Late outcome of reoperative coronary revascularization on the beating heart.

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) is associated with a higher morbidity and mortality than first-time CABG. An off-cardiopulmonary bypass (off-pump) approach to redo CABG, however, may potentially benefit redo patients. The aim of the present report is to describe the early and long-term clinical outcome of patients who underwent off-pump redo CABG between July 1985 and January 1999 in our institution. METHODS: Redo patients (n = 138) represented 13% of patients who had off-pump CABG during the period of study (n = 1072). Mean patient age was 63 +/- 12 years, and 67% were men. Surgical approaches included median sternotomy (n = 93, 67%), anterior (n = 20, 15%) and lateral (n = 25, 18%) minimally invasive direct coronary artery bypass (MIDCAB). RESULTS: Operative mortality was 2% (n = 3). Target lesion re-intervention was 6% (n = 9) Actuarial survival at a mean period of follow-up of 2.5 +/- 1 year (range: 1 month to 11 years) was 83%. Event-free survival (freedom from death, myocardial infarction, and repeat intervention) was 67%. Overall cardiac-related mortality was 10% (n = 14). CONCLUSION: Off-pump redo CABG can be safely performed with a relatively low mortality rate and a low rate of target lesion revascularization.

Stroke after coronary artery bypass: incidence, predictors, and clinical outcome.

BACKGROUND AND PURPOSE: Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG. METHODS: We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis. RESULTS: Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P<0.001), (2) recent myocardial infarction (P=0.01), (3) previous cerebrovascular accident (P<0.001), (4) carotid artery disease (P<0.001), (5) hypertension (P<0.001), (6) diabetes (P=0.001), (7) age >75 years (P=0.008), (8) moderate/severe left ventricular dysfunction (P=0.01), (9) low cardiac output syndrome (P<0.001), and (10) atrial fibrillation (P<0.001). Postoperative stroke was associated with longer postoperative stay (11+/-4 versus 7+/-3 days for patients without stroke, P<0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke; P<0.001). CONCLUSIONS: Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.

Minimally invasive coronary revascularization in women: A safe approach for a high-risk group.

PURPOSE: Female gender has been shown to be an independent risk factor for mortality in coronary artery bypass graft (CABG) surgery. This report analyzes our early outcomes in 304 women who underwent off-pump coronary artery bypass (OPCAB) surgery at the Washington Hospital Center (Washington, DC) over the last 3 years to determine whether this is a safe approach for coronary bypass in women. METHODS: A retrospective review of 5528 cases of CABG bypass (on-pump) and 840 cases of OPCAB surgery, from June 1996 to July 1999, was performed. Women accounted for 1527 (27.6%) of the on-pump bypass cases and 304 (36.2%) of the OPCABs. All cases without cardiopulmonary bypass were included, with the majority of the most recent cases being multivessel revascularization. The data for analysis were obtained from our cardiac surgery database and included cases from all surgeons operating at the Washington Hospital Center, although the majority of off-pump cases were performed by only a few of these surgeons. RESULTS: The two groups were similar with respect to urgent cases, redos, and other comorbities including preoperative congestive heart failure, peripheral vascular disease, transient ischemic attack (TIA), cerebral vascular accident, and previous myocardial infarction. The mean age for the two groups was similar, 67 years for the off-pump group and 66 years for the on-pump group. The absolute number of all off-pump cases increased each year (from 175 to a total of 373), representing a corresponding increase in percentage of all coronary artery bypass procedures (from 9% to 16%). Of the total number of patients undergoing CABG, the percentage of women who underwent OPCAB doubled from 3% to 6% over the time period analyzed. The percentage of single-vessel cases in the off-pump group fell from 88% to 41% as multivessel bypasses became more routine However, the percentage of patients aged > 75 years was greater for the off-pump group (30%) than for the on-pump group (24%). Otherwise, the two groups differed only in diabetic disease (36% off-pump compared with 46% on-pump; p = 0.001) and previous transcatheter therapy (38% off-pump compared with 29% on-pump; p = 0.003). Patients who had OPCABs received fewer postoperative transfusions (40%) than the on-pump group (59%; p < 0.001). The off-pump group also had fewer neurological complications in the form of TIAs or strokes (0.3%) compared with the on-pump group (3.5%; p = 0.001). The mortality rate was 2.3% off -pump versus 4.1% on pump but did not reach statistical significance in this study (p =.12). CONCLUSION: Myocardial revascularization in women can be performed safely without cardiopulmonary bypass. In our series, the mortality for women receiving off-pump revascularization was lower than the on-pump cohorts despite an older age and higher incidence of diabetes. Although the absolute mortality rates did not reach statistical significance, we were encouraged that the mortality rate for women operated on without CPB dropped to the mortality rate typically seen in men. We also observed a favorable tendency in the off-pump group for a shorter length of stay and a lower incidences of transient ischemic attacks, strokes, post-op bleeding, and blood transfusions. A larger series of patients with multivariate analysis and/or a prospective trial will need to be analyzed in order to confirm our findings.

Coronary revascularization of the circumflex system: different approaches and long-term outcome.

