Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis

Clinical and financial outcomes associated with the utilization of right internal mammary artery versus radial artery in multivessel coronary artery bypass grafting

BACKGROUND

Multi-arterial coronary bypass grafting with the left internal mammary artery as a conduit has been shown to offer superior long-term survival compared to single-arterial coronary bypass grafting. Nevertheless, the selection of a secondary conduit between the right internal mammary artery and the radial artery remains controversial. Using a national cohort, we examined the relationships between the right internal mammary artery and the radial artery with acute clinical and financial outcomes.

METHODS

Adults undergoing on-pump multivessel coronary bypass grafting with left internal mammary artery as the first arterial conduit were identified in the 2016 to 2020 Nationwide Readmissions Database. Patients receiving either the right internal mammary artery or the radial artery, but not both, were included in the analysis. Multivariable regression models were fitted to examine the association between the conduits and in-hospital mortality, as well as additional secondary outcomes.

RESULTS

Of an estimated 49,798 patients undergoing multi-arterial coronary bypass grafting, 29,729 (59.7%) comprised the radial artery cohort. During the study period, the proportion of multi-arterial coronary bypass grafting utilizing the radial artery increased from 51.3% to 65.2% (nptrend <0.001). Following adjustment, the radial artery was associated with reduced odds of in-hospital mortality (adjusted odds ratio 0.44), prolonged mechanical ventilation (adjusted odds ratio 0.78), infectious complications (adjusted odds ratio 0.69), and 30-day nonelective readmission (adjusted odds ratio 0.77, all P < .05).

CONCLUSION

Despite no definite endorsement from surgical societies, the radial artery is increasingly utilized as a secondary conduit in multi-arterial coronary bypass grafting. Compared to the right internal mammary artery, the radial artery was associated with lower odds of in-hospital mortality, complications, and reduced healthcare expenditures. These results suggest that whenever feasible, the radial artery should be the favored conduit over the right internal mammary artery. Nevertheless, future studies examining long-term outcomes associated with these vessels remain necessary.

Case Management in Prevention of 30-Day Readmission in Post-Coronary Artery Bypass Graft Surgery

PURPOSE OF STUDY

Thirty-day readmission is associated with increased morbidity and mortality among postoperative coronary artery bypass graft (CABG) surgery patients. Interventions such as case management and follow-up care may reduce 30-day readmission. The purpose of this article is to report a study on modifiable factors that may have significant implications for case management in the prevention of readmission after CABG surgery.

PRIMARY PRACTICE SETTINGS

The study population included all the adult patients who underwent first-time CABG surgery from January 1, 2013, to January 1, 2016, from a Mid-South hospital.

METHODOLOGY AND SAMPLE

A retrospective case-control study was employed to examine 1,712 patients who underwent CABG surgery.

RESULTS

The results revealed that patients readmitted within 30 days had a significantly shorter length of stay (LOS) (6 days vs. 10 days; p < .0001), more days in intensive care unit (6 days vs. 4 days; p = .0391), and significantly higher diabetes/renal (4% vs. 1%), infection (17% vs. 2%), and respiratory-related diagnoses (10% vs. 1%; p < .0001).

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Among these factors, hospital LOS is a major factor that can be addressed through case management in addition to other modifiable risk factors. Understanding modifiable factors associated with higher readmission risk is crucial for effective intervention and case management planning.

An overview of reviews and synthesis across 440 studies examines the importance of hospital readmission predictors across various patient populations

OBJECTIVES

The scientific literature contains an abundance of prediction models for hospital readmissions. However, no review has yet synthesized their predictors across various patient populations. Therefore, our aim was to examine predictors of hospital readmissions across 13 patient populations.

STUDY DESIGN AND SETTING

An overview of systematic reviews was combined with a meta-analytical approach. Two thousand five hundred four different predictors were categorized using common ontologies to pool and examine their odds ratios and frequencies of use in prediction models across and within different patient populations.

RESULTS

Twenty-eight systematic reviews with 440 primary studies were included. Numerous predictors related to prior use of healthcare services (odds ratio; 95% confidence interval: 1.64; 1.42-1.89), diagnoses (1.41; 1.31-1.51), health status (1.35; 1.20-1.52), medications (1.28; 1.13-1.44), administrative information about the index hospitalization (1.23; 1.14-1.33), clinical procedures (1.20; 1.07-1.35), laboratory results (1.18; 1.11-1.25), demographic information (1.10; 1.06-1.14), and socioeconomic status (1.07; 1.02-1.11) were analyzed. Diagnoses were frequently used (in 37.38%) and displayed large effect sizes across all populations. Prior use of healthcare services showed the largest effect sizes but were seldomly used (in 2.57%), whereas demographic information (in 13.18%) was frequently used but displayed small effect sizes.

CONCLUSION

Diagnoses and patients' prior use of healthcare services showed large effects both across and within different populations. These results can serve as a foundation for future prediction modeling.

