Coronary artery bypass surgery in Brazil: analysis of the national reality through the bypass registry

Abstract Introduction: Coronary artery bypass grafting (CABG) is the most frequently performed heart surgery in Brazil. Recent international guidelines recommend that national societies establish a database on the practice and results of CABG. In anticipation of the recommendation, the BYPASS Registry was introduced in 2015. Objective: To analyze the profile, risk factors and outcomes of patients undergoing CABG in Brazil, as well as to examine the predominant surgical strategy, based on the data included in the BYPASS Registry. Methods: A cross-sectional study of 2292 patients undergoing CABG surgery and cataloged in the BYPASS Registry up to November 2018. Demographic data, clinical presentation, operative variables, and postoperative hospital outcomes were analyzed. Results: Patients referred to CABG in Brazil are predominantly male (71%), with prior myocardial infarction in 41.1% of cases, diabetes in 42.5%, and ejection fraction lower than 40% in 9.7%. The Heart Team indicated surgery in 32.9% of the cases. Most of the patients underwent cardiopulmonary bypass (87%), and cardioplegia was the strategy of myocardial protection chosen in 95.2% of the cases. The left internal thoracic artery was used as a graft in 91% of the cases; the right internal thoracic artery, in 5.6%; and the radial artery in 1.1%. The saphenous vein graft was used in 84.1% of the patients, being the only graft employed in 7.7% of the patients. The median number of coronary vessels treated was 3. Operative mortality was 2.8%, and the incidence of cerebrovascular accident was 1.2%. Conclusion: CABG data in Brazil provided by the BYPASS Registry analysis are representative of our national reality and practice. This database constitutes an important reference for indications and comparisons of therapeutic procedures, as well as to propose subsequent models to improve patient safety and the quality of surgical practice in the country.

Glycated hemoglobin as a predictor of the length of hospital stay in patients following coronary bypass graft surgery in the saudi population

Abstract Objective: The diabetic population has a high prevalence of coronary artery disease, and frequently patients with diabetes undergo coronary artery bypass graft (CABG) surgery. Elevated glycated hemoglobin (HbA1c) in diabetics is shown to be associated with morbidity and mortality, but the association of HbA1c with postoperative length of hospital stay (LOS) has conflicting results. In this study, we aim to identify if elevated HbA1c levels are associated with prolonged LOS after CABG surgery. Methods: A retrospective chart review study was performed, using a total of 305 patients who were referred for CABG surgery. HbA1c levels were measured before the day of surgery. Patients were classified into two groups according to HbA1c levels: <7% and ≥7%. A LOS of more than 14 days was proposed as an extended LOS. HbA1c and the LOS relationship were assessed using appropriate statistical methods. Results: Patients who had diabetes mellitus comprised 81.6% of our studied population. Sixty-four percent had HbA1c levels ≥ 7%. There was no significant difference in the total LOS in HbA1c <7% compared to HbA1c ≥7% patients (P=0.367). Conclusion: Our study results rejected the proposed hypothesis that elevated HbA1c levels ≥7% would be associated with prolonged hospital stay following CABG surgery in a Saudi population.

Impact of myocardial revascularization method on smoking cessation: coronary artery bypass grafting versus percutaneous coronary intervention

Abstract Introduction: Smoking is a serious public health issue, being a precursor of heart disease and a predictor of sudden death due to myocardial ischemia. Major events in the patient's health can lead to radical changes in habits and the choice for different myocardial revascularization methods might differently impact smoking cessation and relapse. Objective: To study the rate and perpetuation of smoking cessation after myocardial revascularization comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Methods: Smokers submitted to myocardial revascularization were divided into CABG and PCI groups. The research was conducted through interviews at the Hospital Santa Lucinda outpatient clinic. Patients with smoking cessation longer than 90 days before hospital admission, combined procedures, hospital readmission before 360 days after discharge, cases of death at any time, and emergency procedures were excluded from the study. The start of the smoking cessation period was determined as just after hospital discharge, with a follow-up of 12 months. Results: The proportion of patients reporting smoking relapse was significantly lower in the CABG than in the PCI group at 30 (11.1% vs. 20.8%; P=0.039) and at 180 days (23.1% vs. 41.5%; P=0.002), but no differences were observed between the two groups at 360 days after hospital discharge (51.9% vs. 54.1%; P=0.719). High levels of nicotine dependence and passive smoking showed to be important predictors of smoking relapse in the long-term. Conclusion: The occurrence of a major surgical procedure seems to have beneficial psychological effects, representing an interesting setting for smoking cessation counseling to have higher chances of success.

