Long-term beneficial effect of coronary artery bypass grafting in patients with COPD

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Risk Score for Predicting Long-Term Mortality Following Off-Pump Coronary Artery Bypass Grafting

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) comprises 15-30% of all bypass grafting surgeries. The currently available perioperative scores such as Euroscore and STS score do not specifically predict long-term mortality after off-pump procedures. The neutrophil-to-lymphocyte ratio (NLR) is one of the new, easily accessible markers of inflammation with proven predictive value in cardiovascular diseases. We aimed to develop the first risk score for long-term mortality after OPCAB and to determine if the perioperative value of NLR predicts long-term mortality in OPCAB patients.

METHODS

In total, 440 consecutive patients with multivessel stable coronary artery disease undergoing OPCAB were recruited. Differential leukocyte counts were obtained by a routine hematology analyzer. Data regarding mortality during a median follow-up time of 5.3 years were obtained from the Polish National Health Service database. An independent population of 242 patients served as a validation cohort.

RESULTS

All-cause mortality was influenced by different clinical risk factors. In multivariate regression analysis, chronic obstructive pulmonary disease, stroke history, post-operative NLR and LVEF were independent predictors of mortality. Combing all independent predictors predicted long-term all-cause mortality with 68.5% sensitivity and 71.5% specificity (AUC = 0.704, p < 0.001). After weighing these variables according to their estimates in a multivariate regression model, we developed a score to predict mortality in patients undergoing OPCAB (PREDICT-OPCAB Score, ranging from 0 to 10). Patients with a high score were at higher risk of mortality within the median 5.3 years of follow-up (score 0-3: 8.3%; 4-6: 27.0%; 7-10: 40.0%; p < 0.001 for score 0-3 vs. 4-6 and 7-10). This association was confirmed in the validation cohort.

CONCLUSIONS

We developed and validated the first simplified risk score to predict mortality following OPCAB based on easily accessible clinical factors. This risk score can be used when obtaining a patient's informed consent and as an aid in determining treatment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of vital capacity on outcome after total arch replacement

OBJECTIVES

Although chronic obstructive pulmonary disease has been recognized as a significant risk factor for open-heart surgery, the relationship between vital capacity and postoperative outcomes remains unclear. Our objective was to analyze the effect of vital capacity on outcomes after total arch replacement.

METHODS

Between January 2003 and December 2018, 228 patients undergoing total arch replacement who were elective cases with preoperative spirometry records were retrospectively reviewed. Patients were divided into two groups, based on whether their preoperative vital capacity was less than or greater than 2.5 L. We compared perioperative data and long-term outcome after adjusting their backgrounds by propensity score matching analysis.

RESULTS

The lower vital capacity group had more tracheostomy patients (5.1% vs 0.0%; p = 0.045). The actuarial survival rate was 58.0% in the lower vital capacity group and 86.3% in the higher vital capacity group at 8 years. Log-rank analysis revealed a significant difference between the two groups (p = 0.011). In the multivariate Cox proportional hazard model, vital capacity < 2.5 L (p = 0.024) and estimated glomerular filtration rate < 30mL/minute/1.73 m² (p = 0.012) showed a significant association with a higher risk of long-term mortality.

CONCLUSIONS

Vital capacity should be considered an important risk factor for postoperative respiratory complications and long-term mortality in patients undergoing total arch replacement.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of Renal and Hepatic Tissue-Protective Effects of N-Acetylcysteine via Ammonia Metabolism: A Prospective Randomized Study

Background

The present study sought to assess the renal and liver protective effect of N-acetylcysteine through NH3 and urea metabolism in patients with chronic obstructive pulmonary disease who were scheduled for coronary artery bypass grafting surgery.

Material/Methods

Patients with chronic obstructive pulmonary disease (COPD) who were scheduled for coronary artery bypass grafting were divided into 2 groups so as to receive (Group 1, n=35) or not receive (Group 2, n=35) 900 mg/day of n-acetylcysteine for 7 days before the operation starting from their admission to the service by a pulmonologist with the purpose of treating COPD until the day of surgery. Both groups were subjected to the same anesthesia protocol. Blood samples were taken preoperatively, within the first 15^th minute following cessation of the cardiopulmonary bypass, at postoperative 24^th hour, and at postoperative 48^th hour. Blood tests included ammonia (NH3), lactate, blood urea nitrogen, creatinine, aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), troponin I (Tn I), and creatinine kinase-muscle brain (CKMB).