Predicting post-discharge complications in cardiothoracic surgery: A clinical decision support system to optimize remote patient monitoring resources

Cardiac surgery patients are highly prone to severe complications post-discharge. Close follow-up through remote patient monitoring can help detect adverse outcomes earlier or prevent them, closing the gap between hospital and home care. However, equipment is limited due to economic and human resource constraints. This issue raises the need for efficient risk estimation to provide clinicians with insights into the potential benefit of remote monitoring for each patient. Standard models, such as the EuroSCORE, predict the mortality risk before the surgery. While these are used and validated in real settings, the models lack information collected during or following the surgery, determinant to predict adverse outcomes occurring further in the future. This paper proposes a Clinical Decision Support System based on Machine Learning to estimate the risk of severe complications within 90 days following cardiothoracic surgery discharge, an innovative objective underexplored in the literature. Health records from a cardiothoracic surgery department regarding 5 045 patients (60.8% male) collected throughout ten years were used to train predictive models. Clinicians' insights contributed to improving data preparation and extending traditional pipeline optimization techniques, addressing medical Artificial Intelligence requirements. Two separate test sets were used to evaluate the generalizability, one derived from a patient-grouped 70/30 split and another including all surgeries from the last available year. The achieved Area Under the Receiver Operating Characteristic curve on these test sets was 69.5% and 65.3%, respectively. Also, additional testing was implemented to simulate a real-world use case considering the weekly distribution of remote patient monitoring resources post-discharge. Compared to the random resource allocation, the selection of patients with respect to the outputs of the proposed model was proven beneficial, as it led to a higher number of high-risk patients receiving remote monitoring equipment.

Non-pharmacological interventions to support coronary artery bypass graft (CABG) patient recovery following discharge: protocol for a scoping review

BACKGROUND

In Canada, approximately 15 000 people undergo coronary artery bypass grafting (CABG) each year. However, 9.5% of these patients are urgently readmitted to hospital within 30 days of surgery. Postoperative interventions following discharge play an important role in reducing readmissions and improving CABG patient outcomes. Therefore, it is important to determine effective interventions available to enhance CABG patient recovery following postoperative discharge.

OBJECTIVES

Our scoping review aims to identify non-pharmacological interventions available to support recovery of patients who are discharged after CABG in the community setting.

METHODS

The methodological framework described by Arksey and O'Malley will be applied to this review. Our search strategy will include electronic databases (Medline, Embase, Cochrane Library and CINAHL), and studies will be screened and reviewed by two independent reviewers. Studies looking at non-pharmacological interventions targeting patients who are discharged after CABG will be included. Preliminary searches were conducted March 2022 and following abstract screening, full-text screening was completed May 2023. Data extraction is planned to begin September 2023 with an expected finish date of October 2023. The study is expected to be completed by January 2024.

ETHICS AND DISSEMINATION

This scoping review will retrieve and analyse previously published studies in which informed consent was obtained by primary investigators. Therefore, no ethical review or approval will be required. This scoping review aims to enumerate available non-pharmacological interventions to support recovery of patients who are discharged after CABG and identify gaps in postoperative recovery after discharge to support the development of innovative and targeted interventions. On completion of this review, we will ensure broad dissemination of our findings through peer-reviewed, open-access journals, conference presentations and hold meetings to engage stakeholders, including clinicians, policy makers and others.

Safety and Outcomes of Outpatient Pleural Drainage in Symptomatic Postoperative Cardiac Surgery Patients

BACKGROUND

Symptomatic pleural effusions and anticoagulant/antiplatelet medication use in postoperative cardiac surgery are common. Guidelines and recommendations are currently mixed regarding medication management related to invasive procedure performance. We aimed to describe the outcomes of postoperative cardiac surgery patients referred for outpatient, symptomatic pleural effusion management.

METHODS

A retrospective study of post-cardiac surgery patients undergoing outpatient thoracentesis from 2016 to 2021 was performed. Demographics, operative details, pleural disease characteristics, outcomes, and complications were collected. Odds ratios with confidence intervals were estimated and adjusted by multivariate logistic regression to investigate the association with multiple thoracenteses.

RESULTS

A total of 110 patients underwent 332 thoracenteses. The median age was 68 years and most common operation was coronary artery bypass. Anticoagulation or antiplatelet use was identified in 97%. Thirteen complications were identified, with all major complications (n=3) related to bleeding. The amount of fluid present at the time of initial thoracentesis (>1500 milliliters) was associated with increased odds ratio of subsequent multiple thoracentesis (Unadjusted odds ratio, 6.75 (CI - 1.43 to 31.9). No other variables had a significant association with the need for multiple procedures.