Coronary artery bypass graft surgery cost coverage by the brazilian unified health system (SUS)

Abstract Introduction: Cost management has been identified as an essential tool for the general control and evaluation of health organizations. Objectives: To identify the coverage percentage of transferred funds from the Unified Health System for coronary artery bypass grafts in a philanthropic hospital having a consolidated costing system in the municipality of São Paulo. Methods: A quantitative, descriptive and cross-sectional research with information provided from a database composed of 1913 patients undergoing coronary artery bypass graft from March 13 to September 30, 2012, including isolated elective coronary artery bypass graft with the use of extracorporeal circulation. It excluded 551 (28.8%) patients, among them 76 (4.0%) deaths and 8 hospitalized patients, since the cost was compared according to the length of hospital stay. Therefore, the sample consisted of 1362 patients. Results: The average total cost per patient was $7,992.55. The average fund transfer by the Unified Health System was $3,450.73 (48.66%), resulting in a deficit of $4,541.82 (51.34%). Conclusion: The Unified Health System transfers covered 48.66% of the average total cost of hospitalization. Although the amount transferred increased with increasing costs, it was not proportional to the total cost, resulting in a percentage difference in revenue that was increasingly negative for each increase in cost and hospital stay. Those hospitalized for longer than seven days presented higher costs, older age, higher percentage of diabetics and chronic kidney disease patients and more postoperative complications.

The brazilian registry of adult patient undergoing cardiovascular surgery, the bypass project: results of the first 1,722 patients

Abstract Objective: To report the early results of the BYPASS project - the Brazilian registrY of adult Patient undergoing cArdiovaScular Surgery - a national, observational, prospective, and longitudinal follow-up registry, aiming to chart a profile of patients undergoing cardiovascular surgery in Brazil, assessing the data harvested from the initial 1,722 patients. Methods: Data collection involved institutions throughout the whole country, comprising 17 centers in 4 regions: Southeast (8), Northeast (5), South (3), and Center-West (1). The study population consists of patients over 18 years of age, and the types of operations recorded were: coronary artery bypass graft (CABG), mitral valve, aortic valve (either conventional or transcatheter), surgical correction of atrial fibrillation, cardiac transplantation, mechanical circulatory support and congenital heart diseases in adults. Results: 83.1% of patients came from the public health system (SUS), 9.6% from the supplemental (private insurance) healthcare systems; and 7.3% from private (out-of -pocket) clinic. Male patients comprised 66%, 30% were diabetics, 46% had dyslipidemia, 28% previously sustained a myocardial infarction, and 9.4% underwent prior cardiovascular surgery. Patients underwent coronary artery bypass surgery were 54.1% and 31.5% to valve surgery, either isolated or combined. The overall postoperative mortality up to the 7th postoperative day was 4%; for CABG was 2.6%, and for valve operations, 4.4%. Conclusion: This first report outlines the consecution of the Brazilian surgical cardiac database, intended to serve primarily as a tool for providing information for clinical improvement and patient safety and constitute a basis for production of research protocols.

Relationship between pre-extubation positive endexpiratory pressure and oxygenation after coronary artery bypass grafting / Relação entre a pressão expiratória positiva final pré-extubação e a oxigenação após revascularização cirúrgica do miocárdio

AbstractIntroductionAfter removal of endotracheal tube and artificial ventilation, ventilatory support should be continued, offering oxygen supply to ensure an arterial oxygen saturation close to physiological.Objective:The aim of this study was to investigate the effects of positive-end expiratory pressure before extubation on the oxygenation indices of patients undergoing coronary artery bypass grafting.Methods:A randomized clinical trial with seventy-eight patients undergoing coronary artery bypass grafting divided into three groups and ventilated with different positive-end expiratory pressure levels prior to extubation: Group A, 5 cmH2O (n=32); Group B, 8 cmH2O (n=26); and Group C, 10 cmH2O (n=20). Oxygenation index data were obtained from arterial blood gas samples collected at 1, 3, and 6 h after extubation. Patients with chronic pulmonary disease and those who underwent off-pump, emergency, or combined surgeries were excluded. For statistical analysis, we used Shapiro-Wilk, G, Kruskal-Wallis, and analysis of variance tests and set the level of significance at P<0.05.ResultsGroups were homogenous with regard to demographic, clinical, and surgical variables. There were no statistically significant differences between groups in the first 6 h after extubation with regard to oxygenation indices and oxygen therapy utilization.Conclusion:In this sample of patients undergoing coronary artery bypass grafting, the use of different positive-end expiratory pressure levels before extubation did not affect gas exchange or oxygen therapy utilization in the first 6 h after endotracheal tube removal.

