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Vallabhajosyula S, Arora S, Sakhuja A, Lahewala S, Kumar V, Shantha GPS, Egbe AC, Stulak JM, Gersh BJ, Gulati R, Rihal CS, Prasad A, Deshmukh AJ. Trends, Predictors, and Outcomes of Temporary Mechanical Circulatory Support for Postcardiac Surgery Cardiogenic Shock. Am J Cardiol 2019; 123:489-497. [PMID: 30473325 DOI: 10.1016/j.amjcard.2018.10.029] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 12/30/2022]
Abstract
Postcardiac surgery cardiogenic shock (PCCS) is seen in 2% to 6% of patients who undergo cardiac surgery. There are limited large-scale data on the use of mechanical circulatory support (MCS) in these patients. This study sought to evaluate the in-hospital mortality, trends, and resource utilization for PCCS admissions with and without MCS. A retrospective cohort of PCCS between 2005 and 2014 with and without the use of temporary MCS was identified from the National Inpatient Sample. Admissions for permanent MCS and heart transplant were excluded. Propensity-matching for baseline characteristics was performed. The primary outcome was in-hospital mortality and secondary outcomes included trends in use, hospital costs and lengths of stay. In the period between 2005 and 2014, there were 132,485 admissions with PCCS, with 51.3% requiring MCS. The intra-aortic balloon pump was the predominant device used with a steady increase in other devices. MCS use for more frequent in younger patients, males and those with higher co-morbidity. There was a decrease in MCS use across all demographic categories and hospital characteristics over time. Older age, female sex, previous cardiovascular morbidity and MCS use were independently predictive of higher in-hospital mortality. In 6,830 propensity-matched pairs, PCCS admissions that required MCS use, had higher in-hospital mortality (odds ratio 2.4; p<0.001), higher hospital costs ($98,759 ± 907 vs $81,099 ± 698; p<0.001) but not a longer length of stay compared with those without MCS use. In conclusion, in patients with PCCS, this study noted a steady decrease in MCS use. Use of MCS identified PCCS patients at higher risk for in-hospital mortality and greater resource utilization.
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shilpkumar Arora
- Division of Cardiovascular Diseases, Department of Medicine, Robert Packer Hospital/Guthrie Clinic, Towanda, Pennsylvania
| | - Ankit Sakhuja
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sopan Lahewala
- Division of Cardiovascular Diseases, Department of Medicine, Jersey City Medical Center, Jersey City, New Jersey
| | - Varun Kumar
- Division of Cardiovascular Diseases, Department of Medicine, Robert Packer Hospital/Guthrie Clinic, Towanda, Pennsylvania
| | - Ghanshyam P S Shantha
- Division of Cardiovascular Diseases, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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van Dijk D, Diephuis JC, Nierich AP, Keizer AMA, Kalkman CJ. Beating Heart Versus Conventional Cardiopulmonary Bypass: The Octopus Experience: A Randomized Comparison of 281 Patients Undergoing Coronary Artery Bypass Surgery With or Without Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2016; 10:167-70. [PMID: 16959744 DOI: 10.1177/1089253206288999] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the Octopus Study, 281 coronary artery bypass surgery patients were randomized to surgery with or without cardiopulmonary bypass. The primary objective was to compare cognitive outcome between off-pump and on-pump coronary artery bypass surgery. Before and after surgery, psychologists administered a battery of 10 neuropsychological tests to the patients. Cognitive decline was defined as a decrease in an individual’s performance of at least 20% from baseline, in at least 20% of the main variables. According to this definition, cognitive decline was present in 21% in the off-pump group and 29% in the on-pump group, 3 months after the procedure ( P = .15). At 12 months, cognitive decline was present in 31% in the off-pump group and 34% in the on-pump group ( P = .69). These results indicated that patients undergoing coronary artery bypass surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months. The same definition of cognitive decline was also applied to 112 volunteers not undergoing surgery. The definition labeled 28% of the control subjects as suffering from cognitive decline, 3 months after their first assessment. This suggests that the natural fluctuations in performance during repeated neuropsychological testing should be included in the statistical analysis of cognitive decline. Using an alternative definition of cognitive decline that takes these natural fluctuations in performance into account, the proportions of coronary artery bypass surgery patients displaying cognitive decline were substantially lower. This indicates that the incidence of cognitive decline after coronary artery bypass surgery has been overestimated.
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Affiliation(s)
- Diederik van Dijk
- University Medical Center Utrecht, Department of Anesthesiology, 3508 GA Utrecht, The Netherlands.
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Lewis DM, Dove S, Jordan RE. Results of the 2015 Perfusionist Salary Study. J Extra Corpor Technol 2016; 48:179-187. [PMID: 27994258 PMCID: PMC5153304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 10/04/2016] [Indexed: 06/06/2023]
Abstract
Presently, there exists no published valid and reliable salary study of clinical perfusionists. The objective of the 2015 Perfusionist Salary Study was to gather verifiable employee information to determine current compensation market rates (salary averages) of clinical perfusionists working in the United States. A salary survey was conducted between April 2015 and March 2016. The survey required perfusionists to answer questions about work volume, scheduling, and employer-paid compensation including benefits. Participants were also required to submit a de-identified pay stub to validate the income they reported. Descriptive statistics were calculated for all survey questions (e.g., percentages, means, and ranges). The study procured 481 responses, of which 287 were validated (i.e., respondents provided income verification that matched reported earnings). Variables that were examined within the validated sample population include job title, type of institution of employment, education level, years of experience, and geographic region, among others. Additional forms of compensation which may affect base compensation rates were also calculated including benefits, call time, bonuses, and pay for ancillary services (e.g., extracorporeal membrane oxygenation and ventricular assist device). In conclusion, in 2015, the average salary for all perfusionists is $127,600 with 19 years' experience. This research explores the average salary within subpopulations based on other factors such as position role, employer type, and geography. Information from this study is presented to guide employer compensation programs and suggests the need for further study in consideration of attrition rates and generational changes (i.e., perfusionists reaching retirement age) occurring alongside the present perfusionist staffing shortage affecting many parts of the country.
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Affiliation(s)
| | - Steven Dove
- Trident Health Resources, Inc., Dunedin, Florida
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Samolyk KA, Beckmann SR, Bissinger RC. A new practical technique to reduce allogeneic blood exposure and hospital costs while preserving clotting factors after cardiopulmonary bypass: the Hemobag®. Perfusion 2016; 20:343-9. [PMID: 16363320 DOI: 10.1191/0267659105pf831oa] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Recent data independently linking allogeneic blood use to increased morbidity and mortality after cardiopulmonary bypass (CPB) warrants the study of new methods to employ unique and familiar technology to reduce allogeneic blood exposure. The Hemobag® allows the open-heart team to concentrate residual CPB circuit contents and return a high volume of autologous clotting factors and blood cells to the patient. Fifty patients from all candidates were arbitrarily selected to receive the Hemobag® (HB) therapy. A retrospective control group of 50 non-Hemobag® (NHB) patients were matched to the HB group patient-by-patient for comparison according to surgeon, type of procedure, age, body surface area (BSA), body weight and CPB time. Many efforts to conserve blood (Cell Saver® and ANH) were employed in both groups. Post-CPB cell washing of circuit contents was additionally employed in the control group. There were no significant differences between the HB and NHB groups in regard to patient morphology, pre-op cell concentrations, distribution of surgeon or procedures (41% valve, 16% valve/coronary artery bypass graft (CABG), balance CABG), pump and ischemic times and Bayes National Risk scores. The average volume returned to the patient from the HB was 8179/198 mL (1 SD). Average processing time was 11 min. The Hemobag®contained an average platelet count of 2309/80 K/mm3, fibrinogen concentration of 4139/171 mg/dl, total protein of 8.09/2.8 gm/dl, albumin of 4.49/1.2 gm/dl and hematocrit of 439/7%. Factor VII, IX and X levels in three HB contents averaged 259% greater than baseline. Substantial reductions were achieved in both allogeneic blood product avoidance and cost to the hospital with use of the HB. Infusion of the Hemobag® concentrate appears to recover safely substantial proteins, clotting factor and cell concentration for all types of cardiac procedures, maintaining the security of a primed circuit.