CONCLUSION

Within a postoperative cardiac surgery population presenting with symptomatic pleural disease, we observed that thoracentesis performed on antiplatelet and/or anticoagulant medication is relatively safe. We also identified that many patients can be managed as outpatients and that most pleural effusions remain self-limited. The presence of larger amounts of pleural fluid at initial thoracentesis may be associated with increased odds for additional drainage.

Behavioral Weight Loss Interventions for Overweight and Obese Cardiac Rehabilitation Patients: A Systematic Review

The purpose of this systematic review was to identify evidence pertaining to the effectiveness of behavioral weight loss interventions for overweight and obese cardiac rehabilitation participants. A database search of PUBMED, CINAHL, PsycINFO, and PROSPERO yielded 10 eligible studies. Quantitative studies implementing behavioral weight loss interventions for overweight and obese adult cardiac rehabilitation participants were reviewed. Evidence supported the usefulness and effectiveness of behavioral weight loss interventions for overweight cardiac rehabilitation participants. With the limited number of studies and inclusion of quasi-experimental studies with comparative groups, it was not possible to determine the relative power of behavioral weight loss interventions across studies. In conclusion, behavioral weight loss interventions can be incorporated into cardiac rehabilitation or offered following cardiac rehabilitation to improve weight loss of overweight and obese cardiac rehabilitation participants. Findings reinforce national guidelines emphasizing the role of cardiac rehabilitation to address secondary cardiovascular disease risk factor modification, including integrating behavioral weight loss programs in cardiac rehabilitation, or referring overweight patients to weight management programs following completion of cardiac rehabilitation.

Nonelective coronary artery bypass graft outcomes are adversely impacted by Coronavirus disease 2019 infection, but not altered processes of care: A National COVID Cohort Collaborative and National Surgery Quality Improvement Program analysis

Objective

The effects of Coronavirus disease 2019 (COVID-19) infection and altered processes of care on nonelective coronary artery bypass grafting (CABG) outcomes remain unknown. We hypothesized that patients with COVID-19 infection would have longer hospital lengths of stay and greater mortality compared with COVID-negative patients, but that these outcomes would not differ between COVID-negative and pre-COVID controls.

Methods

The National COVID Cohort Collaborative 2020-2022 was queried for adult patients undergoing CABG. Patients were divided into COVID-negative, COVID-active, and COVID-convalescent groups. Pre-COVID control patients were drawn from the National Surgical Quality Improvement Program database. Adjusted analysis of the 3 COVID groups was performed via generalized linear models.

Results

A total of 17,293 patients underwent nonelective CABG, including 16,252 COVID-negative, 127 COVID-active, 367 COVID-convalescent, and 2254 pre-COVID patients. Compared to pre-COVID patients, COVID-negative patients had no difference in mortality, whereas COVID-active patients experienced increased mortality. Mortality and pneumonia were higher in COVID-active patients compared to COVID-negative and COVID-convalescent patients. Adjusted analysis demonstrated that COVID-active patients had higher in-hospital mortality, 30- and 90-day mortality, and pneumonia compared to COVID-negative patients. COVID-convalescent patients had a shorter length of stay but a higher rate of renal impairment.

Conclusions

Traditional care processes were altered during the COVID-19 pandemic. Our data show that nonelective CABG in patients with active COVID-19 is associated with significantly increased rates of mortality and pneumonia. The equivalent mortality in COVID-negative and pre-COVID patients suggests that pandemic-associated changes in processes of care did not impact CABG outcomes. Additional research into optimal timing of CABG after COVID infection is warranted.

The effect of early follow-up after open cardiac surgery in a student clinic

Objectives. Readmission rates following open cardiac surgery are high, affecting patients and the cost of care. This study aimed to investigate the effect of early additional follow-up after open cardiac surgery when 5th-year medical students conducted follow-ups under the supervision of physicians. The primary endpoint was unplanned cardiac-related readmissions within one year. The secondary outcomes were the detection of impending complications and health-related quality of life (HRQOL). Methods. Patients undergoing open cardiac surgery were prospectively included. For intervention, additional follow-up visits, including point-of-care ultrasound, were conducted by supervised 5th-year medical students on postoperative days 3, 14 and 25. Unplanned cardiac-related readmissions, including emergency department visits, were registered within the first year of surgery. Danish National Health Survey 2010 questionnaire was used for HRQOL. In standard follow-up, all patients were seen 4-6 weeks postoperative. Results. For data analysis, 100 of 124 patients in the intervention group and 319 of 335 patients in the control group were included. The 1-year unplanned readmission rates did not differ; 32% and 30% in the intervention and control groups, respectively (p = 0.71). After discharge, 1% of patients underwent pericardiocentesis. The additional follow-up initiated scheduled drainage, contrary to more unscheduled/acute drainages in the control group. Pleurocentesis was more common in the intervention group (17% (n = 17) vs 8% (n = 25), p = 0.01) and performed earlier. There was no difference between groups on HRQOL. Conclusion. Supervised student-led follow-up of newly cardiac-operated patients did not alter readmission rates or HRQOL but may detect complications earlier and initiate non-emergent treatment of complications.