Results

There was a significant difference between the groups’ NH3 and lactate levels after cardiopulmonary bypass, postoperative 24^th hour, and postoperative 48^th hour (respectively, NH3: 39.0±8.8 vs. 55.4±19.6 and 40.1±8.4 vs. 53.2±20.2 mcg/dl, lactate: 1.7±0.9 vs. 2.1±1.2 and 1.2±0.5 vs. 1.8±1.4 mmol/L; p<0.01). Creatinine and BUN levels in Group 2 were found to be significantly higher at the postoperative 48^th hour compared to the levels of Group 1 (P<0.05).

Conclusions

N-acetylcysteine pretreatment appears to improve renal and hepatic functions through regulation of ammonia and nitrogen metabolism and reduction of lactate in patients with chronic obstructive pulmonary disease who undergo coronary artery bypass grafting surgery. We found that N-acetylcysteine improved kidney and/or liver functions.

Arterial Blood Gas Analysis in Chronic Obstructive Pulmonary Disease Patients Undergoing Coronary Artery Bypass Surgery

OBJECTIVES

We aimed to investigate the impact of arterial blood gas (ABG) on morbidity and mortality in chronic obstructive pulmonary disease (COPD) patients undergoing CABG surgery.

MATERIAL AND METHODS

The records for 75 COPD patients who underwent elective CABG surgery our institution clinic between November 2008 to 2011 and had a forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) ≤ 70% value in the pulmonary function tests (PFT) performed prior to the surgery were evaluated retrospectively. COPD patients were divided into two groups; Group 1; FEV₁ ≥ 60% and Group 2; FEV₁ ≤ 59%. Groups were compared for mortality and adverse events after identification of other preoperative and postoperative factors that could affect mortality and adverse events. An ABG was obtained immediately before and 3 to 6 hours after surgery to study the predictive value of ABG in seperate COPD groups.

RESULTS

There were no significant differences in patients with high partial pressure carbondioxide (PaCO₂) preoperative values compared to patients with normal values. Also there were no significant differences in patients with lower partial pressure of oxygen (PaO₂) preoperative values compared to patients with normal values in terms of mortality. Postoperative myocardial infarction (MI) was significantly higher in patients with low PaO₂ values (p< 0.05).

CONCLUSION

In conclusion, in our study, there could not be found a relation between the degree of preoperative obstruction and mortality for COPD patients who underwent CABG surgery. ABG was not found useful for predicting mortality in COPD patients undergoing CABG surgery, but could be useful to predict postoperative MI in patients with COPD.

Do preoperative pulmonary function indices predict morbidity after coronary artery bypass surgery?

Context:

The reported prevalence of chronic obstructive pulmonary disease (COPD) varies among different groups of cardiac surgical patients. Moreover, the prognostic value of preoperative COPD in outcome prediction is controversial.

Aims:

The present study assessed the morbidity in the different levels of COPD severity and the role of pulmonary function indices in predicting morbidity in patients undergoing coronary artery bypass graft (CABG).

Settings and Design:

Patients who were candidates for isolated CABG with cardiopulmonary bypass who were recruited for Tehran Heart Center-Coronary Outcome Measurement Study.

Methods:

Based on spirometry findings, diagnosis of COPD was considered based on Global Initiative for Chronic Obstructive Lung Disease category as forced expiratory volume in 1 s [FEV1]/forced vital capacity <0.7 (absolute value, not the percentage of the predicted). Society of Thoracic Surgeons (STS) definition was used for determining COPD severity and the patients were divided into three groups: Control group (FEV1 >75% predicted), mild (FEV1 60–75% predicted), moderate (FEV1 50–59% predicted), severe (FEV1<50% predicted). The preoperative pulmonary function indices were assessed as predictors, and postoperative morbidity was considered the surgical outcome.

Results:

This study included 566 consecutive patients. Patients with and without COPD were similar regarding baseline characteristics and clinical data. Hypertension, recent myocardial infarction, and low ejection fraction were higher in patients with different degrees of COPD than the control group while male gender was more frequent in control patients than the others. Restrictive lung disease and current cigarette smoking did not have any significant impact on postoperative complications. We found a borderline P = 0.057 with respect to respiratory failure among different patients of COPD severity so that 14.1% patients in control group, 23.5% in mild, 23.4% in moderate, and 21.9% in severe COPD categories developed respiratory failure after CABG surgery.