ResumoIntrodução:Após a remoção do tubo endotraqueal e ventilação artificial, o suporte ventilatório deve ser continuado, oferecendo suprimento de oxigênio para garantir uma saturação arterial de oxigênio próxima da fisiológica.Objetivo:O objetivo deste estudo foi investigar os efeitos da pressão expiratória positiva final antes de extubação nos índices de oxigenação de pacientes submetidos à cirurgia de revascularização miocárdica.Métodos:Ensaio clínico randomizado com 78 pacientes submetidos à cirurgia de revascularização do miocárdio, divididos em três grupos e ventilados com diferentes níveis de pressão expiratória positiva final antes da extubação: Grupo A, 5 cmH2O (n=32); Grupo B, 8 cm H2O (n=26); e grupo C, 10 cmH2O (n=20). Dados do índice de oxigenação foram obtidos a partir de amostras de gases sanguíneos arteriais coletados em 1, 3 e 6 h após a extubação. Pacientes com doença pulmonar crônica e aqueles que foram submetidos à cirurgia sem circulação extracorpórea, de emergência ou combinadas foram excluídos. Para a análise estatística, foram utilizados Shapiro-Wilk, G, Kruskal-Wallis, e análise dos testes de variância e definição do nível de significância em P<0,05.Resultados:Os grupos foram homogêneos em relação às variáveis ​​demográficas, clínicas e cirúrgicas. Não houve diferenças estatisticamente significativas entre os grupos nas primeiras 6 h após extubação no que diz respeito aos índices de oxigenação e a utilização de oxigenoterapia.Conclusão:Nesta amostra de pacientes submetidos à revascularização do miocárdio, o uso de diferentes níveis de pressão expiratória positiva final antes da extubação não afetou as trocas gasosas ou utilização de oxigenoterapia nas primeiras 6h após a remoção do tubo endotraqueal.

Changes in the Practice of Coronary Revascularization between 2006 and 2010 in the Republic of Korea

PURPOSE: Evidence suggests that technological innovations and reimbursement schemes of the National Health Insurance Service may have impacted the management of coronary artery disease. Thus, we investigated changes in the practice patterns of coronary revascularization. MATERIALS AND METHODS: Revascularization and in-hospital mortality among Koreans > or =20 years old were identified from medical claims filed between 2006 and 2010. The age- and sex-standardized procedure rate per 100000 person-years was calculated directly from the distribution of the 2008 Korean population. RESULTS: The coronary revascularization rate increased from 116.1 (95% confidence interval, 114.9-117.2) in 2006 to 131.0 (129.9-132.1) in 2010. Compared to the rate ratios in 2006, the rate ratios for percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery in 2010 were 1.16 (1.15-1.17) and 0.80 (0.76-0.84), respectively. Among patients who received PCI, the percentage with drug-eluting stents increased from 89.1% in 2006 to 93.0% in 2010. In-hospital mortality rates from PCI significantly increased during the study period (p=0.03), whereas those from CABG significantly decreased (p=0.01). The in-hospital mortality rates for PCI and CABG were higher in elderly and female patients and at the lowest-volume hospitals. CONCLUSION: The annual volume of coronary revascularization continuously increased between 2006 and 2010 in Korea, although this trend differed according to procedure type. A high percentage of drug-eluting stent procedures and a high rate of in-hospital mortality at low-volume hospitals were noted.

Risk factors for prolonged hospital stay after isolated coronary artery bypass grafting / Fatores de risco para tempo de internação prolongada após revascularização isolada do miocárdio

INTRODUCTION: Characteristics of the patient and the coronary artery bypass grafting may predispose individuals to prolonged hospitalization, increasing costs and morbidity and mortality. OBJECTIVE: The objective of this study was to evaluate individual and perioperative risk factors of prolonged hospitalization in intensive care units and wards. METHODS: We conducted a case-control study of 104 patients undergoing isolated coronary artery bypass grafting with cardiopulmonary bypass. Patients hospitalized >3 days in the intensive care unit or >7 days in the ward were considered for the study. The association between variables was estimated by the chi-square test, odds ratio and logistic regression; P <0.05 was considered statistically significant. RESULTS: Hospital stay >3 days in the intensive care unit occurred for 22.1% of patients and >7 days in the ward for 27.9%. Among preoperative factors, diabetes (OR=3.17) and smoking (OR=4.07) were predictors of prolonged intensive care unit stay. Combining the pre-, intra-and postoperative variables, only mechanical ventilation for more than 24 hours (OR=6.10) was predictive of intensive care unit outcome. For the ward outcome, the preoperative predictor was left ventricular ejection fraction <50% (OR=3.04). Combining pre- and intraoperative factors, diabetes (OR=2.81), and including postoperative factors, presence of infection (OR=4.54) were predictors of prolonged hospitalization in the ward. CONCLUSION: Diabetes and smoking were predictors of intensive care unit outcome, and ejection fraction <50% of ward outcome. For the set of perioperative factors, prolonged hospitalization after isolated coronary artery bypass grafting was associated with mechanical ventilation >24 hours for the intensive care unit and presence of infection for the ward.