Postoperative pulmonary complications in patients undergoing aortic surgery: A single-center retrospective study

Postoperative pulmonary complications (PPCs) are among the most common complications after cardiovascular surgery. This study aimed to explore the real incidence of and risk factors for PPC in patients with acute type A aortic dissection (ATAAD) who underwent total aortic arch replacement combined with the frozen elephant trunk (TAR + FET). In total, 305 ATAAD patients undergoing TAR + FET from January 2021 to August 2022 in a single-center were divided into PPCs or non-PPCs group. The incidence of PPCs was calculated, risk factors of PPCs were analyzed, and postoperative outcomes were compared between these 2 groups. The incidence of any PPC was 29.2%. And the incidence of respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, acute respiratory distress syndrome, aspiration pneumonitis, pulmonary edema and bronchospasm was 23.0%, 12.5%, 10.5%, 1.0%, 0.7%, 1.0%, 0%, 0.7%, 0%, respectively. The logistic regression analysis revealed that the history of diabetes, history of renal dysfunction, preoperative SpO2 <90%, cardiopulmonary bypass duration, fresh frozen plasma volume and platelet concentrates volume were independent risk factors for PPCs. Among 2 groups, postoperative ventilation duration, postoperative length of stay in intensive care unit and hospital were (73.5 ± 79.0 vs 24.8 ± 35.2 hours; P < .001), (228.3 ± 151.2 vs 95.2 ± 72.0 hours; P < .001) and (17.9 ± 8.8 vs 11.5 ± 6.2 days; P < .001). There was no difference between 2 groups of in-hospital mortality rate. Additionally, other short-term outcomes were also significantly poorer in patients with PPCs. PPCs are common in ATAAD patients undergoing TAR + FET, and could be multifactorial. PPCs occurrence are associated with poor patient outcomes postoperatively and worth further investigation.

Clinical characteristics and outcome of Mycobacterium chimaera infections after cardiac surgery: systematic review and meta-analysis of 180 heater-cooler unit-associated cases

OBJECTIVES

Since 2013, heater-cooler unit (HCU) associated Mycobacterium chimaera infections linked to a global outbreak have been described. These infections were characterised by high morbidity and mortality due to delayed diagnosis, as well as challenges in antimycobacterial and surgical therapy. This study aimed to investigate the clinical characteristics and outcome of published cases of HCU-associated M. chimaera infections.

METHODS

We searched PubMed and the Web of Science until 15 June 2022 for case reports, case series, and cohort studies, without language restriction, on patients with M. chimaera infection and a prior history of cardiac surgery. In this systematic review of case reports, no risk of bias assessment could be performed. Clinical, microbiological, and radiological features were recorded. Logistic regression and time-to-event analyses were performed to identify the potential factors associated with better survival.

RESULTS

One hundred eighty patients from 54 publications were included. Most patients underwent surgical aortic valve (67.0%; 118/176 of patients with available data) or combined aortic valve and root replacement (15.3%; 27/176). The median period between the time point of surgery and the first symptoms was 17 months (interquartile range 13-26 months). The overall case fatality rate was 45.5% (80/176), with a median survival of 24 months after the initiation of antimycobacterial therapy or diagnosis. A reoperation (including the removal or exchange of foreign material) was associated with better survival in multivariate logistic regression (OR 0.32 for lethal events; 95% CI 0.12-0.79; p 0.015) and in time-to-event analysis (p 0.0094).

DISCUSSION

This systematic review and meta-analysis confirm the high overall mortality of HCU -associated disseminated M. chimaera infections after cardiac surgery. A reoperation seems to be associated with better survival. Physicians have to stay aware of this infection, as patients might still be present today due to the long latency period.

Patient-Centred Outcomes after Totally Endoscopic Cardiac Surgery: One-Year Follow-Up

Patient-centred outcomes have grown in popularity over recent years in surgical care research. These patient-centred outcomes can be measured through the health-related quality of life (HRQL) without professional interpretations. In May 2022, a study regarding patient-centred outcomes up to 90 days postoperatively was published. Fourteen days after surgery, the HRQL decreased and returned to baseline levels after 30 days. Next, the HRQL significantly improved 90 days postoperatively. However, this study only focuses on a short-term follow-up of the patients. Hence, this follow-up study aims to assess the HRQL one year after totally endoscopic cardiac surgery. At baseline, 14, 30, and 90 days, and one year after surgery, the HRQL was evaluated using a 36-item short form and 5-dimensional European QoL questionnaires (EQ-5D). Using the 36-item short form questionnaire, a physical and mental component score is calculated. Over the period of one year, this physical and mental component score and the EQ-5D index value significantly improve. According to the visual analogue scale of the EQ-5D, patients score their health significantly higher one year postoperatively. In conclusion, after endoscopic cardiac surgery, the HRQL is significantly improved 90 days postoperatively and remains high one year afterward.