Conclusion:

Among post-CABG complications, patients with different levels of COPD based on STS definition, more frequently developed respiratory failure. This finding may imply the prognostic value of preoperative pulmonary function test for determining COPD severity and postoperative morbidities.

Postoperative Complications After Coronary Artery Bypass Grafting in Patients With Chronic Obstructive Pulmonary Disease

Coronary artery disease is common in patients with chronic obstructive pulmonary disease (COPD). Previous studies have shown that patients with COPD have a higher risk of mortality than those without COPD after coronary artery bypass grafting (CABG). However, most of the previous studies were small, single-center studies with limited case numbers (or their only focus was mortality). The aim of our study was to focus on readmission, acute myocardial infarction (AMI), acute respiratory failure (ARF), cerebrovascular accident, and venous thromboembolism rates after CABG in an Asian COPD population.We conducted a nationwide case-control study in Taiwan using the claims database of hospitalization between January 1, 2009 and December 31, 2013. Patients with COPD before CABG were defined as the case groups. Each case was propensity score-matched by age, sex, hypertension, diabetes, dyslipidemia, cardiovascular disease, cerebrovascular disease, and chronic kidney disease, with 2 controls selected from CABG patients without COPD. The outcomes of interest were mortality, wound infection, and the readmission rate over 30 days for the following diseases: AMI, pneumonia, ARF, cerebrovascular accident, and venous thromboembolism.There were 14,858 patients without COPD and 758 patients with COPD who underwent CABG. After propensity score matching, the 30-day mortality and 30-day readmission rates and AMI were higher in the non-COPD group. The incidences of pneumonia and ARF after CABG were higher in the COPD group.Chronic obstructive pulmonary disease does not necessarily lead to mortality, readmission, or AMI after CABG, and the major respiratory complications associated with CABG in patients with COPD were pneumonia and ARF.

When is an invasive palliative intervention in an acute internal medical patient worth it? A structured palliative approach

A 67-year-old patient with coronary artery disease (CAD), diabetes, and chronic obstructive pulmonary disease (COPD) was scheduled for coronary artery bypass graft (CABG) surgery after a recent myocardial infarction despite a high perioperative risk of death. While waiting, acute renal failure developed, and the patient was admitted to the intensive care unit (ICU). After the patient and his wife were informed that CABG surgery was no longer possible, he declined further intensive care treatment and subsequently died peacefully.We show that a structured palliative approach which has been proposed for cancer patients may also be feasible in palliative situations concerning nononcologic patients.

Time trends in coronary revascularization procedures among people with COPD: analysis of the Spanish national hospital discharge data (2001-2011)

Background

People with COPD suffering from coronary artery disease are frequently treated with revascularization procedures. We aim to compare trends in the use and outcomes of these procedures in COPD and non-COPD patients in Spain between 2001 and 2011.

Methods

We identified all patients who had undergone percutaneous coronary interventions (PCIs) and coronary artery bypass graft (CABG) surgeries, using national hospital discharge data. Discharges were grouped into: COPD and no COPD.

Results

From 2001 to 2011, 428,516 PCIs and 79,619 CABGs were performed. The sex and age-adjusted use of PCI increased by 21.27% per year from 2001 to 2004 and by 5.47% per year from 2004 to 2011 in patients with COPD. In-hospital mortality (IHM) among patients with COPD who underwent a PCI increased significantly from 2001 to 2011 (odds ratio 1.11; 95% confidence interval 1.03–1.20). Among patients with COPD who underwent a CABG, the sex and age-adjusted CABG incidence rate increased by 9.77% per year from 2001 to 2003, and then decreased by 3.15% through 2011. The probability of dying during hospitalization in patients who underwent a CABG did not change significantly in patients with and without COPD (odds ratio, 1.06; 95% confidence interval 0.96–1.17).

Conclusion

The annual percent change in PCI procedures increased in COPD and non-COPD patients. We found a decrease in the use of CABG procedures in both groups. IHM was higher in patients with COPD who underwent a PCI than in those without COPD. However, COPD did not increase the probability of dying during hospitalization in patients who underwent a CABG.

Pre-treatment before coronary artery bypass surgery improves post-operative outcomes in moderate chronic obstructive pulmonary disease patients

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) has traditionally been recognised as a predictor of poorer early outcomes in patients undergoing coronary artery bypass grafting (CABG). The aim of this study was to analyse the impact of different COPD stages, as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) spirometric criteria, on the early surgical outcomes in patients undergoing primary isolated non-emergency CABG.