INTRODUÇÃO: Características do paciente e da cirurgia de revascularização do miocárdio podem predispor à internação prolongada, aumentando custos e a morbimortalidade. OBJETIVO: Avaliar fatores de risco individuais e transoperatórios para internação prolongada na unidade de terapia intensiva e na enfermaria. MÉTODOS: Realizou-se estudo de caso-controle com 104 pacientes submetidos à revascularização do miocárdio isolada sob circulação extracorpórea. Consideraram-se casos os pacientes com internação >3 para terapia intensiva ou >7 dias para enfermaria. A associação entre variáveis foi estimada pelo teste do qui-quadrado e pela razão de chances (odds ratio-OR) empregando-se a regressão logística, ao nível de P<0,05. RESULTADOS: A permanência >3 dias na terapia intensiva ocorreu em 22,1% dos pacientes e >7 dias na enfermaria em 27,9%. Entre os fatores pré-operatórios, o diabetes (OR=3,17) e o tabagismo (OR=4,07) foram os preditores para permanência prolongada na terapia intensiva. Combinando-se as variáveis pré-, intra- e pós-operatórias, somente a ventilação mecânica por mais que 24 horas (OR=6,10) foi preditora para o desfecho na terapia intensiva. Para o desfecho na enfermaria, o preditor pré-operatório foi a fração de ejeção ventricular esquerda <50% (OR=3,04). Combinando os fatores pré- e intraoperatórios, o diabetes (OR=2,81) e, somando-se os pós-operatórios, a presença de infecção (OR=4,54), foram os preditores para internação prolongada na enfermaria. CONCLUSÃO: Diabetes e tabagismo foram os preditores para o desfecho na terapia intensiva, e a fração de ejeção <50% para a enfermaria. Para o conjunto dos fatores transoperatórios, internação prolongada após revascularização do miocárdio isolada associou-se à ventilação mecânica >24 horas para terapia intensiva e à presença de infecção para a enfermaria.

Diferenças regionais no acesso a cirurgia cardiovascular no Brasil, 2002 -2010 / Regional differences in access to coronary bypass surgery in Brazil, 2002-2010

As taxas internação por angioplastia e cirurgia de revascularização vêm sendo usadas como proxies de acesso a serviços de alta complexidade. O objetivo é analisar sua evolução e discutir quais seriam as possíveis causas associadas às desigualdades regionais. Foram calculadas as taxas padronizadas de realização de angioplastia e cirurgia de revascularização por sexo e idade por 100 mil habitantes de 20 anos e mais, no período 2002 a 2010. A comparação com os dados internacionais mostra que o Brasil tem taxas menores que as observadas nos países da OECD. No Brasil, as taxas padronizadas de internação por angioplastia na população de 20 anos ou mais apresentaram uma tendência de crescimento, passando de 27,5 por 100 mil habitantes em 2002 para 39 por 100 mil em 2010. Na comparação das taxas padronizadas por idade e sexo entre as grandes regiões do Brasil, além das diferenças marcantes no eixo Norte - Sul, o que chama atenção é que mantenham um padrão estável e também as diferenças regionais. A constituição de redes assistenciais regionais hierarquizadas para cirurgias cardíacas constitui uma estratégia importante para: garantir a qualidade do cuidado, a optimização dos custos operacionais e reduzir as desigualdades no acesso entre as regiões brasileiras.

The hospitalization rates for angioplasty and coronary bypass surgery have been used as proxies for access to highly specialized services. The scope of this study is to analyze the evolution of these rates and discuss what are the possible causes associated with regional inequalities. Standardized rates of angioplasty and coronary bypass surgery by age and sex per 100,000 inhabitants aged 20 and over, in the period from 2002 to 2010 were calculated. Comparison with international data shows that Brazil has lower rates than those observed in OECD countries. In Brazil, the standardized rates of hospitalization for angioplasty in the population aged 20 and over showed an upward trend, rising from 27.5 per 100,000 in 2002 to 39 in 2010. When mortality rates by age and sex from different geographical regions were compared, besides the marked differences in the north - south axis, what is notable is the maintenance of a stable pattern of these rates and regional differences over the period analyzed. The definition of regional health care networks for cardiac surgery is an important strategy to ensure the quality of care, optimization of operating costs and reduction of inequalities in access to healthcare between Brazilian regions.

