Analysis of mortality in low-risk patients undergoing coronary artery bypass grafting

The Prognostic Value of Inflammatory Indices in Predicting Poor Postoperative Outcomes in Isolated Coronary Artery Bypass Graft Surgery

BACKGROUND

This study aimed to analyze the predictive effect of various inflammatory indices and inflammatory biomarkers on prognosis after coronary artery bypass grafting (CABG).

METHODS

In this retrospective observational study, data were recorded from 99 patients who underwent isolated elective CABG between January 2019 and June 2021 and met the inclusion criteria. The patients were divided into two main groups according to the postoperative clinical results: "favorable outcome" and "poor outcome." Preoperative inflammatory parameters, inflammatory indices (such as systemic inflammation index (SII), neutrophil/lymphocyte ratio (NLR), derived NLR (dNLR)), and clinical variables were compared between the groups.

RESULTS

Poor postoperative outcomes developed in 31 (31.3%) patients. In the univariate analysis, white blood cell count (p=0.008), neutrophil count (p=0.002), SII (p=0.018), NLR (p=0.003), and dNLR (p=0.003) were found to be significant predictors for poor outcomes. In the multivariate analysis, only the presence of chronic obstructive pulmonary disease (COPD) (OR=8.765; 95% CI 1.308-58.702; p=0.025) and high creatinine levels (OR=1.049; 95% CI 1.005-1.094; p=0.027) were independent risk factors for poor outcomes. Optimal cut-off values were 603.08 (areas under the curve (AUC)=0.632, p=0.036) for SII, 2.34 (AUC=0.669, p=0.007) for NLR, and 1.76 (AUC=0.667, p=0.008) for dNLR.

CONCLUSION

SII, NLR, dNLR, and inflammatory markers, such as white blood cell and neutrophil counts, are feasible markers for predicting poor outcomes following CABG procedures. These parameters may aid in the development of early therapeutic interventions to improve patient outcomes.

Failure to achieve a satisfactory cardiac outcome after isolated coronary surgery in low-risk patients

OBJECTIVES

This study aims to investigate the incidence and determinants of major early adverse events in low-risk patients undergoing isolated coronary artery bypass grafting (CABG).

METHODS

The multicentre E-CABG registry included 7352 consecutive patients who underwent isolated CABG from January 2015 to December 2016. Patients with an European System for Cardiac Operative Risk Evaluation (EuroSCORE) II of <2% and without any major comorbidity were the subjects of the present analysis.

RESULTS

Out of 2397 low-risk patients, 11 (0.46%) died during the index hospitalization or within 30 days from surgery. Five deaths were cardiac related, 4 of which were secondary to technical failures. We estimated that 8 out of 11 deaths were potentially preventable. Logistic regression model identified porcelain aorta [odds ratio (OR) 34.3, 95% confidence interval (CI) 1.3-346.3] and E-CABG bleeding grades 2-3 (OR 30.2, 95% CI 8.3-112.9) as independent predictors of hospital death.

CONCLUSIONS

Mortality and major complications, although infrequently, do occur even in low-risk patients undergoing CABG. Identification of modifiable causes of postoperative adverse events may be useful to develop preventative strategies to improve the quality of care of patients undergoing cardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT02319083 (https://clinicaltrials.gov/ct2/show/NCT02319083).

Most deaths in low-risk cardiac surgery could be avoidable

It is observed that death rates in cardiac surgery has decreased, however, root causes that behave like triggers of potentially avoidable deaths (AD), especially in low-risk patients (less bias) are often unknown and underexplored, Phase of Care Mortality Analysis (POCMA) can be a valuable tool to identify seminal events (SE), providing valuable information where it is possible to make improvements in the quality and safety of future procedures. Our results show that in São Paul State, only one third of AD in low-risk cardiac surgery was related to specific surgical problems. After a revisited analysis, 75% of deaths could have been avoided, which in the pre-operative phase, the SE was related judgment, patient evaluation and preparation. In the intra-operative phase, most occurrences could have been avoided if other surgical technique had been used. Sepsis was responsible for 75% of AD in the intensive care unit. In the ward phase, the recognition/management of clinical decompensations and sepsis were the contributing factors. Logistic regression model identified age, previous coronary stent implantation, coronary artery bypass grafting + heart valve surgery, ≥ 2 combined heart valve surgery and hospital-acquired infection as independent predictors of AD.

Death in low-risk cardiac surgery revisited

Background

A systematic review of low-risk death has been shown successful in identifying system weaknesses. The aim was to analyse early mortality in low-risk patients undergoing cardiac surgery and to determine the cause of death, classify if they were unavoidable or potentially preventable as a result of technical or system errors.

Methods

We included all low-risk patients who underwent cardiac surgery at our institution from 1 September 2009 to 31 August 2019. In patients operated between 2009 and 2011, we defined low risk as an additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) I less than or equal to 3, and from 2012 and onwards as a EuroSCORE II less than or equal to 1.5. The medical records for the patients who died within 30 days of surgery were thoroughly examined and the cause of death was classified as cardiac or non-cardiac. Furthermore, deaths were categorised as not preventable, preventable (technical error) or preventable (system error).

Results

During the study period 3103 low-risk patients underwent surgery, and 11 patients died within 30 days of the operation (0.35%). Six of these (55%) were classified as preventable and five non-preventable. Four of the preventable deaths were classified as technical errors and two were due to system errors.

Conclusions

A repeated systematic review of deaths in patients with a low preoperative risk showed that a majority of deaths were preventable, and therefore potentially avoidable. Similar to the previous assessment at our unit, mortality was very low and failure to communicate remains a modifiable factor that should be addressed.