METHOD

Between January 2008 and April 2012, 1 737 consecutive patients underwent isolated CABG in the Department of Cardiovascular Surgery of Gulhane Military Academy of Medicine; 127 patients with the diagnosis of moderate-risk COPD were operated on. Only 104 patients with available pulmonary function tests and no missing data were included in the study. Two different treatment protocols had been used before and after 2010. Before 2010, no treatment was applied to patients with moderate COPD before the CABG procedure. After 2010, a pre-treatment protocol was initiated. Patients who had undergone surgery between 2008 and 2010 were placed in group 1 (no pre-treatment, n = 51) and patients who had undergone surgery between 2010 and 2012 comprised group 2 (pre-treatment group, n = 53). These two groups were compared according to the postoperative morbidity and mortality rates retrospectively, from medical reports.

RESULTS

The mean ages of the patients in both groups were 62.1 ± 7.6 and 64.5 ± 6.4 years, respectively. Thirty-nine of the patients in group 1 and 38 in group 2 were male. There were similar numbers of risk factors such as diabetes, hypertension, renal disease (two patients in each group), previous stroke and myocardial infarction in both groups. The mean ejection fractions of the patients were 53.3 ± 11.5% and 50.2 ± 10.8%, respectively. Mean EuroSCOREs of the patients were 5.5 ± 2.3 and 5.9 ± 2.5, respectively in the groups. The average numbers of the grafts were 3.1 ± 1.0 and 2.9 ± 0.9. Mean extubation times were 8.52 ± 1.3 hours in group 1 and 6.34 ± 1.0 hours in group 2. The numbers of patients who needed pharmacological inotropic support were 12 in group 1 and five in group 2. Duration of hospital stay of the patients was shorter in group 2. While there were 14 patients with post-operative atrial fibrillation (PAF) in group 1, the number of patients with PAF in group 2 was five. Whereas there were seven patients who had pleural effusions requiring drainage in group 1, there were only two in group 2. There were three mortalities in group 1, and one in group 2. There were no sternal infections and sternal dehiscences in either group.

CONCLUSION

Pre-treatment in moderate-risk COPD patients improved post-operative outcomes while decreasing adverse events and complications. Therefore for patients undergoing elective CABG, we recommend the use of medical treatment.

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

OBJECTIVES

We sought to investigate the long-term survival of patients with obstructive, restrictive and chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

METHODS

A prospective database was retrospectively analysed and cross-correlated with the UK strategic tracking service to evaluate survival after primary coronary artery bypass grafts (CABG). Univariate and multivariate Cox regression analyses were performed. Three separate multivariate analyses were performed: COPD GOLD criteria for obstructive and/or restrictive lung disease, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and the FEV1/FVC ratio to investigate the effect of FEV1 and FVC individually.

RESULTS

We analysed 13 337 primary CABG procedures. The median follow-up was 7 years. Univariate analysis demonstrated that obstructive (P < 0.0001), restrictive (P < 0.0001) and mixed obstructive and restrictive pulmonary disease (P < 0.0001), and COPD as defined by the GOLD criteria (P < 0.0001), are all significant factors determining long-term survival. Cox regression analysis identified age, diabetes, moderate LV, poor LV, peripheral vascular disease, dialysis, left internal mammary artery (LIMA) usage, EuroSCORE, cardiopulmonary bypass and creatinine kinase muscle-brain isoenzyme as significant factors in addition to pulmonary disease that determine long-term survival. Moderate and severe COPD defined by GOLD criteria were significant factors determining long-term survival, but mild COPD had no significant effect. Obstructive and restrictive lung disease were both significant factors determining long-term survival. Restrictive lung disease, however, carried a greater prognostic significance (higher hazard ratio 2.2 vs 1.6) than obstructive. LIMA utilization in patients with COPD was not associated with an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate.

CONCLUSIONS

Pulmonary disease is a significant factor determining long-term survival. Patients with severe COPD still have a relatively good long-term survival and should not be denied surgery. LIMA utilization in patients with COPD results in a significantly increased long-term survival, without an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate.

Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung, and Blood Institute dynamic registry

BACKGROUND

Previous studies have demonstrated that patients with COPD are at higher risk for death after percutaneous coronary intervention (PCI), but other clinical outcomes and possible associations with adverse events have not been described.