Current concepts in coronary artery revascularisation

Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.

Impact of Post-Operative Infection after CABG on Long-Term Survival

Coronary artery bypass grafting (CABG) is one of the most common cardiac surgical procedures. It is commonly known that post-operative infection has a negative impact on the patient's short-term treatment outcomes and long-term prognosis. The aim of the present study was to assess the impact of perioperative infection on 5-year and 10-year survival in patients undergoing elective on-pump CABG surgery. The present prospective observational study was carried out between 1 July 2010 and 31 August 2012 among patients undergoing cardiac surgery at our centre. Infections were identified according to the ECDC definitions. We initially assessed the incidence of infection and its relationship with the parameters analysed. We then analysed the effect of particular parameters, including infection, on 5-year and 10-year survival after surgery. We also analysed the impact of particular types of infection on the risk of death within the period analysed. The significant risk factors for reduced survival were age (HR 1.05, CI 1.02-1.07), peripheral artery disease (HR 1.99, CI 1.28-3.10), reduced LVEF after surgery (HR 0.96, CI 0.94-0.99), post-operative myocardial infarction (HR 1.45, CI 1.05-2.02) and infection (HR 3.10, CI 2.20-4.28). We found a strong relationship between post-operative infections and 5-year and 10-year mortality in patients undergoing CABG. Pneumonia and BSI were the only types of infection that were found to have a significant impact on increased long-term mortality after CABG surgery.

Five-Year Hospital Readmission After Coronary Artery Bypass Surgery and the Association With Off-Pump Surgery and Sex

Background Limited data exist on long-term readmission and its association with patient and procedural characteristics after coronary artery bypass grafting. We aimed to investigate 5-year readmission after coronary artery bypass grafting and specifically focus on the role of sex and off-pump surgery. Methods and Results We performed a post hoc analysis of the CORONARY (Coronary Artery Bypass Grafting [CABG] Off or On Pump Revascularization) trial, involving 4623 patients. The primary outcome was all-cause readmission, and the secondary outcome was cardiac readmission. Cox models were used to investigate the association of outcomes with sex and off-pump surgery. Hazard function for sex was studied over time using a flexible, fully parametric model, and time-segmented analyses were performed accordingly. Rho coefficient was calculated for the correlation between readmission and long-term mortality. Median follow-up was 4.4 years (interquartile range, 2.9-5.4 years). The cumulative incidence rates of all-cause and cardiac readmission were 29.4% and 8.2% at 5 years, respectively. Off-pump surgery was not associated with either all-cause or cardiac readmission. The hazard for all-cause readmission in women over time was constantly higher than the hazard for men (hazard ratio [HR], 1.21 [95% CI, 1.04-1.40]; P=0.011). Time-segmented analyses confirmed the higher risk for all-cause (HR, 1.21 [95% CI, 1.05-1.40]; P<0.001) and cardiac (HR, 1.26 [95% CI, 1.03-1.69]; P=0.033) readmission in women after the first 3 years of follow-up. All-cause readmission was strongly correlated with long-term all-cause mortality (Rho, 0.60 [95% CI, 0.48-0.66]), whereas cardiac readmission was strongly correlated with long-term cardiovascular mortality (Rho, 0.60 [95% CI, 0.13-0.86]). Conclusions Readmission rates are substantial at 5 years after coronary artery bypass grafting and are higher in women but not with off-pump surgery. Registration URL: http://www.clinicaltrials.gov/; Unique identifier: NCT00463294.

Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity

The aim. To analyze the effectiveness of the developed algorithms for the perioperative management of high-risk cardiac surgery patients with coronary artery disease (CAD) and polymorbidity. Materials and methods. We analyzed perioperative management of 354 high-risk cardiac surgery patients with CAD with EuroSCORE II predicted mortality >5%, among which 194 (54.8%) underwent isolated coronary artery bypass grafting, and 160 (45.2%) had surgical myocardial revascularization with accompanying valvular pathology correction or left ventricular postinfarction aneurysm resection. All the patients were discharged after cardiac surgery performed at the Department of Surgical Treatment of CAD of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 2009 to 2019. As part of the study, general clinical examinations, electrocardiography, echocardiography, coronary angiography, cardiosurgical treatment were provided, and perioperative patient management protocols were developed and implemented. Results. Based on the conducted detailed analysis, it was established that the success of surgical revascularization of the myocardium depends not only on cardiac factors, but also on the compensation of concomitant diseases, the work of an experienced cardiac team consisting of a cardiologist, an interventionist, an anesthesiologist, a cardiac surgeon, and an intensivist. Treatment and prevention measures should be personalized and aimed at timely response to changes in laboratory and hemodynamic indicators of patients at all stages of their management, as well as stabilization of concomitant diseases. An important point in the preoperative preparation of cardiac surgery patients is verification of concomitant diseases with the aim of their timely compensation. The implemented algorithm for searching for comorbid conditions made it possible to improve the diagnosis of initial disorders of glucose metabolism, abnormal uric acid levels and cerebrovascular disease. Lowering the glucose level according to the developed algorithm of management of patients with impaired glucose metabolism in the perioperative period made it possible to reduce the number of postoperative wound infections by 3.4% and arrhythmological complications by 19.4%. Correction of drug therapy taking into account the glomerular filtration rate made it possible to avoid postoperative hemodialysis. Preventive prescription of therapeutic doses of proton pump inhibitors against the background of dual antiplatelet therapy, according to the developed protocol, led to a decrease in postoperative gastroduodenal complications from 5.1% to 0.3%. Conclusions. Implementation of the system of personalized treatment and preventive management of patients in the perioperative period made it possible to reduce postoperative complications from 16.7% to 4% (p=0.0190).