Estenose carotídea e cirurgia de revascularização miocárdica / Carotid stenosis and coronary artery bypass grafting

OBJETIVO: Identificar a prevalência de estenose carotídea (EC) e os possíveis preditores de mortalidade em indivíduos submetidos à cirurgia de revascularização miocárdica (CRM) eletiva. MÉTODOS: Estudo de coorte que incluiu 393 candidatos à CRM. Todos os pacientes realizaram ultrassonografia com Doppler em cores de artérias carótidas antes da CRM e foram seguidos durante a internação quanto à morbidade e mortalidade. A EC foi considerada clinicamente relevante quando > 50 por cento. Um p < 0,05 foi considerado significativo. Regressão logística foi realizada para definir preditores independentes de mortalidade. RESULTADOS: A prevalência de EC foi de 17,4 por cento. Após regressão logística, EC > 50 por cento (p = 0,001) e insuficiência renal crônica (IRC) (p = 0,03) foram preditores, independentes de mortalidade. CONCLUSÃO: EC mostrou ter uma prevalência elevada na amostra estudada e, conjuntamente com a IRC, foi preditor, independente de mortalidade.

OBJECTIVE: To identify carotid stenosis (CS) prevalence and potential mortality predictors in individuals undergoing elective coronary artery bypass grafting (CABG). METHODS: Cohort study including 393 scheduled for CABG. All patients underwent a color Doppler ultrasound study of the carotid arteries prior to CABG and were assessed for morbidity and mortality over the hospitalization. CS was considered clinically relevant when if > 50 percent. Significance was set at p < 0.05. Logistic regression was used to define mortality independent predictors. RESULTS: CS prevalence was 17.4 percent. Following logistic regression analysis, CS > 50 percent (p = 0.001) and chronic renal failure (CRF) (p = 0.03) remained as mortality independent predictors. CONCLUSION: CS showed a high prevalence in the study sample and together with CRF was a mortality independent factor.

Prophylactic administration of recombinant activated factor vii in coronary revascularization surgery

The objective of this clinical trial is to study the effectiveness of administering recombinant activated factor VII [rFVIIa] in reducing the amount of bleeding and the need for homologous blood and products transfusion in cardiac surgical coronary revascularisation procedures done under cardiopulmonary bypass [CPB]. this is a randomised controlled prospective observational study. 30 patients scheduled for elective cardiac revascularisation under CPB were enrolled in the study. Patients were randomly allocated into two groups; Control group where no rFVIIa was administered and rFVIIa group to whom a single dose of 45ug/Kg of rFVIIa was administered following weaning off CPB and heparin reversal. The total amount of chest tube drain during the first 24 hours following surgery was recorded as well as the qualitative and quantitative assessment of homologous blood and products transfusion. Serial analysis of haematological parameters including haemoglobin level and coagulation test carried on in a definite data points. TO = baseline readings prior to CPB, Tl = off CPB; after protamine sulphate administration and before administration of the study drug, T2 = on CICU admission, T3 = 12 hours post CICU admission, T4 = 24 hours post CICU admission. Total chest tube drainage was lower [p= 0.001] in rFVIIa group. Blood and products transfusion were statistically lower in the rFVIIa group [p= 0.05]. Moreover; results showed statistically lower INR values at CICU admission and 12 hrs post CICU admission [p= 0.018 and 0.004 respectively]. Also, the PTT mean values were statistically lower at same timings [p= 0.04 and 0.001 respectively]. No thrombotic complications were reported in both groups. Prophylactic use of 45 ug/kg rFVIIa in patients undergoing coronary revascularisation surgery under the management of CPB had a remarkable significant results on both the amount of postoperative bleeding as well as the amount of blood and products transfusion. However, these reductions require quantification. Furthermore, future studies that examine the question of blood loss and transfusion requirement reduction with rFVIIa should include an analysis of cost benefits. Future studies should also formally investigate the dose-dependent effects of rFVIIa in cardiac surgery, and investigate effects in both routine and high-risk cardiac surgery

Clinical outcome using the vacuum-assisted closure system for sternal wound complications after coronary artery bypass surgery