METHODS

Using waves 1 through 5 (1999-2006) of the National Heart, Lung, and Blood Institute Dynamic Registry, patients with COPD (n = 860) and without COPD (n = 10,048) were compared. Baseline demographics, angiographic characteristics, and in-hospital and 1-year adverse events were compared.

RESULTS

Patients with COPD were older (mean age 66.8 vs 63.2 years, P < .001), more likely to be women, and more likely to have a history of diabetes, prior myocardial infarction, peripheral arterial disease, renal disease, and smoking. Patients with COPD also had a lower mean ejection fraction (49.1% vs 53.0%, P < .001) and a greater mean number of significant lesions (3.2 vs 3.0, P = .006). Rates of in-hospital death (2.2% vs 1.1%, P = .003) and major entry site complications (6.6% vs 4.2%, P < .001) were higher in pulmonary patients. At discharge, pulmonary patients were significantly less likely to be prescribed aspirin (92.4% vs 95.3%, P < .001), β-blockers (55.7% vs 76.2%, P < .001), and statins (60.0% vs 66.8%, P < .001). After adjustment, patients with COPD had significantly increased risk of death (hazard ratio [HR] = 1.30, 95% CI = 1.01-1.67) and repeat revascularization (HR = 1.22, 95% CI = 1.02-1.46) at 1 year, compared with patients without COPD.

CONCLUSIONS

COPD is associated with higher mortality rates and repeat revascularization within 1 year after PCI. These higher rates of adverse outcomes may be associated with lower rates of guideline-recommended class 1 medications prescribed at discharge.

Sternal dehiscence in patients with moderate and severe chronic obstructive pulmonary disease undergoing cardiac surgery: the value of supportive thorax vests

OBJECTIVE

Sternal dehiscence after open surgery is a major cause of morbidity and mortality, and chronic obstructive pulmonary disease is a significant risk factor. Therefore, we aimed to determine whether moderate and severe chronic obstructive pulmonary disease had an effect on the development of sternal dehiscence and whether the use of the Robicsek technique for sternal closure along with sternal support vest postoperatively would reduce the incidence of sternal dehiscence in patients with moderate/severe chronic obstructive pulmonary disease undergoing cardiac surgery.

METHODS

Two studies were performed. In study 1, 842 patients undergoing cardiac surgery and figure-of-8 wire closure were retrospectively evaluated in 2 groups: group 1a (328 patients with chronic obstructive pulmonary disease) and group 1b (514 patients without chronic obstructive pulmonary disease). In study 2, 221 patients with moderate and severe COPD who were scheduled for open surgery were prospectively enrolled. The Robicsek technique was used for sternal closure. The postoperative thorax support vest was used in 100 patients (group 2a), and no additional procedure was applied in 121 patients (group 2b).

RESULTS

In study 1, the dehiscence rate was significantly higher in group 1a (7.9%) than in group 1b (1.2%; P < .001), and mortality rates in patients with dehiscence were 53.8% and 33.3%, respectively. In study 2, the dehiscence rate was significantly lower in group 2a (1%) than in group 2b (11.5%; P = .002). None of the patients with dehiscence in group 2a died, and 35.7% of patients died in group 2b.

CONCLUSIONS

The Robicsek technique for sternal closure and the use of a thorax support vest postoperatively are highly effective in preventing sternal dehiscence after cardiac surgery in patients with moderate and severe chronic obstructive pulmonary disease.

Preoperative pulmonary function and mortality after cardiac surgery

BACKGROUND

The aim of the study was to examine the relationship between preoperative pulmonary function and outcomes after cardiac surgery.

METHODS

We performed preoperative pulmonary function tests (PFTs) in 1,169 patients undergoing cardiac surgery at the Minneapolis Veterans Affairs Medical Center. Airway obstruction was defined as forced expiratory volume in 1 minute (FEV(1)) to forced vital capacity ratio <0.7.

RESULTS

Of the 1,169 patients, 483 (41%) had a prior history of chronic obstructive pulmonary disease (COPD). However, 178 patients with a history of COPD had no airway obstruction on PFT. Conversely, 186 patients without a COPD history had airway obstruction on PFT. Thus, PFT results helped reclassify the COPD status of 364 patients (31%). Operative mortality was 2% in patients with no or mild airway obstruction versus 6.7% in those with moderate or severe obstruction (ie, FEV(1) to forced vital capacity ratio <0.7 and FEV(1) <80% predicted). Postoperative mortality was higher (odds ratio 3.2, 95% CI 1.6-6.2, P = .001) in patients with moderate or severe airway obstruction and in patients with diffusing capacity of the lung for carbon monoxide <50% of predicted (odds ratio 4.9, 95% CI 2.3-10.8, P = .0001). Notably, mortality risk was 10x higher (95% CI 3.4-27.2, P = .0001) in patients with moderate or severe airway obstruction and diffusing capacity of the lung for carbon monoxide <50% of predicted.