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Affiliation(s)
- Keith A Samolyk
- Address for correspondence: Keith A Samolyk, CCP, LCP, Global Blood Resources LLC, PO Box 383, Somers, CT 06071, USA.
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Birim Ö, Bogers AJJC, Kappetein AP. Comparing cost aspects of coronary artery bypass graft surgery with coronary artery stenting. J Cardiovasc Surg (Torino) 2012; 53:641-650. [PMID: 22252542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Randomized trials have compared revascularization of coronary artery disease by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). CABG is an expensive treatment. However, it manages to improve quality of life, restore general well being, and alleviate symptoms of patients. Coronary stents have improved the safety and durability of PCI. Nonetheless, stenting remains limited by a relatively high in-stent restenosis and thrombosis rate. The costs and cost-effectiveness for these different treatment modalities are relevant issues because cardiovascular disease and its management are prime targets for cost reduction initiatives. There is a debate as to which is the optimal treatment strategy as well as to the cost-effectiveness comparing CABG and PCI. This review provides an overview of cost-effectiveness of CABG compared with PCI. PCI has high costs due to the need for subsequent revascularization procedures, with absence of mortality and survival benefit compared with CABG. Despite the relative lower initial costs of PCI in the first year, PCI is not a cost-effective intervention in comparison with CABG. However, the studies undertaken to date have predominantly been short term and provide a very limited evidence base by which to assess the cost-effectiveness of modern clinical practice. It seems that in longer term, the benefits of CABG may exceed those of stenting and the difference in net cost may be in favour of CABG as the risk of repeat revascularization still increases with PCI regardless of the use of DES. However, to date no long-term data are available in cost-effectiveness between CABG and PCI. The 5-year outcome of the ongoing SYNTAX trial is essential and might therefore provide new insights into the comparison of cost-effectiveness between CABG and DES PCI.
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Affiliation(s)
- Ö Birim
- Department of Cardio-Thoracic Surgery, Erasmus MC Rotterdam, Rotterdam, The Netherlands.
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Affiliation(s)
- Alan M Gaffney
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
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Mozol K, Haponiuk I, Byszewski A, Maruszewski B. Cost-effectiveness of mini-circuit cardiopulmonary bypass in newborns and infants undergoing open heart surgery. Kardiol Pol 2008; 66:925-930. [PMID: 18924019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND AND AIM Miniaturisation of the extracorporeal circuit is a current trend in modern paediatric cardiac surgery. Many investigators stress that reduction of priming volume and artificial surface area of extracorporeal circulation could lead to clinical and economic benefits. The aim of this paper was to evaluate the costs of mini-circuit use in infants undergoing open heart surgery. METHODS We assessed post-operative course and cost of treatment in 60 infants undergoing open heart surgery. This group was prospectively randomised and divided into 2 equal subgroups: with miniaturised (group M) and conventional cardio pulmonary bypass circuits (group C). The study groups were clinically comparable. Surgical complications, duration of hospitalisation and cost of postoperative treatment were assessed in both groups. RESULTS Miniaturisation of the extracorporeal circuit led to a significant reduction of priming volume and artificial surface area (by 46.6% and 68.8% respectively, p=0.0000001). Post-operative cardio-respiratory insufficiency (2 vs. 8, p=0.038), and infection (3 vs. 9, p=0.049) occurred less often in children from group M. Hospital stay was significantly shorter in group M. Total cost of treatment was significantly lower in children from group M (median: 4361.4 vs. 6660.5 euro, p=0.037). CONCLUSIONS Miniaturisation of the extracorporeal circulation significantly improve post-operative outcome in infants undergoing open heart surgery. The mini-circuit significantly reduces cost of treatment in small children undergoing open heart surgery.
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Mangoush O, Purkayastha S, Haj-Yahia S, Kinross J, Hayward M, Bartolozzi F, Darzi A, Athanasiou T. Heparin-bonded circuits versus nonheparin-bonded circuits: an evaluation of their effect on clinical outcomes. Eur J Cardiothorac Surg 2007; 31:1058-69. [PMID: 17306555 DOI: 10.1016/j.ejcts.2007.01.029] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Revised: 12/30/2006] [Accepted: 01/15/2007] [Indexed: 11/16/2022] Open
Abstract
Heparinization of the blood contact surface in cardiopulmonary bypass circuits has been promoted as an important step in the development of open heart surgery. As it decreases the inflammatory response resulting from the extracorporeal circulation, it may have a positive effect on clinical outcomes. This meta-analysis was carried out to examine if heparin-bonded circuits (HBCs) reduce the need for blood products and improve overall clinical outcome. A systematic literature search was performed to identify randomized controlled trials reporting outcomes of HBCs compared with non-HBCs. Primary outcomes assessed were postoperative blood/blood-product transfusion and blood loss. Secondary outcomes included all-cause mortality, acute postoperative myocardial infarction, stroke, re-sternotomy for postoperative bleeding, wound infection, atrial fibrillation, duration of ventilation, intensive care unit (ICU) and hospital-length of stay (LOS). Random effects meta-analytical techniques were applied to identify differences in outcomes between the two groups. Quality of the included studies and heterogeneity were assessed. From an initial review of 762-published studies, 41-randomized trials fulfilled the inclusion criteria, leaving 3434-patients' data for analysis. HBCs significantly decreased the incidence of blood transfusion required (OR=0.8; 95% CI=0.6:0.9, P=0.004). It also significantly decreased re-sternotomy (OR=0.6; 95% CI=0.4:0.8, P=0.002), duration of ventilation (WMD= -1.3h; 95% CI= -1.9:-0.6, P<0.001), ICU-LOS (WMD= -9.3h; 95% CI=-14.7:-3.9, P<0.001) and hospital-LOS (WMD= -0.5 day; 95% CI= -0.9:-0.1, P=0.02). HBCs had no effect on other adverse events evaluated. Although HBCs showed a positive effect on some of the clinical outcomes, we identified only marginal differences for other outcomes. Further evaluation of the cost-effectiveness of this technology is required.
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Affiliation(s)
- Omar Mangoush
- National Heart & Lung Institute, Imperial College of Science, Technology and Medicine, Department of Cardiothoracic Surgery, The Heart Hospital, UCLH, London, UK.
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Abstract
A 31-year-old woman who had undergone aortic and mitral valve replacement 1 year previously was hospitalized with suspected prosthetic valve endocarditis. Freestyle stentless aortic xenograft was successfully replaced using freestanding total aortic root replacement techniques at the left ventricular outflow tract position, and aorta-to-right coronary artery bypass was also applied with a saphenous vein graft. The patient developed multiple systemic problems during the preoperative and postoperative periods and was successfully treated with intensive interventions. She was discharged at the postoperative fourth month, and the following 28 months were uneventful.