Thoracic sarcopenia predicts clinical outcomes in patients undergoing coronary artery bypass grafting: A 6-year cohort study

BACKGROUND

The relationship between thoracic sarcopenia and clinical outcomes in patients underwent coronary artery bypass grafting (CABG) is unclear. This study aims to evaluate whether thoracic sarcopenia has a satisfactory prognostic effect on adverse outcomes after CABG.

METHODS

From December 2015 to May 2021, 338 patients who underwent isolated CABG at our institution were recruited in this study. Skeletal muscle area at T12 level acquired by chest computed tomography (CT) was normalized to assess thoracic sarcopenia. Univariate and multivariate analyses were performed to evaluate the risk factors of postoperative complications and overall survival (OS).

RESULTS

The prevalence of thoracic sarcopenia in patients underwent CABG was 13.02%. The incidence of total major complication was significantly higher in thoracic sarcopenia group (81.8% vs 61.9%, p = 0.010). Thoracic sarcopenic patients also had longer postoperative hospital stays (p = 0.047), intensive care unit (ICU) stays (p = 0.001), higher costs (p = 0.001) and readmission rates within 30 days of discharge (18.2% vs 4.4%, p = 0.001). Patients without thoracic sarcopenia showed significantly higher OS at the 2-year follow-up period (93.9% vs 72.7%, p<0.001). Multivariate analyses demonstrated that thoracic sarcopenia was significantly and independently associated with postoperative complications and long-term OS after CABG.

CONCLUSION

Thoracic sarcopenia is an effective clinical predictor of adverse postoperative complications and long-term OS in patients underwent CABG. Thoracic sarcopenia based on chest CT should be included in preoperative risk assessment of CABG.

Conventional and two-dimensional strain echocardiography in predicting postoperative atrial fibrillation after coronary artery bypass grafting surgery

Background

Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery.

Methods

All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded.

Results

Of the 105 patients included, 85 patients (81%) were men with a mean age of 60.26±10.61 years. POAF was seen in 22.9% of patients during hospitalization, and AF duration was 10 hours (median; IQR: 2.0-19.5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0.018). Patients with sinus rhythm had higher rates of LA reservoir (26.97±6.87 VS. 20.46±4.27, p<0.001), LA contractile (14.98±3.68 VS. 12.76±3.72, p =0.012) and LA global strain (24.28±6.57 VS. 17.71±4.11, p<0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0.014) and LA global strain (p=0.027) were independent predictors of AF detection.

Conclusion

Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Single-blind, randomized study comparing clinical equivalence of trulene and prolene polypropylene sutures in elective primary coronary artery bypass graft surgery

BACKGROUND

Coronary artery bypass graft surgery (CABG) is one of the principle therapies for coronary artery disease, as it improves survival rate and quality of life (QoL). Polypropylene suture is commonly used in vascular and cardiac surgeries for anastomosis due to its long-term tensile strength and minimal tissue trauma. This study compared the clinical equivalence of Trulene® (Healthium Medtech Limited) and Prolene® (Ethicon-Johnson & Johnson) polypropylene sutures regarding incidence of myocardial infarction, stroke, renal failure and cardiac death (MACCE) occurring up to 26 weeks' period post-CABG surgery.

METHODS

This multicenter, prospective, two-arm, parallel-group, randomized (1:1), single-blind study (n = 89) was conducted between August 2020 and September 2021. The primary endpoint, post-surgery cumulative incidence of MACCE was evaluated. In addition, anastomotic revision, surgical site infection (SSI), operative time, length of post-operative hospital stay, repeat revascularization, intraoperative suture handling characteristics, time taken to return to work and resume normal day to day activities, subject satisfaction score and QoL, and other adverse events were also recorded.