CONCLUSIONS

These data show that PFT before cardiac surgery reclassifies the COPD status of a substantial number of patients and provides important prognostic information that the current risk estimate models do not capture.

Comorbidity and Outcomes of Coronary Artery Bypass Graft Surgery at Cardiac Specialty Hospitals Versus General Hospitals

BACKGROUND

Cardiac specialty hospitals assert better patient outcomes and efficiency, whereas general hospitals contend they attract healthier patients.

OBJECTIVES

To ascertain whether increased cardiac specialization of a hospital's services is associated with improved outcomes for coronary artery bypass graft (CABG) surgery and whether patients with and without comorbid disease have equivalent outcomes to their counterparts at general hospitals.

METHODS

We conducted a retrospective cohort study of a 5% sample of Medicare beneficiaries undergoing CABG procedures from 2001 to 2003. Using multivariate analyses, we assessed the hospital degree of cardiac specialization on mortality, length of stay, hospital readmissions, and emergency room visits leading to rehospitalization for all patients and those with more comorbidities.

RESULTS

Patients at cardiac specialty hospitals had less comorbid disease (29.7% with Charlson scores > or =2) than those at moderately (37.2%) and least specialized hospitals (36.6%, P = 0.001). Overall, CABG outcomes in all 3 groups were similar for inpatient mortality (P = 0.78), 30-day postdischarge mortality (P = 0.69), emergency room visit leading to rehospitalization (P = 0.35), and hospital readmission within 30 days postdischarge (P = 0.70). However, for patients with greater comorbidity, 30-day postdischarge mortality was worse at cardiac specialty hospitals compared with least specialized hospitals from across the United States (adjusted odds ratio, 1.71; 95% confidence interval, 1.26-2.32; P = 0.001). Results were robust when hospitals were compared within metropolitan statistical areas.

CONCLUSIONS

Favorable patient selection may occur at cardiac specialty hospitals. Although healthier patients fare comparably across types of hospitals, patients with greater comorbid disease seem to experience worse 30-day postdischarge mortality at specialty hospitals.

Nurse-Led Preoperative Screening and Targeted Optimization of Pulmonary Dysfunction in Patients Undergoing Cardiac Surgery

Postoperative pulmonary dysfunction prolonging intensive care treatment after cardiac surgery most commonly occurs in patients with a background of pre-existing pulmonary dysfunction. However, many patients have occult dysfunction and present primarily after surgery. We describe and discuss the results of a respiratory optimization program utilizing a peak expiratory flow rate below 400 L/min as a screening test to identify patients in a nurse-directed preoperative clinic.

Long-Term Survival of Patients With Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Surgery

Background— Chronic obstructive pulmonary disease (COPD) is associated with increased in-hospital mortality in patients undergoing coronary artery bypass surgery (CABG). Long-term survival is less well understood. The present study examined the effect of COPD on survival after CABG.

Methods and Results— We conducted a prospective study of 33 137 consecutive isolated CABG patients between 1992 and 2001 in northern New England. Records were linked to the National Death Index for long-term mortality data. Cox proportional hazards regression was used to calculate hazard ratios (HRs). Patients were stratified by: no comorbidities (none), COPD, COPD plus comorbidities, and other comorbidities with no COPD. There were 131 434 person years of follow-up and 5344 deaths. The overall incidence rate (deaths per 100 person years) was 4.1. By group, rates were: 2.1 (none), 4.0 (COPD alone), 5.5 (other), and 9.4 (COPD plus; log rank P <0.001). After adjustment, survival with COPD alone was worse compared with none (HR, 1.8; 95% CI, 1.6 to 2.1; P <0.001). Patients with other comorbidities compared with none had even worse survival (HR, 2.2; 95% CI, 2.1 to 2.4; P <0.001). Patients with COPD plus other comorbidities compared with none had the worst long-term survival (HR, 3.6; 95% CI, 3.3 to 3.9; P <0.001).

Conclusions— Patients with only COPD had significantly reduced long-term survival compared with patient with no comorbidities. Patients with COPD and ≥1 other comorbidity had the worst survival rate when compared with all of the other groups.