Sternal infections after median sternotomy remain a serious cause of postoperative morbidity and mortality. There is still no consensus regarding the ideal treatment of this complication. The vacuum-assisted closure [VAC] system is a non-invasive therapy based on the application of negative pressure by controlled suction to the wound surface. The aim of this work was to evaluate the clinical outcome in patients to whom we applied the VAC system in terms of wound healing, duration of treatment, and complications related to the procedure in addition to early follow-up. Methods: 15 patients [7 men, 8 women] with a mean age of 69.3 years who presented with sternal wound complications [infection / dehiscence] after coronary artery bypass surgery were managed using the VAC system after surgical debridement. The VAC therapy was used either as definitive treatment till healing was achieved by secondary intention or followed by flap reconstruction [muscle or omental], skin graft or delayed sternal rewiring. Patients were followed up for a mean period of 14 months as regards recurrence of infection, wound healing and fistula formation. Healing was successful in all patients. 3 patients had pectoralis major muscle flap reconstruction, the wound was covered by an omental flap in one patient, 2 patients had only a skin graft to cover the defect, healing by secondary intention was achieved in 5 patients, and delayed sternal rewiring was performed in another 4 patients. Follow-up for a mean of 14 months [range 7 months - 26 months] showed complete healing in all surviving patients without recurrence of infection or fistula formation with one mortality due to multi-organ failure 6 months after presentation with mediastinitis. VAC system is an effective and safe device in managing patients with complicated sternal wounds providing wound control so that reconstructive surgery can be electively planned, or may obviate the need for a second closure operation by allowing the wound to contract and rapidly granulate in addition to its stabilizing effect allowing early extubation and mobilization of the patient. Outcomes are encouraging with excellent results

Early outcome of concurrent mitral valve replacement and coronary artery bypass grafting

Concomitant coronary artery bypass surgery [CABG] in patients undergoing mitral valve replacement [MVR] has been shown to be an important risk factor for hospital mortality. We evaluated preoperative characteristics, postoperative complications, in-hospital mortality rate, and length of stay in hospital for patients undergoing concurrent CABG with MVR. Preoperative and postoperative clinical data from 175 patients undergoing concurrent CABG with MVR operation at Tehran Heart Center from 2002 through 2006 were collected and entered into a database. Information was obtained by clinical and case note review as well as detailed questionnaires to physicians and patients. Mean age of patients was 57.95 +/- 10.54 years and 51.4% were male. Mean New York Heart Association [NYHA] score was 2.46 +/- 0.84. Among studied patients, 18.3% and 2.9% underwent aortic and tricuspid valve replacement, respectively. In-hospital mortality was 6.9% and 96.0% of patients were hospitalized >/= 14 days. History of congestive heart failure [P = 0.027] and postoperative brain stroke [P = 0.004] were independent predictors for in-hospital mortality. Exact considering of congestive heart failure and postoperative brain stroke related to in-hospital mortality in concurrent CABG with MVR operation are necessary

Cirugía de revascularización miocárdica en pacientes con síndrome coronario agudo: análisis de resultados / Coronary artery bypass graft surgery in patients with acute coronary syndrome: analysis of results

Objetivo: identificar los principales factores de riesgo que influyen en el pronóstico, resultados, tipo y tasas de morbilidad y mortalidad de los pacientes con síndrome coronario agudo sometidos a cirugía de revascularización miocárdica. Material y métodos: se trató de un estudio retrospectivo de pacientes sometidos a cirugía por síndrome coronario agudo de enero de 2000 a diciembre de 2003. Se identificaron factores demográficos, indicación de cirugía, enfermedades intercurrentes, resultados de la intervención, morbilidad y mortalidad, y se compararon con escalas internacionales. Resultados: fueron 73 varones y 23 mujeres, la edad osciló entre 46 y 88 años. Predominó la angina inestable (42.7 %). Dos pacientes fueron operados por angioplastia coronaria percutánea fallida y 28 por complicaciones mecánicas del infarto del miocardio. La cirugía fue realizada como urgencia en 90.6 %. La mayoría de los pacientes estuvieron en clasificación Killip-Kimball y Forrester I y II. Los factores de riesgo detectados fueron falla del ventrículo izquierdo, complicaciones mecánicas, cirugía de emergencia, diabetes y falla respiratoria o renal. La mortalidad perioperatoria fue de 14.5 % y la morbilidad de 41.6 %, que comparadas con la clasificación de riesgo de nuestros pacientes fueron más bajas que las esperadas, según las escalas de Parsonnet y Tuman. Conclusiones: aunque el mayor número de factores de riesgo y valores más altos en las escalas de riesgo empeoran en forma importante el pronóstico, en nuestro centro los resultados obtenidos con el tratamiento quirúrgico en síndrome coronario agudo muestran resultados favorables.