RESULTS

A total of 80 (89.89%) males and 9 (10.11%) females participated in the study. No incidence of MACCE was recorded in any of the study participants. Non-significant difference was observed in anastomotic revision, SSI, operative time, post-operative hospital stay, revascularization, return to work and normal day-to-day activities, subject satisfaction score and QoL, and intraoperative handling parameters (except ease of passage) between the treatment groups, Trulene® and Prolene®. Compared to screening visit, proportion of subjects with 'no problems' for each QoL dimension and the mean visual analogue scale increased with each subsequent follow-up visit.

CONCLUSION

Trulene® polypropylene suture is clinically equivalent to Prolene® polypropylene suture and is safe and effective for anastomosis construction in CABG surgery during a routine clinical procedure. Trial registration CTRI Registration No.: CTRI/2020/05/025157 (Registered on: 13/05/2020).

Enhanced Telehealth Home-Monitoring Intervention for Vulnerable and Frail Patients after Cardiac Surgery (THE-FACS Pilot Intervention Study)

Background

Frail cardiac surgery patients have an increased risk of worse postoperative outcomes. The purpose of this study was to evaluate the implementation of a novel Telehealth Home monitoring Enhanced-Frailty And Cardiac Surgery (THE-FACS) intervention and determine its impact on clinical outcomes in frail patients post-cardiac surgery.

Methods

Frail/vulnerable patients defined by Edmonton Frailty Scale (EFS > 4) undergoing cardiac surgery were prospectively enrolled (November 2019 -March 2020) at the New Brunswick Heart Centre. Exclusion criteria included age < 55 years, emergent status, minimally invasive surgery, lack of home support, and > 10-days postoperative hospital stay. Following standard training on THE-FACS, participants were sent home with a tablet device to answer questions about their health/recovery and measure blood pressure for 30-consecutive days. Transmitted data were monitored by trained cardiac surgery follow-up nurses. Patients were contacted only if the algorithm based on the patient’s self-collected data triggered an alert. Patients who completed the study were compared to historical controls. The primary outcome of interest was to determine the number of patients that could complete THE-FACS; secondary outcomes included participant/caregiver satisfaction and impact on hospital readmission.

Results

We identified 86 eligible (EFS > 4), out of 254 patients scheduled for elective cardiac surgery during the study period (vulnerable: 34%). The patients who consented to participate in THE-FACS (64/86, 74%) had a mean age of 69.1 ± 6.4 years, 25% were female, 79.7% underwent isolated Coronary Artery Bypass Graft (CABG) and median EFS was 6 (5–8). 29/64 (45%) were excluded post-enrollment due to prolonged hospitalization (15/64) or requirement for hospital-to-hospital transfer (12/64). Of the remaining 35 patients, 21 completed the 30-day follow-up (completion rate:60%). Reasons for withdrawal (14/35, 40%) were mostly due to technical difficulties with the tablet. Hospital readmission, although non-significant, was reduced in THE-FACS participants compared to controls (0% vs. 14.3%). A satisfaction survey revealed > 90% satisfaction and ~ 67% willingness to re-use a home monitoring device.

Conclusions

THE-FACS intervention can be used to successfully monitor vulnerable patients returning home post-cardiac surgery. However, a significant number of frail patients could not benefit from THE-FACS given prolonged hospitalization and technological challenges. Our findings suggest that despite overall excellent satisfaction in participants who completed THE-FACS, there remain major challenges for wide-scale implementation of technology-driven home monitoring programs as only 24% completed the study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03531-4.

Chronic kidney disease, risk of readmission, and progression to end-stage renal disease in 519,387 patients undergoing coronary artery bypass grafting

Objective

The association between chronic kidney disease and adverse outcomes after coronary artery bypass grafting is well established; in contrast, the association between chronic kidney disease and readmission has been less thoroughly investigated. We hypothesized that patients at higher chronic kidney disease stages have greater risk of readmission, poorer operative outcomes, and greater hospitalization cost.

Methods

Using the 2016-2018 Nationwide Readmissions Database, we identified 519,387 patients who underwent isolated coronary artery bypass grafting. Patients were stratified by chronic kidney disease stage based on International Classification of Diseases 10^th Revision classification. Multivariable logistic regression was used to assess risk factors for in-hospital mortality and 90-day readmission.

Results

Hospital readmission, in-hospital mortality, and cost progressively increased with worsening chronic kidney disease stage; patients with end-stage renal disease had the highest in-hospital mortality rate (7.2%), hospitalization costs ($59,616) (P < .001), and 90-day readmission rate (40%) (P < .001). Chronic kidney disease stage greater than 3 was associated with in-hospital mortality (odds ratio, 1.56, 95% confidence interval, 1.40-1.73; P < .001) and 90-day readmission (odds ratio, 1.66, 95% confidence interval, 1.56-1.76; P < .001). At 30 days after discharge, new-onset dialysis dependence was more frequent in patients readmitted with chronic kidney disease 4 to 5 (8.9%; n = 1495) than in patients with chronic kidney disease 1 to 3 (1.4%; n = 8623) and patients without chronic kidney disease (0.3%; n = 38,885). At 90 days after discharge, dialysis dependence increased to 11.1% (n = 1916) in readmitted patients with chronic kidney disease 4 to 5 but remained stable for patients with chronic kidney disease 1 to 3 (1.4%; n = 10,907) and patients without chronic kidney disease (0.3%; n = 50,200).