BACKGROUND: Minimally invasive direct coronary artery bypass, without cardiopulmonary bypass, through a left lateral thoracotomy approach (lateral MIDCAB), is a safe alternative to coronary artery bypass surgery using cardiopulmonary bypass (on-pump CABG) of the circumflex system via median sternotomy. However, it is unknown whether lateral MIDCAB may yield an improved long-term outcome over the conventional on-pump median sternotomy approach. METHODS: We compared the perioperative outcomes of patients undergoing lateral MIDCAB (n = 34) versus conventional on-pump CABG of the circumflex system (n = 16) from June 1996 to July 1999. The two groups were similar with respect to baseline characteristics and risk stratification. Patients who required only one or two grafts for complete revascularization were included. RESULTS: Lateral MIDCAB patients had a lower need than on-pump CABG patients for intraoperative (12% MIDCAB vs 43% on-pump CABG, p = 0.03) and postoperative transfusions (29% vs 69%, p = 0.01), had fewer neuropsychologic changes (0% vs 19%, p = 0.03), and had a lower rate of postoperative atrial fibrillation (12% vs 44%, p = 0.02). Lateral MIDCAB was also associated with a significantly lower postoperative length of stay (5 +/- 2 vs 7 +/- 3 days, p = 0.02). Actuarial survival at a mean period of follow-up of 19 +/- 11 months was 97% for the lateral MIDCAB versus 88% for the on-pump CABG group (p = 0.6). Event-free survival was 88% for lateral MIDCAB versus 81% for on-pump CABG (p = 0.1). CONCLUSIONS: Lateral MIDCAB may safely be performed in patients with isolated coronary artery disease of the circumflex system with improved early morbidity and an abbreviated hospital stay compared with conventional median sternotomy on-pump CABG.

Beating heart versus conventional single-vessel reoperative coronary artery bypass.

BACKGROUND: Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG. METHODS: We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 +/- 9 for on-pump versus 24 +/- 8 for off-pump patients (p = nonsignificant). RESULTS: On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 +/- 4 days on-pump versus 5 +/- 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03). CONCLUSIONS: Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.

Atrial fibrillation after beating heart surgery.

Postoperative atrial fibrillation (AF) is a frequent adverse event after coronary artery bypass grafting (CABG) and may negatively affect the early clinical outcome. We sought to investigate the risk factors, prevalence, and prognostic implications of postoperative AF in patients submitted to CABG without cardiopulmonary bypass (off-pump). The study population comprised 969 patients, 645 men (67%) and 324 women (33%) who had off-pump CABG at the Washington Hospital Center from January 1987 to May 1999. Preoperative AF patients were excluded (n = 15). Two hundred six patients (age 69 +/- 10 years, 137 men [66%]) developed AF, whereas 763 patients (age 61 +/- 12 years, 508 men [67%]) did not. Predictors of AF included age >75 years (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.9 to 4.5; p <0.001), history of stroke (OR 2.1, CI 1.2 to 3.7; p = 0. 007), postoperative pleural effusion requiring thoracentesis (OR 3.2, CI 1.0 to 9.4; p = 0.03), and postoperative pulmonary edema (OR 5.1, CI 1.2 to 21; p = 0.02). Minimally invasive direct CABG was associated with a lower incidence of AF (OR 0.4, CI 0.3 to 0.7; p <0. 001). AF was associated with a prolonged postoperative hospital stay (9 +/- 6 days AF vs 6 +/- 5 days no AF, p <0.001). In-hospital mortality was significantly higher in AF patients (3% AF vs 1% no AF, p = 0.009). Patients with persistent AF had a higher postoperative in-hospital stroke rate than patients without persistent AF (9% vs 0. 6%, p <0.001). AF after beating heart surgery is associated with a higher in-hospital morbidity, mortality, and prolonged hospital stay. A minimally invasive surgical approach (minimally invasive direct CABG) is associated with a lower risk of AF.

Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups.

BACKGROUND: Octogenarians have higher morbidity and mortality rates (9% to 16%) after coronary artery bypass grafting with cardiopulmonary bypass, compared with younger patients. METHODS: We compared the perioperative outcome and hospital stay after coronary artery bypass grafting without cardiopulmonary bypass (off-pump) from January 1987 to May 1999, among patients older than 80 years (n = 71), patients between 70 and 79 years (n = 228), and patients whose age ranged from 60 to 69 years (n = 296). In comparison with younger patients, more octogenarians were female (51% versus 39% in patients aged 70 to 79 years and 35% in those aged 60 to 69 years, p = 0.04), they had previous myocardial infarction more frequently (48% versus 47% versus 34%, respectively, p = 0.008), and were operated on urgently (69% versus 56% versus 52%, respectively, p = 0.04). RESULTS: Postoperative complications that were significantly higher in octogenarians compared with younger groups included pneumonia (6% in octogenarians versus 2% in patients aged 70 to 79 years and 0% in patients aged 60 to 69 years, p = 0.001) and atrial fibrillation (47% versus 32% versus 21%, respectively, p<0.001). By multivariate logistic regression analysis, age over 80 years was an independent predictor of prolonged hospital stay (odds ratio = 2.7, 95% confidence interval, 1.4 to 5, p<0.001). The in-hospital mortality rate was higher in octogenarians (6% versus 3% for 70 to 79 year-olds and 0.3% for 60 to 69 year-olds, p = 0.006). CONCLUSIONS: When appropriately applied in patients older than 80 years, off-pump coronary artery bypass grafting can be done with acceptable postoperative morbidity, mortality, and hospital stay.