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Affiliation(s)
- B Gersak
- Department of Cardiovascular Surgery, University Medical Center, Ljubljana, Slovenia.
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Hravnak M, Hoffman LA, Saul MI, Zullo TG, Cuneo JF, Pellegrini RV. Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass. Am J Crit Care 2004; 13:499-507; discussion 508. [PMID: 15568655 PMCID: PMC3655795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.
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Affiliation(s)
- Marilyn Hravnak
- Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pa., USA
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Boethig D, Minami K, Lueth JU, El-Banayosy A, Breymann T, Koerfer R. Intermittent Aortic Cross-Clamping for Isolated CABG Can Save Lives and Money: Experience with 15 307 Patients. Thorac Cardiovasc Surg 2004; 52:147-51. [PMID: 15192774 DOI: 10.1055/s-2004-817979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The ideal myocardial protection during isolated CABG is still a matter of debate. Cardioplegia versus intermittent aortic cross-clamping (IACC) are the main opponents; the following article shows that IACC can be safe, efficient and might be cheaper than cardioplegia. METHODS Demographics and co-morbidities of 15307 CABG only patients consecutively operated on between January 1993 and October 2001 in the Heart Center in Bad Oeynhausen were assessed by the German Quality Assurance data set and risk-stratified using the EuroSCORE. Outcome (30-day or in-hospital mortality) was compared to the expected EuroSCORE estimation. RESULTS Expected mortality was 3.25 %, observed mortality was 1.3 %, being significantly lower in the low, medium as well as high risk patients subgroup. Complication rates increased steadily with expected mortality rates. Stroke and myocardial infarction rates for patients with peripheral vessel disease were not higher than in comparable studies. More than 1000000 EUR were saved by lower cardioplegia bills. CONCLUSION Myocardial protection with intermittent aortic cross-clamping for isolated CABG can be safe, effective, and economically advantageous when compared to cardioplegic solutions.
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Affiliation(s)
- D Boethig
- Department of Pediatric Cardiology and Intensive Care, Hannover Medical University, Hannover, Germany.
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Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA 2004; 291:1841-9. [PMID: 15100202 DOI: 10.1001/jama.291.15.1841] [Citation(s) in RCA: 449] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
CONTEXT Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG). OBJECTIVE To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up. DESIGN, SETTING, AND PATIENTS Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year. INTERVENTIONS One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass. The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols. MAIN OUTCOME MEASURES Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s). RESULTS Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P =.19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P =.27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was 2272 dollars (95% CI, 755 dollars-3732 dollars) less for OPCAB (P =.002) and 1955 dollars (95% CI, -766 dollars to 4727 dollars) less at 1 year (P =.08). CONCLUSIONS In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective.
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Affiliation(s)
- John D Puskas
- Division of Cardiothoracic Surgery,Emory University School of Medicine and Emory Center for Outcomes Research, Atlanta, Ga, USA.
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Tsuda Y, Takemura T, Shimamura Y, Iwasa S. [Economic evaluation of off-pump coronary artery bypass grafting; compared to conventional coronary artery bypass grafting]. Kyobu Geka 2003; 56:718-21. [PMID: 12910958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
This study was undertaken to compare economic outcomes of off-pump coronary artery bypass grafting (off-pump CABG: OPCAB) and conventional CABG (CCABG). We reviewed the medical records of 5 patients with ischemic coronary disease (IHD) who underwent OPCAB and 5 patients with IHD who underwent CCABG. A hospital income which was based on a current Japanese health insurance system was indicated. There were significant differences in total cost (OPCAB = 208,200 +/- 7,383 yen versus CCABG = 324,300 +/- 10,290 yen, 35.8% decreased), costs of medical materials and transfusions (OPCAB = 14,760 +/- 3,270 yen versus CCABG = 87,540 +/- 3,326, 81.3% decreased) and charges of surgery and anesthesia (OPCAB = 130,400 +/- 1,853 yen versus CCABG = 147,650 +/- 4,167 yen, 12% decreased) OPCAB markedly reduces the cost of hospitalization. But charges of surgery and anesthesia of OPCAB seems to be valued properly in a current Japanese health insurance system.
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Affiliation(s)
- Y Tsuda
- Department of Cardiovascular Surgery, National Nagano Hospital, Ueda, Japan
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Healey J, Fenwick E, O'Brien B. Off-pump coronary bypass surgery. N Engl J Med 2003; 348:1928-31; author reply 1928-31. [PMID: 12740969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
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Iakovou I, Dangas G, Mehran R, Lansky AJ, Stamou SC, Pfister AJ, Dullum MKC, Leon MB, Corso PJ. Minimally invasive direct coronary artery bypass (MIDCAB) versus coronary artery stenting for elective revascularization of the left anterior descending artery. Am J Cardiol 2002; 90:885-7. [PMID: 12372581 DOI: 10.1016/s0002-9149(02)02715-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ioannis Iakovou
- Cardiovascular Research Foundation, New York, New York 10022, USA
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Gill IS. Off-pump extraction of an embedded high posterior left ventricular bullet utilizing a new cardiac stabilization device. J Trauma 2002; 53:169; author reply 169. [PMID: 12131413 DOI: 10.1097/00005373-200207000-00036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Patients undergoing cardiopulmonary bypass may develop clinically significant physiologic alterations in the perioperative period, including alteration of thyroid hormone concentrations. Alterations in the concentration of thyroid hormones are of concern due to the effects of these hormones on cardiac function. Hypothyroidism is associated with a decrease in cardiac performance; therefore, supplementation with the active thyroid hormone triiodothyronine (T3) in patients undergoing cardiopulmonary bypass has been investigated to improve outcomes. In addition, T3 has been studied as an agent to reduce the frequency of atrial fibrillation after cardiopulmonary bypass.
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Affiliation(s)
- M G Reichert
- Department of Pharmacy, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina 27157, USA
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Lancey RA, Soller BR, Vander Salm TJ. Off-pump versus on-pump coronary artery bypass surgery: a case-matched comparison of clinical outcomes and costs. Heart Surg Forum 2001; 3:277-81. [PMID: 11178287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2000] [Indexed: 02/18/2023]
Abstract
BACKGROUND Results of off-pump coronary artery bypass (OPCAB) surgery have demonstrated trends toward fewer complications, faster recoveries and lower costs compared with on-pump coronary artery bypass (ONCAB) surgery. The validity of such comparisons, however, may be impacted by differences in preoperative risk factors between the two surgeries. METHODS A total of 76 OPCAB surgery patients were case-matched (by age, sex and Society of Thoracic Surgeons' risk scores) with an equal number of patients who underwent ONCAB surgery by the same surgeon. Postoperative clinical parameters (time on mechanical ventilation, number of blood transfusions, peak cardiac enzyme levels and metabolic acidosis) and outcomes data (intensive care unit and overall in-hospital lengths of stay, perioperative myocardial infarction, atrial fibrillation, stroke, reoperation for bleeding and mortality) were analyzed, and the variable and total costs for each patient were calculated. RESULTS OPCAB patients required less mechanical ventilation and fewer blood transfusions and had lower peak creatinine phosphokinase levels, as well as a reduced incidence of metabolic acidosis. There were trends toward both shorter intensive care unit and overall in-hospital lengths of stay for OPCAB patients. The average total cost for this group was 20.5% less than for ONCAB patients. There were no differences in rates of atrial fibrillation, myocardial infarction, reoperation for bleeding, stroke or mortality. CONCLUSIONS By reducing the need for mechanical ventilation, transfusions and intensive care unit and overall in-hospital lengths of stay, OPCAB surgery decreases the use of limited and costly resources without increasing risks. These advantages do not appear to be related to patient selection.
