Outcomes after surgical revascularization in diabetic patients

OBJECTIVES

Patients with diabetes mellitus (DM) undergoing coronary artery bypass grafting (CABG) have been repeatedly demonstrated to have worse clinical outcomes compared to patients without DM. The objective of this study was to evaluate the impact of DM on 1-year clinical outcomes after isolated CABG.

METHODS

The European DuraGraft registry included 1130 patients (44.6%) with and 1402 (55.4%) patients without DM undergoing isolated CABG. Intra-operatively, all free venous and arterial grafts were treated with an endothelial damage inhibitor. Primary end point in this analysis was the incidence of a major adverse cardiac event (MACE), a composite of all-cause death, repeat revascularization or myocardial infarction at 1 year post-CABG. To balance between differences in baseline characteristics (n = 1072 patients in each group), propensity score matching was used. Multivariable Cox proportional hazards regression was performed to identify independent predictors of MACE.

RESULTS

Diabetic patients had a higher cardiovascular risk profile and EuroSCORE II with overall more comorbidities. Patients were comparable in regard to surgical techniques and completeness of revascularization. At 1 year, diabetics had a higher MACE rate {7.9% vs 5.5%, hazard ratio (HR) 1.43 [95% confidence interval (CI) 1.05-1.95], P = 0.02}, driven by increased rates of death [5.6% vs 3.5%, HR 1.61 (95% CI 1.10-2.36), P = 0.01] and myocardial infarction [2.8% vs 1.4%, HR 1.99 (95% CI 1.12-3.53) P = 0.02]. Following propensity matching, no statistically significant difference was found for MACE [7.1% vs 5.7%, HR 1.23 (95% CI 0.87-1.74) P = 0.23] or its components. Age, critical operative state, extracardiac arteriopathy, ejection fraction ≤50% and left main disease but not DM were identified as independent predictors for MACE.

CONCLUSIONS

In this study, 1-year outcomes in diabetics undergoing isolated CABG were comparable to patients without DM.

Clinical outcomes and quality of life after contemporary isolated coronary bypass grafting: a prospective cohort study

OBJECTIVES

The objective of the European Multicenter Registry to Assess Outcomes in coronary artery bypass grafting (CABG) patients (DuraGraft Registry) was to determine clinical outcomes and quality of life (QoL) after contemporary CABG that included isolated CABG and combined CABG/valve procedures, using an endothelial damage inhibitor (DuraGraft) intraoperatively for conduit preservation. Here, we report outcomes in the patient cohort undergoing isolated CABG.

METHODS

The primary outcome was the composite of all-cause death, myocardial infarction (MI), or repeat revascularization (RR) [major adverse cardiac events (MACE)] at 1 year. Secondary outcomes included the composite of all-cause death, MI, RR, or stroke [major adverse cardiac and cerebrovascular events (MACCE)], and QoL. QoL was assessed with the EuroQol-5 Dimension questionnaire. Independent risk factors for MACE at 1 year were determined using Cox regression analysis.

RESULTS

A total of 2532 patients (mean age, 67.4±9.2 years; 82.5% male) underwent isolated CABG. The median EuroScore II was 1.4 [interquartile range (IQR), 0.9-2.3]. MACE and MACCE rates at 1 year were 6.6% and 7.8%, respectively. The rates of all-cause death, MI, RR, and stroke were 4.4, 2.0, 2.2, and 1.9%, respectively. The 30-day mortality rate was 2.3%. Age, extracardiac arteriopathy, left ventricular ejection fraction less than 50%, critical operative state, and left main disease were independent risk factors for MACE. QoL index values improved from 0.84 [IQR, 0.72-0.92] at baseline to 0.92 [IQR, 0.82-1.00] at 1 year ( P <0.0001).

CONCLUSION

Contemporary European patients undergoing isolated CABG have a low 1-year clinical event rate and an improved QoL.