Conclusions

Chronic kidney disease stage is strongly associated with mortality, new-onset dialysis dependence, readmission, and higher cost after coronary artery bypass grafting. Patients with chronic kidney disease 4 and 5 and patients with end-stage renal disease are readmitted at the highest rates. Although further research is needed, a targeted approach may reduce costly readmissions and improve outcomes after coronary artery bypass grafting in patients with chronic kidney disease.

Effects of Video-Based Patient Education and Consultation on Unplanned Health Care Utilization and Early Recovery After Coronary Artery Bypass Surgery (IMPROV-ED): Randomized Controlled Trial

BACKGROUND

Health care utilization after coronary artery bypass graft (CABG) surgery is high and is partly of an unplanned nature. eHealth applications have been proposed to reduce care consumption, which involve and assist patients in their recovery. In this way, health care expenses could be reduced and quality of care could be improved.

OBJECTIVE

The aim of this study was to evaluate if an eHealth program can reduce unplanned health care utilization and improve mental and physical health in the first 6 weeks after CABG surgery.

METHODS

A single-blind randomized controlled trial was performed, in which patients scheduled for nonacute CABG surgery were included from a single center in the Netherlands between February 2020 and October 2021. Participants in the intervention group had, alongside standard care, access to an eHealth program consisting of online education videos and video consultations developed in conjunction with the Dutch Heart Foundation. The control group received standard care. The primary outcome was the volume and costs of a composite of unplanned health care utilization, including emergency department visits, outpatient clinic visits, rehospitalization, patient-initiated telephone consultations, and visits to a general practitioner, measured using the Medical Technology Assessment Medical Consumption Questionnaire. Patient-reported anxiety and recovery were also assessed. Intention-to-treat and "users-only" analyses were used.

RESULTS

During the study period, 280 patients were enrolled and randomly allocated at a 1:1 ratio to the intervention or control group. The intention-to-treat analysis consisted of 136 and 135 patients in the intervention and control group, respectively. At 6 weeks, the primary endpoint had occurred in 43 of 136 (31.6%) patients in the intervention group and in 61 of 135 (45.2%) patients in the control group (hazard ratio 0.56, 95% CI 0.34-0.92). Recovery was faster in the intervention group, whereas anxiety was similar between study groups. "Users-only" analysis yielded similar results.

CONCLUSIONS

An eHealth strategy comprising educational videos and video consultations can reduce unplanned health care utilization and can aid in faster patient-reported recovery in patients following CABG surgery.

TRIAL REGISTRATION

Netherlands Trial Registry NL8510; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8510.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1007/s12471-020-01508-9.

Articulation of postsurgical patient discharges: coordinating care transitions from hospital to home

BACKGROUND

Cardiac surgery patients are at high risk for readmissions after hospital discharge- few of these readmissions are preventable by mitigating barriers underlying discharge care transitions. An in-depth evaluation of the nuances underpinning the discharge process and the use of tools to support the process, along with insights on patient and clinician experiences, can inform the design of evidence-based strategies to reduce preventable readmissions.

OBJECTIVE

The study objectives are 3-fold: elucidate perceived factors affecting the postsurgical discharge care transitions of cardiac surgery patients going home; highlight differences among clinician and patient perceptions of the postsurgical discharge experiences, and ascertain the impact of these transitions on patient recovery at home.

METHODS

We conducted a prospective multi-stakeholder study using mixed methods, including general observations, patient shadowing, chart reviews, clinician interviews, and follow-up telephone patient and caregiver surveys/interviews. We followed thematic and content analyses.

FINDINGS

Participants included 49 patients, 6 caregivers, and 27 clinicians. We identified interdependencies between the predischarge preparation, discharge education, and postdischarge follow-up care phases that must be coordinated for effective discharge care transitions. We identified several factors that could lead to fragmented discharges, including limited preoperative preparation, ill-defined discharge education, and postoperative plans. To address these, clinicians often performed behind-the-scenes work, including offering informal preoperative preparation, tailoring discharge education, and personalizing postdischarge follow-up plans. As a result, majority of patients reported high satisfaction with care transitions and their positive impact on their home recovery.

DISCUSSION AND CONCLUSIONS

Articulation work by clinicians (ie, behind the scenes work) is critical for ensuring safety, care continuity, and overall patient experience during care transitions. We discuss key evidence-based considerations for re-engineering postsurgical discharge workflows and re-designing discharge interventions.