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Affiliation(s)
- R A Lancey
- University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester 01655, USA.
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Puskas JD, Thourani VH, Marshall JJ, Dempsey SJ, Steiner MA, Sammons BH, Brown WM, Gott JP, Weintraub WS, Guyton RA. Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients. Ann Thorac Surg 2001; 71:1477-83; discussion 1483-4. [PMID: 11383786 DOI: 10.1016/s0003-4975(01)02473-0] [Citation(s) in RCA: 161] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND This retrospective study compared clinical outcomes and resource utilization in patients having off-pump coronary artery bypass grafting (OPCAB) versus conventional coronary artery bypass grafting (CABG). Angiographic patency was documented in the OPCAB group. METHODS From April 1997 through November 1999, OPCAB was performed in 200 consecutive patients, and the results were compared with those in a contemporaneous matched control group of 1,000 patients undergoing CABG. Patients were matched according to age, sex, preexisting disease (renal failure, diabetes, pulmonary disease, stroke, hypertension, peripheral vascular disease, previous myocardial infarction, and primary or redo status. Follow-up in the OPCAB patients was 93% and averaged 13.4 months. RESULTS Hospital death (1.0%), postoperative stroke (1.5%), myocardial infarction (1.0%), and re-entry for bleeding (1.5%) occurred infrequently in the OPCAB group. There were reductions in the rates of transfusion (33.0% versus 70.0%; p < 0.001) and deep sternal wound infection (0% versus 2.2%; p = 0.067) in the OPCAB group compared with the CABG group. Angiographic assessment of 421 grafted arteries was performed in 167 OPCAB patients (83.5%) prior to hospital discharge. All but five were patent (98.8%) (93.3% FitzGibbon A, 5.5% FitzGibbon B, 1.2% FitzGibbon O). All 163 internal mammary artery grafts were patent. Off-pump coronary artery bypass grafting reduced postoperative hospital stay from 5.7 +/- 5.3 days in the CABG group to 3.9 +/- 2.6 days (p < 0.001), with a decrease in hospital cost of 15.0% (p < 0.001). CONCLUSIONS Off-pump coronary artery bypass grafting reduces hospital cost, postoperative length of stay, and morbidity compared with CABG on cardiopulmonary bypass. Off-pump coronary bypass grafting is safe, cost effective, and associated with excellent graft patency and clinical outcomes.
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Affiliation(s)
- J D Puskas
- Division of Cardiothoracic Surgery, Carlyle Fraser Heart Center, Crawford Long Hospital of Emory University, Atlanta, Georgia 30365, USA.
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Ascione R, Williams S, Lloyd CT, Sundaramoorthi T, Pitsis AA, Angelini GD. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomized study. J Thorac Cardiovasc Surg 2001; 121:689-96. [PMID: 11279409 DOI: 10.1067/mtc.2001.112823] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Coronary artery bypass grafting on the beating heart through median sternotomy is a relatively new treatment, which allows multiple revascularization without the use of cardiopulmonary bypass. A prospective randomized study was designed to investigate the effect of coronary bypass with or without cardiopulmonary bypass on postoperative blood loss and transfusion requirement. METHODS Two hundred patients with coronary artery disease were prospectively randomized to (1) on-pump treatment with conventional cardiopulmonary bypass and cardioplegic arrest and (2) off-pump treatment on the beating heart. Postoperative blood loss identified as total chest tube drainage, transfusion requirement, and related costs together with hematologic indices and clotting profiles were analyzed. RESULTS There was no difference between the groups with respect to preoperative and intraoperative patient variables. The mean ratio of postoperative blood loss and 95% confidence interval between groups was 1.64 and 1.39 to 1.94, respectively, suggesting on average a postoperative blood loss 1.6 times higher in the on-pump group compared with the off-pump group. Seventy-seven patients in the off-pump group required no blood transfusion compared with only 48 in the on-pump group (P <.01). Furthermore, less than 5% of patients in the on-pump group required fresh frozen plasma and platelet transfusion compared with 30% and 25%, respectively, in the on-pump group (both P <.05). Mean transfusion cost per patient was higher in the on-pump compared with that in the off-pump group ($184.8 +/- $35.2 vs $21.47 +/- $6.9, P <.01). CONCLUSIONS Coronary artery bypass grafting on the beating heart is associated with a significant reduction in postoperative blood loss, transfusion requirement, and transfusion-related cost when compared with conventional revascularization with cardiopulmonary bypass and cardioplegic arrest.
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Affiliation(s)
- R Ascione
- Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
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Abstract
Most cardiac operations involve the use of extracorporeal circulation with its attendant systemic inflammatory response syndrome. Many anti-inflammatory strategies hold promise for reducing the associated morbidity of cardiopulmonary bypass. The application of pharmacological and mechanical strategies to control this inflammatory response now has demonstrable clinical benefit. The additional costs of these successful strategies are offset by the economic savings and improved quality of care.
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Affiliation(s)
- J P Gott
- Fuqua Heart Center, Piedmount Hospital, Atlanta, Georgia 30309, USA.
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Bull DA, Neumayer LA, Stringham JC, Meldrum P, Affleck DG, Karwande SV. Coronary artery bypass grafting with cardiopulmonary bypass versus off-pump cardiopulmonary bypass grafting: does eliminating the pump reduce morbidity and cost? Ann Thorac Surg 2001; 71:170-3; discussion 173-5. [PMID: 11216740 DOI: 10.1016/s0003-4975(00)02205-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) may contribute to the complications and cost of coronary artery bypass grafting (CABG). Off-pump CABG (OPCAB) allows coronary revascularization without CPB. We hypothesized that OPCAB provides satisfactory graft patency while reducing complications and cost compared with CABG with CPB. METHODS We prospectively followed 80 patients undergoing CABG: 40 patients undergoing OPCAB and 40 patients undergoing CABG with CPB. OPCAB patients underwent angiography within 48 hours of surgery to determine early graft patency. Incidence of complications, length of stay, and costs were recorded for each patient. The influence of the number of vessels bypassed was analyzed. RESULTS OPCAB patients (n = 40) underwent grafting of 2.7 +/- 0.7 vessels per patient compared with 3.6 +/- 0.8 vessels per patient in the CABG with CPB group (n = 40) (p < 0.0001). Angiography demonstrated 105 of 108 (97%) of grafts were patent in the OPCAB group. Incidence of complications, length of stay, and costs did not differ between the OPCAB and CABG with CPB groups. Number of vessels grafted showed a positive correlation to total costs in both groups. CONCLUSIONS While OPCAB provided satisfactory early graft patency, there was no significant difference between OPCAB and CABG with CPB with regard to cost, length of stay, or incidence of complications. In this study, eliminating CPB did not reduce morbidity or cost after CABG.
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Affiliation(s)
- D A Bull
- Department of Surgery, University of Utah Health Sciences Center, Salt Lake City 84132, USA.
