early re-revascularization was significantly higher in OPCAB (pooled OR: 3.22, 95%CI: 1.28-8.09, p=0.01), with a higher percentage of incomplete revascularization being reported for OPCAB in trials included in this pooled result (34% in OPCAB vs 29% in ONCAB, p<0.01). CONCLUSIONS Data from RCTs in elderly patients showed that OPCAB and ONCAB provide similar mid-term results. OPCAB was associated with a higher risk of early rerevascularization. As CABG on the elderly is still insufficiently explored, further RCTs, specifically designed targeting this population, are needed to establish a better CABG strategy for these patients.
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Affiliation(s)
- Rui J Machado
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Francisca A Saraiva
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Jennifer Mancio
- Intensive Care and Perioperative Medicine Department, Royal Brompton and Harefield & Guys and St. Thomas NHS Foundation Trust, London, UK
| | - Patrícia Sousa
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Rui J Cerqueira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - António S Barros
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal
| | - André P Lourenço
- Anaesthesiology Department, Centro Hospitalar Universitário São João, Porto, Portugal
| | - Adelino F Leite-Moreira
- Surgery and Physiology Department and Cardiovascular Research & Development Centre, Faculty of Medicine, University of Porto, Porto, Portugal - .,Cardiothoracic Surgery Department, Centro Hospitalar Universitário São João, Porto, Portugal
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22
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Seo EJ, Hong J, Lee HJ, Son YJ. Perioperative risk factors for new-onset postoperative atrial fibrillation after coronary artery bypass grafting: a systematic review. BMC Cardiovasc Disord 2021; 21:418. [PMID: 34479482 PMCID: PMC8414730 DOI: 10.1186/s12872-021-02224-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/24/2021] [Indexed: 12/20/2022] Open
Abstract
Background Postoperative atrial fibrillation (POAF) is the most common cardiac dysrhythmia to occur after coronary artery bypass grafting (CABG). However, the risk factors for new-onset POAF after CABG during the perioperative period have yet to be clearly defined. Accordingly, the aim of our systematic review was to evaluate the perioperative predictors of new-onset POAF after isolated CABG. Method Our review methods adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. We searched seven electronic databases (PubMed, Embase, CINAHL, PsycArticles, Cochrane, Web of Science, and SCOPUS) to identify all relevant English articles published up to January 2020. Identified studies were screened independently by two researchers for selection, according to predefined criteria. The Newcastle–Ottawa Scale was used to evaluate the quality of studies retained. Results After screening, nine studies were retained for analysis, including 4798 patients, of whom 1555 (32.4%) experienced new-onset POAF after CABG. The incidence rate of new-onset POAF ranged between 17.3% and 47.4%. The following risk factors were identified: old age (p < 0.001), a high preoperative serum creatinine level (p = 0.001), a low preoperative hemoglobin level (p = 0.007), a low left ventricle ejection fraction in Asian patients (p = 0.001), essential hypertension (p < 0.001), chronic obstructive pulmonary disease (p = 0.010), renal failure (p = 0.009), cardiopulmonary bypass use (p = 0.002), perfusion time (p = 0.017), postoperative use of inotropes (p < 0.001), postoperative renal failure (p = 0.001), and re-operation (p = 0.005). All studies included in the analysis were of good quality. Conclusions The risk factors identified in our review could be used to improve monitoring of at-risk patients for early detection and treatment of new-onset POAF after CABG, reducing the risk of other complications and negative clinical outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02224-x.
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Affiliation(s)
- Eun Ji Seo
- Ajou University College of Nursing and Research Institute of Nursing Science, Suwon, 16499, Republic of Korea
| | - Joonhwa Hong
- Department of Thoracic and Cardiovascular Surgery, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Hyeon-Ju Lee
- Department of Nursing, Tongmyoung University, Busan, 48520, Republic of Korea
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-ro Dongjak-Gu, Seoul, 06974, Republic of Korea.
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23
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Anand PA, Keshavamurthy S, Shelley EM, Saha S. Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting? Int J Angiol 2021; 30:202-211. [PMID: 34776820 PMCID: PMC8580610 DOI: 10.1055/s-0041-1735221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.
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Affiliation(s)
- Pavan Ashwini Anand
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Suresh Keshavamurthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Ellis M. Shelley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
| | - Sibu Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, Kentucky
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24
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Palaniappan A, Sellke F. An Analysis of Medical Malpractice Litigations in Coronary Artery Bypass Grafting from 1994-2019. Ann Thorac Surg 2021; 113:600-607. [PMID: 33794168 DOI: 10.1016/j.athoracsur.2021.03.042] [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: 01/20/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardiothoracic surgery is one of the more highly litigated medical specialties, and coronary artery bypass grafting (CABG) constitutes a substantial portion of cardiothoracic surgery cases. Therefore, understanding litigations relating to CABG would be of benefit to surgeons working to uphold the standards of care that their patients seek and minimize their own legal liability. This study analyzed CABG litigations to identify predictive factors of litigation and verdict type. METHODS This study utilized the Westlaw legal database to compile litigations from 1994-2019 across the United States, and resulted in 307 total litigations. After individual screening, 211 litigations met the criteria for inclusion, and were analyzed for demographic, clinical, chronological, and verdict characteristics. RESULTS Litigations were present in 33 U.S. states, with California, New York, and Florida having the most litigations. Defendant verdicts were reached in 67.78% of litigations, followed by 20.38% of plaintiff verdicts and 11.85% of settlements. Plaintiff verdicts were associated with the incidence of myocardial infarction during hospitalization. The winter season had the most litigations (42.18%), and the most defendant verdicts (37.76%). Patient mortality occurred in 47.39% of litigations. The most common alleged reason for litigation was a procedural error (55.45%). CONCLUSIONS Defendant verdicts were significantly associated with an alleged reason of procedural errors, an alleged reason of a failure to monitor, and congestive heart failure present in patients. The common nature of defendant verdicts, and the significantly greater occurrence of defendant verdicts during the highly-litigated winter season, suggest that surgeons frequently satisfy the legal standard of care.
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Affiliation(s)
- Ashwin Palaniappan
- Alpert Medical School, Brown University, Providence, Rhode Island; Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, Rhode Island.
| | - Frank Sellke
- Alpert Medical School, Brown University, Providence, Rhode Island; Division of Cardiothoracic Surgery, Rhode Island Hospital, Providence, Rhode Island
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