BACKGROUND: The objective of this work was to determine the main risk factors that influence prognosis, results, morbidity and mortality rates and causes in patients with acute coronary syndrome requiring surgical myocardial revascularization. METHODS: This was a retrospective study including patients in our hospital with acute coronary syndrome requiring coronary artery bypass-graft surgery between January 2000 and December 2003. The following were identified and compared with international values: demographic factors, indications for surgery, intercurrent pathologies, results of the procedures, morbidity and mortality rates and causes. RESULTS: There were 73 males and 23 females with an age range of 46 to 88 years old. The main cause of surgery was unstable angina (42.7%). In two patients, surgery was indicated for percutaneous coronary angioplasty failure and in 28 patients due to mechanical complications of acute myocardial infarction. The procedure was urgent in 90.6%. The majority of patients were in Killip-Kimball or Forrester class I or II. Risk factors detected were left ventricular failure, mechanical complications, emergency surgery, diabetes and respiratory or renal failure. Perioperative mortality was 14.5% and morbidity was 41.6%, both compared with risk classification scales and were lower than expected according to Parsonet and Tuman evaluations. CONCLUSIONS: With a major number of risk factors and the high-risk associated with surgery, in our center surgical treatment for acute coronary syndromes showed favorable results.

Moderate Mitral Regurgitation and Coronary Disease: Treatment with Coronary Bypass Alone?

In cases of moderate[2 or 3+ on a scale of 0 to 4+] nonorganic mitral regurgitation [MR] and coronary artery disease, operative strategy continues to be debated between coronary artery bypass grafting alone [CABG] or concomitant valve repair. To clarify the optimal management of these patients, we evaluated the mid-term results of isolated CABG in the study group. From March 2002 to February 2005, 40 consecutive patients [57.5% male, mean age: 62.45 +/- 8.7 years, mean ejection fraction: 44.15 +/- 12.6%, mean New York Heart Association class 2.5 +/- 0.78] with coronary artery disease and moderate MR without organic mitral valve disease [prolapse, rheumatism, etc.] underwent CABG alone. Thirty one [77.5%] patients had either postoperative or follow-up transthoracic echocardiography with mean follow up time of 10.82 +/- 8.12 months. Patient's pre and postoperative data were compared to evaluate the results of isolated CABG on moderate MR. MR was ischemic [with persistent wall motion abnormality] in 25 [62.5%] patients and functional [without persistent wall motion abnormality] in 15 [31.5%]. Considering postoperative and follow up transthoracic echocardiography, 54.8% had no or mild MR [29% MR 1+, 25.8% no MR] and 45.2% had moderate MR [16.1% MR 3+, 29% MR 2+]. ResoluItion of MR was significant [p<0.001], but it had no correlation with ischemic MR [p=0.46], preoperative ejection fraction [p=0.09], LV systolic [p=0.70] and diastolic dimensions [p=0.80]. Seven patients died, 2 in hospital and 5 later. Although for coronary artery disease accompanying moderate nonorganic MR, CABG alone reduces severlity of MR significantly, many patients are left with moderate MR. Preoperative diagnosis of moderate nonorganic MR may warrant concomitant mitral repair

Early postoperative complications after coronary artery bypass grafting at the San Juan Veterans Affairs Medical Center

OBJECTIVES: Describe the perioperative characteristics of the patients undergoing coronary artery bypass grafting (CABG) in San Juan, Veterans Affairs Medical Center (SJ-VAMC). Determine the in-hospital and 30-day morbidity and mortality following CABG and identify adverse predictors for postoperative complications. BACKGROUND: Preoperative risk factors for complications post-CABG have been identified; however limited data is available regarding the value of these predictors in the Puerto Rican Population. METHODS: Perioperative characteristics and 30-day complications were gathered from all patients undergoing CABG (n = 252) at the SJ-VAMC (2001-2003). Logistic regression analysis was performed to determine factors associated with the occurrence of complications. RESULTS: The population's mean age was 66.9 +/- 8.1 years. Associated illnesses included: hypertension (95.6), diabetes (57), past smoking (61), COPD (26), chronic renal insufficiency (CRI-11.5), cerebrovascular disease (CVD-20.6), disabling angina (78), 3-vessel coronary disease (75.8), significant left main stenosis (20), and non-elective surgical intervention (54). The most frequent primary complications were postoperative myocardial infarction (MI-4.8) and congestive heart failure (4.8). The 30-day mortality was 1.2. Upon multivariate analysis PRBC transfusions > 3 units was associated to increased risks of primary complications, in patients with prior history of CVD. CRI and LVEF < or = 40were independently associated to development of primary complications, in patients with prior MI and CVD. CONCLUSION: The preoperative characteristics are suggestive of an older and sicker patient that is undergoing CABG at the SJ-VAMC. Despite this, the death rate was low and the frequency of other complications comparable to the Society of Thoracic Surgeons (STS) National Adult Cardiac Database.