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Legendre E, Gallais S, Le Teurnier Y, Iooss P, Maupetit JC, Blanloeil Y. [The use of propofol does not increase the cost of the management of patients in heart surgery with extracorporeal circulation]. Ann Fr Anesth Reanim 2000; 19:662-7. [PMID: 11244704 DOI: 10.1016/s0750-7658(00)00308-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Evaluation of the cost of propofol used for fast-track in cardiac surgery and its impact on global cost of management for anaesthesia and intensive care. STUDY DESIGN Case-control study, prospective (1998) and retrospective (1994). PATIENTS Twenty patients operated for cardiac surgery in 1998 and scheduled for fast-track anaesthesia. Twenty patients in 1994 matched for different criteria to the patient of 1998. METHODS In 1998, all drugs, materials used and X-rays, biochemical assays performed were prospectively collected and their cost calculated. In 1994, similar calculations were done retrospectively. Comparison of duration of mechanical ventilation, hospitalization in intensive care and in the hospital were performed. RESULTS Cost of anaesthesia was similar in 1994 and 1998 (2,646 FF versus 2,294 FF). Global cost of management was significantly lower in 1998 in comparison to 1994 (5,439 FF versus 8,558 FF). Duration of mechanical ventilation, hospitalization in intensive care and in the hospital were shorter in 1998 than in 1994. CONCLUSION Despite a higher cost of propofol for anaesthesia and postoperative sedation in comparison to midazolam, the global cost of management decreased significantly in relation to a one day decrease in hospitalization in the intensive care unit.
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Affiliation(s)
- E Legendre
- Service d'anesthésie et de réanimation chirurgicale, CHU, hôpital G-et R-Laennec, 44093 Nantes, France
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Abstract
BACKGROUND Cardiopulmonary bypass initiates a cascade of inflammatory processes that may result in end-organ damage, leading to the increased prevalence of noncardiac complications. Therefore, off-pump coronary artery bypass graft (OP-CAB) procedures have recently been introduced into clinical practice. METHODS This study was a case-controlled study that compared the outcomes and cost of 100 consecutive OP-CAB procedures with a control group of 100 contemporary matched conventional coronary artery bypass grafting procedures. All operations were performed by a single surgeon (J.H.L. ) and complete revascularization that used off-pump techniques was achieved with the use of innovative exposure techniques to the lateral and posterior wall vessels. RESULTS An average of 3.1 grafts per patient were performed in the OP-CAB group (range, 1-5). The incidence of conversion to conventional coronary artery bypass grafting was 1%. The overall mortality rate was 2.0%. There were no instances of stroke, renal failure, or sternal infections in the OPCAB group. Thus, the OP-CAB group had a shorter length of stay (6.1+/-2.5 versus 7.1+/-3.3 d; P =.003), with a corresponding reduction in variable direct cost per case of 29% (P<.001). CONCLUSION Our experience suggests that OP-CAB procedures are feasible for most patients who currently require complete revascularization. It is associated with very a low morbidity rate and may represent the ideal revascularization strategy for patients at high risk for undergoing cardiopulmonary bypass.
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Affiliation(s)
- J H Lee
- Departments of Surgery and Anesthesiology, University Hospitals Heart Institute, University Hospitals of Cleveland, Cleveland, Ohio
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Affiliation(s)
- J L Svennevig
- Department of Thoracic and Cardiovascular Surgery, The National Hospital (Rikshospitalet), Oslo, Norway
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Birdi I, Chaudhuri N, Lenthall K, Reddy S, Nashef SA. Emergency reinstitution of cardiopulmonary bypass following cardiac surgery: outcome justifies the cost. Eur J Cardiothorac Surg 2000; 17:743-6. [PMID: 10856870 DOI: 10.1016/s1010-7940(00)00453-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Crash back on bypass (crash-BOB) is occasionally required in the resuscitation of patients developing life-threatening complications following cardiac surgery. This study aims to determine the incidence, aetiology and cost-effectiveness of such intervention. METHODS Retrospective review of all crash-BOB patients over 5.5 years at one hospital. RESULTS The incidence of crash-BOB was 0.8% and occurred at a mean of 7 h post-operatively (range 1 h-20 days). Pre-operative Parsonnet scores were similar to the overall population of patients undergoing surgery in our institution (mean score 10; range 0-45). The original cardiac operations were coronary revascularization (39), valve surgery (12) and others (4). Indications for crash-BOB were cardiac arrest (23), bleeding (20), hypotension (7), ischaemia (1) and others (4). Of the 55 patients, 20 died on the operating table. Of the remaining 35, a further 12 died in hospital. Overall survival was therefore 42%. Where crash-BOB was for bleeding, 17 of 20 patients (85%) survived to leave theatre, of whom 11 patients (55%) left hospital alive. In the 35 non-bleeders, only 18 (51%) survived crash-BOB and 12 (34%) left hospital alive. Sixteen patients required a second period of aortic cross-clamping of whom 13 (81%) survived to leave theatre, and 11 (69%) left hospital alive. Conversely, of nine patients in whom no specific diagnosis was found during crash-BOB, only two (22%) survived the procedure and none survived to hospital discharge. Multiple logistic regression identified pre-operative Parsonnet score (P=0.045) and the need for aortic cross-clamping to deal with an identified surgical problem (P=0.03) as significant predictors of hospital survival. Indication for crash-BOB (bleeder/non-bleeder) failed to reach significance (P=0.08). Age, sex, intra-aortic balloon pump use at the primary procedure, and time following the primary procedure to crash-BOB were not identified as predictors of hospital survival. Of the 23 hospital survivors, three patients suffered a stroke post-operatively and made a good functional recovery prior to discharge. Two patients developed sternal wound dehiscence requiring surgical rewiring. At follow-up (mean 3 years, range 1-6 years), 19 patients were in NYHA class I and four were in class II. Crash-BOB patients required an average of 8 extra intensive care days and 2 extra ward days. The total cost of these resources was pound164900 (including theatre time, cardiopulmonary bypass and intra-aortic balloon pump use). This was equivalent to pound7170 per life saved. CONCLUSIONS Crash-BOB occurred in 0.8% of cases and was associated with a survival to discharge of 42%, and a justifiable cost of only pound7170 per life saved. Establishing an accurate diagnosis for the cause of clinical deterioration resulting in crash-BOB intervention was important, and the need for a further period of aortic cross-clamping did not preclude a favourable outcome.
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Affiliation(s)
- I Birdi
- Cardiothoracic Surgical Unit, Papworth Hospital, CB3 8RE, Cambridge, UK
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30
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Abstract
BACKGROUND Emphasis on cost containment in coronary artery bypass surgery is becoming increasingly important in modern hospital management. The revival of interest in off-pump (beating heart) coronary artery bypass surgery may influence the economic outcome. This study examines these effects. METHODS Two hundred patients undergoing first-time coronary artery bypass surgery were prospectively randomized to either conventional cardiopulmonary bypass and cardioplegic arrest or off-pump surgery. Variable and fixed direct costs were obtained for each group during operative and postoperative care. The data were analyzed using parametric methods. RESULTS There was no difference between the groups with respect to pre- and intraoperative patient variables. Off-pump surgery was significantly less costly than conventional on-pump surgery with respect to operating materials, bed occupancy, and transfusion requirements (total mean cost per patient: on pump, $3,731.6+/-1,169.7 vs off-pump, $2,615.13+/-953.6; p < 0.001). Morbidity was significantly higher in the on-pump group, which was reflected in an increased cost. CONCLUSIONS Off-pump revascularization offers a safe, cost-effective alternative to conventional coronary revascularization with cardiopulmonary bypass and cardioplegic arrest.
