Stroke and mortality rates after off-pump vs. pump-assisted/no-clamp coronary artery bypass grafting

Survival and Mid-Term Outcomes of On Pump vs. Off Pump Coronary Artery Bypass Grafting: A Propensity Score-Matched Analysis in A First Peruvian Registry

INTRODUCTION

The efficacy and outcomes of on-pump and off-pump coronary artery bypass grafting (CABG) remain uncertain, especially in Latin America. Our study aims to explore survival and shortand mid-term outcomes in the first reported Peruvian registry of patients treated with both techniques.

METHODS

This is an observational, analytical, and longitudinal study using a propensity score-matched (PSM) analysis in a single-center retrospective registry of 2280 patients during 2000-2019; 846 patients were analyzed after PSM (on-pump = 423 vs. off-pump = 423). Baseline variables, comorbidities, and major outcomes were studied in the short term (≤ 30 days) and in midterm (30 days-36 months) with major adverse cardiac and cerebrovascular events. The matched groups were compared by descriptive, multivariate, and Kaplan-Meier survival analyses.

RESULTS

Before PSM, previous myocardial infarction < 7 days (27.03%) and ejection fraction ≥ 50% (45.72%) were higher in off-pump CABG (P<0.05). After PSM, pre-surgery percutaneous coronary intervention (27.18% vs. 26.71%, P=0.049) and Society of Thoracic Surgeons risk score (1.98% vs. 1.90%, P=0.047) were higher in off-pump CABG. In the short term, there was higher mortality (2.12% vs. 0.47%, P=0.048), blood transfusion > 500 ml (57.91% vs. 7.56%, P=0.049), reintervention (7.32% vs. 2.12%, P=0.045), hospital stay (nine vs. four days, P=0.048), arrhythmia (9.92% vs. 4.96%, P=0.049), and renal failure (20.09% vs. 5.91%, P=0.009) in on-pump CABG. Long-term mortality (4.25% vs. 1.65%, P=0.044), myocardial infarction (17.02% vs. 7.32%, P=0.046), and repeat revascularization (17.49% vs. 8.26%, P=0.045) predominated in on-pump CABG. There was a higher 36-month adjusted survival for off-pump over on-pump CABG (97.88% vs. 93.63%, P=0.046).

CONCLUSION

This first reported Peruvian registry of patients treated with CABG has demonstrated that off-pump CABG is associated with lower shortand mid-term morbidity and mortality rates and better-adjusted survival rates compared to on-pump CABG; however, further multicenter studies in Latin America are needed to elucidate its benefits over classic on-pump CABG.

Evaluation of Outcomes in Patients with Previous Stroke History following Cardiac Surgery: A Single-Center Study

Background: The aim of the study to analyze the risk of complications, including neurological sequelae, alongside early and late mortality among patients with antecedent stroke subjected to cardiac surgical interventions with extracorporeal support. Material and methods: A single-center retrospective study was conducted on 10,685 patients who underwent cardiac surgery with extracorporeal circulation at the Department of Cardiac Surgery. The first group comprised all patients eligible for cardiac surgery with extracorporeal circulation. The second group consisted of patients with a preoperative history of stroke. Results: In the study, a statistically significant association was observed between preoperative stroke and the occurrence of postoperative pneumonia (OR = 1.482, p = 0.006), respiratory failure (OR = 1.497, p = 0.006), renal failure (OR = 1.391, p = 0.019), 30-day mortality (OR = 1.528, p = 0.026), 90-day mortality (OR = 1.658, p < 0.001), and one-year mortality (OR = 1.706, p < 0.001). Conclusions: Patients with a history of preoperative stroke more frequently experienced renal failure and respiratory-system complications such as pneumonia and respiratory failure. The survival time of patients with a history of preoperative stroke was shorter compared to that of the control group during the analyzed 30-day, 90-day, and one-year observation periods.

Stroke after Cardiac Surgery: A Risk Factor Analysis of 580,117 Patients from UK National Adult Cardiac Surgical Audit Cohort

Cerebrovascular accident is the most ominous complication observed after cardiac surgery, carrying an increased risk of morbidity and mortality. Analysis of the problem shows its multidimensional nature. In this study, we aimed to identify major determinants among classic variables, either demographic, clinical or type of surgical procedure, based on the analysis of a large dataset of 580,117 patients from the UK National Adult Cardiac Surgical Audit (NACSA). For this purpose, univariate and multivariate logistic regression models were utilized to determine associations between predictors and dependent variable (Stroke after cardiac surgery). Odds ratios (ORs) and 95% confidence intervals (CIs) were constructed for each independent variable. Statistical analysis allows us to confirm with greater certainty the predictive value of some variables such as age, gender, diabetes mellitus (diabetes treated with insulin OR = 1.37, 95%CI = 1.23-1.53), and systemic arterial hypertension (OR = 1.11, 95%CI = 1.05-1.16);, to emphasize the role of preoperative atrial fibrillation (OR = 1.10, 95%CI = 1.03-1.16) extracardiac arteriopathy (OR = 1.70, 95%CI = 1.58-1.82), and previous cerebral vascular accident (OR 1.71, 95%CI = 1.6-1.9), and to reappraise others like smoking status (crude OR = 1.00, 95%CI = 0.93-1.07 for current smokers) or BMI (OR = 0.98, 95%CI = 0.97-0.98). This could allow for better preoperative risk stratification. In addition, identifying those surgical procedures (for example thoracic aortic surgery associated with a crude OR of 3.72 and 95%CI = 3.53-3.93) burdened by a high risk of neurological complications may help broaden the field of preventive and protective techniques.

Stroke and Recent Myocardial Infarction, Reduced Left Ventricular Ejection Fraction, Left Ventricular Thrombus, and Wall Motion Abnormalities

PURPOSE OF REVIEW

To review the evidence regarding stroke and recent myocardial infarction (MI), reduced left ventricular ejection fraction, left ventricular thrombus (LVT), and wall motion abnormalities (WMA).

RECENT FINDINGS

The risk of ischemic stroke associated with acute MI has been greatly reduced with reperfusion treatments that improved myocardium salvage. Acute ischemic stroke is an uncommon complication of diagnostic coronary angiography and percutaneous coronary intervention. For established LVT, anticoagulation is superior to antiplatelet medications to reduce the risk of ischemic stroke. The duration of anticoagulation should be at least 3 to 6 months. Direct oral anticoagulants have been used off-label in this context. In patients with low ejection fraction or WMA, there is no evidence that anticoagulation is superior to antiplatelet treatment in preventing ischemic stroke. In patients with ischemic stroke and recent MI (< 3 months), type of MI (STEMI or NSTEMI), timing, and location should be considered when deciding whether intravenous thrombolysis should be used for stroke treatment. Mechanical thrombectomy should be considered as a therapeutic alternative to intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion and recent MI. Most guidelines regarding prevention of ischemic stroke in patients with these cardiac causes of stroke are derived from expert opinion. There is a need for high quality evidence to support stroke prevention treatments in these patients.