Coronary artery bypass graft outcome: the Trinidad and Tobago experience

The study is retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in-hospital and intermediate-term follow-up results. The mean age of patients was 59 +/- 10 years and 78 were male. Sixty-four per cent were of East Indian descent, whereas 16 were of African descent. Forty-eight per cent of the patients were hypertensive, 46 were diabetic, 33 had hyperlipidaemia, 20 had a recent history of cigarette smoking and 16 were obese. Sixty-five per cent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5 of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 +/- 15. Wall motion abnormalities were seen in 67 of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91, 78, 54 and 5, respectively. Many patients (67) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 +/- 0.8 days. In-hospital mortality was 3.9 (8/205). The most frequent post-operative complication was haemorrhage (2.6). Acute renal failure occurred in 2.1; pulmonary collapse, 1.6; stroke, 1 and cardiac arrest, 1. Both sternal wound infections and systemic sepsis occurred in 0.5. Intermediate-term follow-up data were obtained for 92 (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow-up period, 7 patients (3.4) died. Angina severity was reduced from a mean CCS score of 2.61 +/- 0.95 before CABG to 1.22 +/- 0.55 at the time of follow-up (p < 0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.

Complicaciones operatorias y mortalidad en pacientes octogenarios sometidos a cirugía de revascularización / Surgical complications and mortality in eldery patients treated with bypass surgery

El objetivo fue identificar los factores preoperatorios, operatorios y transoperatorios asociados con complicaciones y mortalidad en pacientes octogenarios con enfermedad arterial coronaria sometidos a cirugía de revascularización. De enero de 1990 a junio de 1994 se incluyeron 37 pacientes: 32 hombres (86.5 por ciento) y cinco mujeres (13.5 por ciento). Las variables son: diabetes mellitus, hipertensión arterial sistémica, enfermedad pulmonar, hipercolesterolemia, función renal, fracción de expulsión, enfermedad arterial coronaria, tiempo de derivación cardiopulmonar, pinzamiento aórtico, número y tipo de puentes, uso de balón intraaórtico de contrapulsación, aminas vasoactivas, soporte ventilatorio, hemorragia, infección insuficiencia hepática o renal, trastornos neurológicos, anormalidades del ritmo o la conducción e isquemia miocardica postoperatoria. Factores de riesgo: diabetes mellitus (p= 0.028), FE < 30 por ciento (p= 0.023), movilidad segmentaria ventricular anormal (p < 0.05), pinzamiento aórtico > 60 minutos (p= 0.026), derivación cardiopulmonar > 120 minutos (p= 0.022), uso de injerto de vena safena, soporte ventilatorio prolongado, aminas vasoactivas y uso de balón intraaórtico de contrapulsación (p= 0.014). Conclusiones: la cirugía deberá ser reservada en enfermedad trivascular, del tronco, lesión próximal de la arteria descendente anterior con isquemia severa y deterioro en la función miocárdica y angina que no responda al tratamiento médico. La sola variable "edad" no es contraindicación. Deberá tenerse en cuenta la morbi-mortalidad de este grupo comparado con la de los grupos sometidos a tratamiento médico u otra alternativa terapéutica

Resultados preliminares de una nueva técnica de revascularización miocárdica mínimamente invasiva / Preliminaries results about new technique of minimally invasive direct coronary artery bypass grafting

Antecedentes: La cirugía coronaria mínimamente invasiva (CRMMI) intenta disminuir la invasividad de la cirugía convencional (CRM). Objetivo: Presentar los resultados iniciales de una técnica de CRMMI y compararla con los de la CRM. Diseño: Estudio observacional prospectivo (grupo experimental), observacional histórico (grupo control). Población: 20 pacientes operados con CRMMI (experimental) y 36 con CRM (control), todos con lesión única de descendente anterior (DA). Método: Descripción de técnica quirúrgica y análisis de morbimortalidad comparativo entre CRMMI y CRM. Resultados: En el grupo con CRMMI el 60 por ciento (12/20) presentaba algún factor de riesgo importante. No surgieron durante las operaciones situaciones que no pudieron ser resueltas por el mismo abordaje, excepto 2 casos de conversión (10 por ciento). El dolor torácico en el posoperatorio alejado fue importante en el 15,8 por ciento (3/19). Los resultados comparativos CRMMI vs CRM fueron: antecedentes CRM previa 20 por ciento (4/20) vs 2,7 por ciento (1/36) p < .04, infarto posoperatorio 5 por ciento (1/20) vs 2,7 por ciento (1/36) p = NS, mortalidad operatoria 0 por ciento (0/20) vs 2,7 por ciento (1/36) p = NS y mortalidad a 6 meses 5 por ciento (1/20) vs 5,7 por ciento (2/35) p = NS. Conclusión: La CRMMI se presenta como una alternativa válida para tratar las estenosis proximales únicas de DA