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Affiliation(s)
- R Ascione
- Bristol Heart Institute, Bristol Royal Infirmary, United Kingdom
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31
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Abstract
BACKGROUND Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients. METHODS Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65. RESULTS Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by $1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency. CONCLUSIONS OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.
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Affiliation(s)
- W D Boyd
- London Health Sciences Centre, University of Western Ontario, Canada.
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Abstract
BACKGROUND Coronary artery bypass grafting without cardiopulmonary bypass is gaining popularity as an alternative to conventional on-pump technique for myocardial revascularization. This includes minimally invasive direct coronary artery bypass (MIDCAB) and full sternotomy off-pump (OPCAB) methods. These two approaches should be evaluated for financial and clinical appropriateness. METHODS Records of patients who had single or double bypass (internal mammary artery and/or saphenous vein) grafts between January 1997 and June 1998 were reviewed. These included 44 MIDCAB, 62 OPCAB, and 243 conventional coronary artery bypass (CCAB) patients. Univariate analysis was applied to pre, intra, and postoperative variables, comparing MIDCAB and OPCAB to the CCAB group. Procedural cost information was obtained from participating institutions. RESULTS MIDCAB patients compared to CCAB patients had a higher predicted risk (5.4+/-11 versus 2.3+/-2.8, p = 0.012) and OPCAB patients had a predicted risk of 5.3+/-7.8. MIDCAB and OPCAB procedures required less operating room time and blood utilization. Observed operative mortality rates were MIDCAB 4.5%, OPCAB 1.6%, and CCAB 2.8% (not significant). Mean hospital costs were CCAB at $19,000, OPCAB at $15,000, and $17,000 for MIDCAB. CONCLUSIONS Off pump procedures currently reflect acute episode-of-care cost savings over CCAB.
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Affiliation(s)
- K V Arom
- Minneapolis Heart Institute, Minnesota 55407, USA.
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Ogella DA. Advances in perfusion technology--an overview. J Indian Med Assoc 1999; 97:436-7, 441. [PMID: 10638107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The introduction of minimally invasive approaches to cardiac surgery offered the opportunity to reduce patient's pain associated with median stemotomy as well as infection and postoperative bleeding. This technique required the use of one small venous cannula necessitating the implementation of kinetic assisted venous drainage (KAVD). However, KAVD proved costly due to the use of a centrifugal pump and could be de-primed if air was introduced into the venous line. Vacuum assisted venous drainage (VAVD), an easy to learn technique, was proved to be a better, safe and less expensive alternative as it required lower prime and small cannulae. Blunt trauma could also be avoided as large cannulae were not used.
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Affiliation(s)
- D A Ogella
- Perfusion Services, Cleveland Clinic Foundation, USA
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Abstract
BACKGROUND Aprotinin therapy is now widely used during cardiac surgery. This study examined the clinical and economic effectiveness of high-dose or low-dose aprotinin in comparison to placebo. METHODS In a double blind, randomized study, three groups of 50 patients received high-dose aprotinin costing AUS$614 per patient (AUS$ = Australian dollars), low-dose aprotinin costing AUS$220 per patient or placebo. Resource use influenced by aprotinin therapy was measured. RESULTS Both doses were effective in reducing chest drainage and postoperative transfusion requirements, high-dose being more effective than low-dose. Both doses reduced the rate of reoperations for hemostasis. A base case of statistically significant differences associated with the high-dose and low-dose aprotinin showed cost savings of AUS$77 and AUS$348 per patient, respectively. If the demonstrated less significant reductions in operating room and ward stay are included, these savings become AUS$463 and AUS$715, respectively. Alternately, if cross-matches are replaced by group-and-hold and cell savers are not used, the savings per patient would be AUS$196 and AUS$467, respectively. CONCLUSIONS While high-dose aprotinin is clinically more effective than low-dose aprotinin, low-dose therapy demonstrates greater cost savings.
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Affiliation(s)
- M J Ray
- Department of Haematology, The Prince Charles Hospital, Brisbane, Deakin University, Victoria, Australia.
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Woolf RL, Mythen MG. Con: heparin-bonded cardiopulmonary bypass circuits do not represent a desirable and cost-effective advance in cardiopulmonary bypass technology. J Cardiothorac Vasc Anesth 1998; 12:710-2. [PMID: 9854674 DOI: 10.1016/s1053-0770(98)90249-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- R L Woolf
- Department of Anaesthesia, University College London Hospitals, UK
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Gott JP, Cooper WA, Schmidt FE, Brown WM, Wright CE, Merlino JD, Fortenberry JD, Clark WS, Guyton RA. Modifying risk for extracorporeal circulation: trial of four antiinflammatory strategies. Ann Thorac Surg 1998; 66:747-53; discussion 753-4. [PMID: 9768925 DOI: 10.1016/s0003-4975(98)00695-x] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite recent rediscovery of beating heart cardiac surgical techniques, extracorporeal circulation remains appropriate for most heart operations. To minimize deleterious effects of cardiopulmonary bypass, antiinflammatory strategies have evolved. METHODS Four state-of-the-art strategies were studied in a prospective, randomized, preoperatively risk stratified, 400-patient study comprising primary (n = 358), reoperative (n = 42), coronary (n = 307), valve (n = 27), ascending aortic (n = 9), and combined operations (n = 23). Groups were as follows: standard, roller pump, membrane oxygenator, methylprednisolone (n = 112); aprotinin, standard plus aprotinin (n = 109); leukocyte depletion, standard plus a leukocyte filtration strategy (n = 112); and heparin-bonded circuitry, centrifugal pumping with surface modification (n = 67). RESULTS Analysis of variance, linear and logistic regression, and Pearson correlation were applied. Actual mortality (2.3%) was less than half the risk stratification predicted mortality (5.7%). The treatment strategies effectively attenuated markers of the inflammatory response to extracorporeal circulation. Compared with the other groups the heparin-bonded circuit had highly significantly decreased complement activation (p = 0.00001), leukocyte filtration blunted postpump leukocytosis (p = 0.043), and the aprotinin group had less fibrinolysis (p = 0.011). Primary end points, length of stay, and hospital charges, were positively correlated with operation type, age, pump time, body surface area, stroke, pulmonary sequelae, predicted risk for stroke, predicted risk for mortality, and risk strata/treatment group interaction (p = 0.0001). In low-risk patients, leukocyte filtration reduced length of stay by 1 day (p = 0.02) and mean charges by $2,000 to $6,000 (p = 0.05). For high-risk patients, aprotinin reduced mean length of stay up to 10 fewer days (p = 0.02) and mean charges by $6,000 to $48,000 (p = 0.0007). CONCLUSIONS These pharmacologic and mechanical strategies significantly attenuated the inflammatory response to extracorporeal circulation. This translated variably into improved patient outcomes. The increased cost of treatment was offset for selected strategies through the added value of significantly reduced risk.