Clinical event rate in patients with and without left main disease undergoing isolated CABG: results from the European DuraGraft registry

OBJECTIVES

Left main coronary artery disease (LMCAD) is considered an independent risk factor for clinical events after coronary artery bypass grafting (CABG). We have conducted a subgroup analysis of the multicentre European DuraGraft registry to investigate clinical event-rates at 1-year in patients with and without LMCAD undergoing isolated CABG in contemporary practice.

METHODS

Patients undergoing isolated CABG were selected. The primary end-point was the incidence of a major adverse cardiac event (MACE) defined as the composite of death, myocardial infarction (MI) or repeat revascularization (RR) at 1-year. The secondary end-point was major adverse cardiac and cerebrovascular events (MACCE) defined as MACE plus stroke. Propensity score matching (PSM) was performed to balance for differences in baseline characteristics.

RESULTS

LMCAD was present in 1,033 (41.2%) and absent in 1,477 (58.8%) patients. At 1-year, the MACE rate was higher for LMCAD patients (8.2% vs 5.1%, p = 0.002) driven by higher rates of death (5.4% vs 3.4%, p = 0.016), MI (3.0% vs 1.3%, p = 0.002) and numerically higher rates of RR (2.8% vs 1.8%, p = 0.13). The incidence of MACCE was 8.8% vs 6.6%, p = 0.043 with a stroke rate of 1.0% and 2.4%, p = 0.011, for LMCAD and non-LMCAD group, respectively. After PSM, the MACE rate was 8.0% vs 5.2%, p = 0.015. The incidence of death was 5.1% vs 3.7%, p = 0.10, MI 3.0% vs 1.4%, p = 0.020, and RR was 2.7% vs 1.6%, p = 0.090, for the LMCAD and non-LMCAD group, respectively. Less strokes occurred in LMCAD patients (1.0% vs 2.4%, p = 0.017). The MACCE rate was not different: 8.5% vs 6.7%, p = 0.12.

CONCLUSIONS

In this large registry, LMCAD was demonstrated to be an independent risk factor for MACE after isolated CABG. Conversely, the risk of stroke was lower in LMCAD patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02922088.

Kinetics of serum procalcitonin in patients with acute mesenteric ischemia and bowel infarction after cardiac surgery

BACKGROUND

The present study reports perioperative changes in PCT levels occuring in cardiac patients with acute mesenteric ischemia (AMI) undergoing laparotomy. The aim of this study was to demonstrate that PCT kinetics may confirm the presence of AMI after cardiac surgery, distinguishing between bowel infarction and diffuse ischemia.

METHODS

PCT values from adult patients undergoing laparotomy for AMI after elective or urgent cardiac surgery (January 2010 - December 2019) were determinated at the ICU admission after cardiac surgery, 24 hours later and at the onset of clinical symptoms. Patients affected by diffuse intestinal ischemia with no need for bowel resection were allocated to Group A (n.8), patients presented with intestinal necrosis requiring small or large bowel resection were allocated to Group B (n.12).

RESULTS

At the beginning of the abdominal symptoms, PCT levels increased in both group, compared to those immediately after cardiac surgery. The PCT increasing resulted much more evident in patients presenting with intestinal necrosis - Group B (20.65 ng/ml [IQR8.47-34.5] vs. 4.31 ng/ml [IQR 8.47-34.5], p <0.05), rather than in those with diffuse ischemia - Group A (13.25 ng/ml [IQR 5.97-27.65] vs. 10.4 ng/ml [IQR 3.68-14.05], p 0.260). This trend was confirmed in the subgroup of patients undergoing CVVHD and in patients who experience AMI recurrence.

CONCLUSIONS

Increasing PCT values after cardiac surgery are proportional to the severity of wall ischemia and high levels of PCT are predictive of intestinal necrosis. Routine PCT monitoring after cardiac surgery should be considered extremely useful in suggesting the possibility of abdominal complications, alerting medical staff to the need of prompt treatment.