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Affiliation(s)
- J P Gott
- Department of Biostatistics, Emory University, Carlyle Fraser Heart Center, Crawford Long Hospital of Emory University, Atlanta, Georgia 30365, USA
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Abstract
BACKGROUND Pharmacoeconomics is becoming increasingly important in the health-care environment, but pharmacoeconomic studies are fraught with problems. Pharmacoeconomics can be applied to analysis of the benefits of pharmacologic hemostasis. METHODS This article reviews the available methods of pharmacoeconomic analysis and their inherent methodologic concerns. It reviews pharmacoeconomic studies of pharmacologic hemostasis, with particular focus on the Pediatric Reoperative Open Heart Surgery study. In this study, patients were randomized to receive either high-dose aprotinin, low-dose aprotinin, or placebo. Results were analyzed from the viewpoint of cost-benefit, cost-effectiveness calculated with use of a roll-back decision tree, and cost-effective ratios. RESULTS Cost-benefit analysis showed low-dose aprotinin to have a greater cost-benefit than high-dose aprotinin, cost-effectiveness analysis and analysis of cost-effective ratios showed high-dose aprotinin to be more cost-effective than low-dose aprotinin, and all analyses showed aprotinin to be preferable to placebo. CONCLUSIONS Aprotinin in pediatric repeat open heart operations not only has a cost-benefit but is cost-effective as well.
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Affiliation(s)
- C C D'Errico
- Department of Pediatric Anesthesiology, Mott Children's Hospital, University of Michigan Medical Center, Ann Arbor 48109-0211, USA
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38
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Abstract
Minimally invasive approaches for cardiac operations currently are gaining increasing attention. Some of these approaches require cannulation of the femoral vessels for cardiopulmonary bypass. A potential complication of femoral cannulation is ischemic injury to the lower extremity in some cases that require long bypass times. To minimize this risk we have begun cannulating the common femoral artery distally, as well as proximally. This technique perfuses the leg for the duration of cardiopulmonary bypass, and it can be accomplished with minimal increases in cost and operative time.
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Affiliation(s)
- S C Hendrickson
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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39
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Abstract
The aim of this study was to use meta-analysis to combine the results of numerous studies and examine the impact of heparin-bonded circuits on clinical outcomes and the resulting costs. Heparin-bonded circuits, both ionically and covalently bonded, are examined separately. The results of the study provide evidence that heparin-bonded circuits result in improved clinical outcomes when compared to the identical nonheparin-bonded circuits. These improved clinical outcomes result in subsequent lower costs per patient with their use. However, differences are apparent in the significance and magnitude of these outcomes between ionically and covalently bonded circuits. Covalently bonded circuits provide a greater magnitude and significance of improvement in clinical outcomes than ionically bonded circuits. Total cost savings can be expected to be three times greater with covalently bonded circuits ($3231 versus $1068). It was concluded that the choice regarding the use of a heparin-bonded circuits and the type of heparin-bonded circuit used has the potential to alter clinical outcomes and subsequent costs. Cost consideration cannot be ignored, but clinical benefits should be the main rationale for the choice of cardiopulmonary bypass circuit. This analysis provides evidence that clinical benefits and cost savings can both be derived from use of the same technology-covalently bonded circuits.
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Affiliation(s)
- C B Mahoney
- Industrial Relations Center, Carlson School of Management, University of Minnesota, Minneapolis 55455-0430, USA
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Bennett-Guerrero E, Sorohan JG, Gurevich ML, Kazanjian PE, Levy RR, Barberá AV, White WD, Slaughter TF, Sladen RN, Smith PK, Newman MF. Cost-benefit and efficacy of aprotinin compared with epsilon-aminocaproic acid in patients having repeated cardiac operations: a randomized, blinded clinical trial. Anesthesiology 1997; 87:1373-80. [PMID: 9416723 DOI: 10.1097/00000542-199712000-00017] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Aprotinin and epsilon-aminocaproic acid are routinely used to reduce bleeding during cardiac surgery. The marked difference in average wholesale cost between these two drug therapies (aprotinin, $1,080 vs. epsilon-aminocaproic acid, $11) has generated significant controversy regarding their relative efficacies and costs. METHODS In a multicenter, randomized, prospective, blinded trial, patients having repeated cardiac surgery received either a high-dose regimen of aprotinin (total dose, 6 x 10(6) kallikrein inactivator units) or epsilon-aminocaproic acid (total dose, 270 mg/kg). RESULTS Two hundred four patients were studied. Overall (data are median [25th-75th percentiles]), aprotinin-treated patients had less postoperative thoracic drainage (511 ml [383-805 ml] vs. 655 ml [464-1,045 ml]; P = 0.016) and received fewer platelet transfusions (0 [range, 0-1] vs. 1 [range, 0-2]; P = 0.036). The surgical field was more likely to be considered free of bleeding in aprotinin-treated patients (44% vs. 26%; P = 0.012). No differences, however, were seen in allogeneic erythrocyte transfusions or in the time required for chest closure. Overall, direct and indirect bleeding-related costs were greater in aprotinin- than in epsilon-aminocaproic acid-treated patients ($1,813 [$1,476-2,605] vs. $1,088 [range, $511-2,057]; P = 0.0001). This difference in cost per case varied in magnitude among sites but not in direction. CONCLUSIONS Aprotinin was more effective than epsilon-aminocaproic acid at decreasing bleeding and platelet transfusions. Epsilon-aminocaproic acid, however, was the more cost-effective therapy over a broad range of estimates for bleeding-related costs in patients undergoing repeated cardiac surgery. A cost-benefit analysis using the lower cost of half-dose aprotinin ($540) still resulted in a significant cost advantage using epsilon-aminocaproic therapy (P = 0.022).
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Young WV, Heemsoth CH, Georgiafandis G, Mitchell DC, Hackett DK, Bahna DG. Extracorporeal circuit sterility after 168 hours. J Extra Corpor Technol 1997; 29:181-4. [PMID: 10176126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
One of the most important tasks of the perfusionist is the proper assembly of the extracorporeal circuit (ECC) prior to the initiation of cardiopulmonary bypass (CPB). The ECC is usually assembled, primed and debubbled 30 minutes to one hour prior to the patient entering the operating room. But there are occasions when the ECC may have been set up and the previously scheduled procedure cancelled. Perfusionists in this situation have found themselves in a quandary; dispose of the ECC because of required nursing compliance and the sterility question, or keep it and use it later because of the economic impact on the "bottom line". Some hospitals may have satisfactorily answered the question of ECC sterility after 24 hours without observation, but the few reported papers regarding this issue, and our desire to save these circuits, inspired us to find out if they were in fact sterile after having been open for a long period of time. The purpose of this study was to evaluate ECC sterility using an open reservoir oxygenator, over a time period of seven days. After obtaining 792 bacterial cultures from three sites within the ECC, the study was terminated. There were no positive bacterial cultures during the study period. Assuming there is no deliberate contamination, pump circuits assembled in an unused operating room can be maintained sterile for a period of seven days.
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Affiliation(s)
- W V Young
- Baptist Hospital of East Tennessee, Department of Perfusion, Knoxville 37920, USA
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Pagani FD, Benedict MB, Marshall BL, Bolling SF. The economics of uncomplicated mitral valve surgery. J Heart Valve Dis 1997; 6:466-9. [PMID: 9330165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS OF THE STUDY Comparisons of mitral valve (MV) replacement and reconstruction have demonstrated lower overall complication rates, better left ventricular (LV) function, and inferred overall lower cost for the latter procedure compared with the former. However, assessment of economic differences between the two procedures in routine cases, without complications, has not been reported. This study retrospectively evaluates the economic impact of uncomplicated MV repair versus replacement. METHODS As this study seeks only to evaluate economic comparisons between routine cases of mitral repair versus replacement, those patients having concomitant procedures performed (coronary revascularization or other valve procedure) or postoperative complications (i.e. pulmonary failure, wound infections, new-onset atrial fibrillation, return for bleeding, or neurologic sequelae) were excluded from the study. Among patients who underwent uncomplicated MV procedures, 30 were selected at random and reviewed. RESULTS Variables for MV replacement versus reconstruction included aortic cross-clamp time (112 +/- 54 versus 92 +/- 20 min; p = NS), cardiopulmonary bypass (CPB) time (189 +/- 70 versus 128 +/- 18 min; p < 0.05), total hospital stay (8.3 +/- 1.6 versus 5.6 +/- 1.6 days; p < 0.0001), and total hospital charges ($44,697 +/- 4903 versus $31,337 +/- 4484; p < 0.0001), respectively. CONCLUSIONS These data suggest that, beyond the recognized benefits of MV reconstruction, namely preservation of LV function and avoidance of long-term anticoagulation, there is an economic advantage to MV reconstruction for patients and payors, even in uncomplicated cases. These differences may become more apparent with longer follow-up and in patients having poor function or combined procedures. This finding reinforces the idea that MV reconstruction is the option of choice for patients with mitral regurgitation.
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Affiliation(s)
- F D Pagani
- Department of Surgery, University of Michigan Hospitals, Ann Arbor 48109-0344, USA
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Abstract
BACKGROUND Growth of the elderly population worldwide, and specifically in the United States, will continue to accelerate and will have a profound impact on the cost and delivery of health care resources in the future. A medical strategy that allows the elderly to live independently is essential to most cost-effective use of our resources. The question remains as to what will be the future of surgical therapy for this increasing population. METHODS We retrospectively studied the cases of 30 consecutive nonagenarians (mean age, 92.3 +/- 1.8 years) who underwent a cardiac operation within a 9-year period. All patients were in New York Heart Association class III or IV and underwent operation urgently or emergently. RESULTS The 30-day mortality rate was 10%, and the actuarial survival rates were 81% +/- 8% and 75% +/- 9% at 1 year and 2 years, respectively. Seventy-eight percent of survivors were in New York Heart Association class I or II within 2 years after operation and had an improved quality of life. The cost of providing care in this age group was 24% higher than in octogenarians. CONCLUSIONS Advanced age in and of itself (>90 years) should not be a contraindication to an open-heart operation, although morbidity, mortality, and cost may be higher. However, selective criteria identifying risks and benefits for individual patients should be applied. The aging of our population will have a profound impact on the cost and delivery of health care resources in the future. This issue must be addressed in the current debate on the provision of expensive procedures under a realigned national health-care system.
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Affiliation(s)
- C Blanche
- Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA
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Abstract
The use of conventional ultrafiltration during cardiopulmonary bypass (CPB) has been well recognized as an efficient modality of therapy to reverse the effects of deliberate haemodilution. Routine use of the haemofilter was prospectively studied on 60 patients undergoing coronary artery bypass surgery. Group A consisted of 30 patients on whom the ultrafiltrator was used and compared to group B who did not receive the ultrafiltration technique. The COBE 1200 ultrafiltration device was used. The results of the study demonstrated that, in group A, the mean total amount of ultrafiltrate collected during bypass was 2510 +/- 804 ml per patient. The mean 24-h postoperative blood loss was 440 +/- 192 ml in group A and 451 +/- 136 ml in group B. The average bank blood transfused was 0.6 +/- 1.3 units per patient in group A and 0.75 +/- 1.5 units per patient in group B. Postoperative weight gain in group A averaged 3.5 +/- 3.45 lb per patient, compared to 4.8 +/- 3.7 lb per patient in group B. Postoperative length of stay averaged 6.4 +/- 1.5 days per patient in group A and 6.4 +/- 2.1 days per patient in group B. Overall patient charges averaged $33,706 +/- 8348 per patient in group A and $33,041 +/- 7674 per patient in group B. It was concluded that routine use of ultrafiltration during routine coronary artery bypass surgery with CPB offers no improvement in the quality of care nor does it decrease the patient's overall charges.
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Affiliation(s)
- R M Babka
- St Mary's Medical Center, Department of Surgical Services, Knoxville, TN 37917, USA
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Meisler N, Midyette P. Results of a multidisciplinary approach to fast-track recovery for cardiac surgery patients. J Cardiovasc Manag 1996; 7:7, 10-8. [PMID: 10162115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- N Meisler
- Birmingham Baptist Medical Center/Montclair, AL, USA
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Odell JA. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996; 62:628. [PMID: 8694651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
The economics of health care in the USA and abroad has caused a shift in the focus on therapeutic interventions that transcend issues of safety and clinical efficacy. Now, cost justification is emerging as a major consideration to influence clinical practice. This brief review of the medical literature attempts to identify leucocyte-mediated adverse reactions that develop in open-hear surgery, quantify the costs incurred to manage such reactions and infer the savings that may accrue by controlling the burden of leucocytes presented to the open-heart surgical patient using commercially available leucocyte reducing filtration technology.
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Spiess BD, Gillies BS, Chandler W, Verrier E. Changes in transfusion therapy and reexploration rate after institution of a blood management program in cardiac surgical patients. J Cardiothorac Vasc Anesth 1995; 9:168-73. [PMID: 7780073 DOI: 10.1016/s1053-0770(05)80189-2] [Citation(s) in RCA: 195] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A retrospective study was performed to determine the impact of a coagulation and transfusion management program on blood utilization in 1,079 sequential patients for myocardial revascularization and open ventricle or combined procedures. Four hundred and eighty-eight patients (group 1) before, and 591 patients (group 2) after institution of thromboelastography (TEG)-guided coagulation were studied and compared for transfusion requirements, donor exposure, and the incidence of reoperation for hemorrhage. Group 2 patients had a significantly lower incidence of overall transfusion (78.5% v 86.3%) during hospitalization and in total transfusion in the operating room (57.9% v 66.4%). The incidence of each transfusion subtype was also significantly lower in group 2 patients. Actual total median donor exposure was 8 in group 1 patients and 6 exposures in group 2 patients. Mediastinal reexploration for hemorrhage was 5.7% before institution of TEG-based coagulation monitoring and 1.5% in TEG-monitored patients. Use of TEG monitoring before reexploration has decreased the cost and potential risk for patients undergoing CABG surgery.
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Affiliation(s)
- B D Spiess
- Department of Anesthesiology, University of Washington, Seattle 98195, USA
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Fedoruk LM, Stewart KM, Hayden RI. The cardiac surgery program at the Royal Columbian Hospital: review of the first fiscal year. Can J Surg 1993; 36:541-5. [PMID: 8258135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
From a budgetary viewpoint, the authors summarize the operative experience of the cardiac surgery program at the Royal Columbian Hospital during its first fiscal year of operation. The program was funded for 250 cardiopulmonary bypass (CPB) procedures: $16,800 per CPB procedure ($4.2 million for the program). The 250 CPB procedures were performed on 248 patients. The 30-day operative mortality was 2%. Thirty patients (12.1%) underwent a second operation for complications or delayed primary closure of the sternum, or both; the complications included aortic prosthetic perivalvular leaks in 2 patients. Eight patients (3.2%) required insertion of an intra-aortic balloon pump preoperatively to stabilize their condition; 10 others (4.0%) required intra-aortic balloon pump insertion at surgery to correct low-cardiac-output syndrome. Blood products were needed for 149 (59.6%) of the 250 CPB procedures. The average hospital stay was 10.4 days for noncoronary procedures and 9.0 days for coronary procedures.
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Affiliation(s)
- L M Fedoruk
- Department of Cardiac Sciences, Royal Columbian Hospital, New Westminster, BC
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