Short-stay intensive care after coronary artery bypass surgery: randomized clinical trial on safety and cost-effectiveness.

OBJECTIVE: To evaluate the safety and cost-effectiveness of short-stay intensive care (SSIC) treatment for low-risk coronary artery bypass patients. DESIGN: Randomized clinical equivalence trial. SETTING: University Hospital Maastricht, the Netherlands. PATIENTS: Low-risk coronary artery bypass patients. INTERVENTIONS: A total of 600 patients were randomly assigned to undergo either SSIC treatment (8 hrs of intensive care treatment) or control treatment (care as usual, overnight intensive care treatment). MEASUREMENTS: The primary outcome measures were intensive care readmissions and total hospital stay. The secondary outcome measures were total hospital costs, quality of life, postoperative morbidity, and mortality. Hospital costs consisted of the cost of hospital admission or admissions and outpatient costs. MAIN RESULTS: The difference in intensive care readmission between the two groups of 1.13% was very small and not significantly different (p = .241; 95% confidence interval, -0.9% to 2.9%). The total hospital stay (p = .807; 95% confidence interval, 1.2 to -0.4) and postoperative morbidity were comparable between the groups. The SSIC group's quality of life improved more compared with the control group's quality of life (p = .0238; 95% confidence interval, 0.0012 to 0.0464). The total hospital costs for SSIC were significantly lower (95% confidence interval, -1,581 to -174) compared with those for the control group (4,625 and 5,441, respectively). The estimated incremental cost-effectiveness ratio (cost/delta quality-adjusted life months) thus showed the dominance of SSIC. Bootstrap and sensitivity analyses confirm the robustness of the study findings. CONCLUSIONS: Compared with usual care, SSIC is a safe and cost-effective approach. SSIC can be considered as an alternative for conventional postoperative intensive care treatment for low-risk coronary artery bypass graft patients.

Evaluation of a new condensed extra-corporeal circuit for cardiac surgery: a prospective randomized clinical pilot study.

This prospective randomized clinical pilot study was conducted to evaluate a recently introduced reduced volume CPB system that is coated with the biopassive Xcoating. Twenty-two patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), either with a fully heparin-coated CPB circuit (control, n=11) or with an Xcoating coated condensed extra-corporeal circuit (CondECC, n=11), were included. We examined activation of the complement system (C3bc and C4bc), activation of neutrophils (BPI), the acute phase response (interleukin (IL)-6, and acute phase proteins (LBP, AGP, and CRP)), myocardial tissue injury (troponin T), hemolysis (free hemoglobin (FHb)), and clinical outcome parameters. Preoperative risk profiles were identical for both patient groups. All patients went through the procedure without major complications and were discharged from the hospital. FHb and BPI levels at the end of pump support (p < 0.01) and at 15 min after the administration of protamine (p < 0.05) were significantly higher in the control group. In addition, FHb levels were still significantly elevated upon arrival on the cardiothoracic intensive care unit (CICU) in the control group (p < 0.05). C3bc and C4bc, acute phase proteins, IL-6, and troponin T concentrations, and clinical outcome variables were identical in both patient groups. In conclusion, the evaluated condensed extracorporeal circuit is a flexible and multifunctional CPB sytem that offers safe procedures. Furthermore, the results indicate improved biocompatibility of this option for extracorporeal circulation.

Neurological complications after coronary artery bypass grafting related to the performance of cardiopulmonary bypass.

STUDY OBJECTIVES: Neurologic disorders belong among the most serious complications of cardiac surgery. We tested the hypothesis that combinations of hemodynamic events from apparently normal cardiopulmonary bypass (CPB) procedures are related to the development of postoperative neurologic complications and affect the impact of common clinical risk factors. DESIGN: Retrospective study. SETTING: Cardiothoracic surgery department in a university hospital. METHODS AND PATIENTS: A multivariate statistical procedure (ie, cluster analysis) was applied to a data set of automatically recorded perfusions from 1,395 patients who had undergone coronary artery bypass grafting. One-way analysis of variance was used to select five parameters with the strongest significant correlation to postoperative neurologic complications for further cluster analysis. The dependencies in the clusters were tested against common clinical risk factors. To our knowledge, this is the first study of its kind. RESULTS: The following five parameters emerged for cluster analysis: mean arterial pressure (MAP); dispersion of MAP; dispersion of systemic vascular resistance; dispersion of arterial pulse pressure; and the maximum value of mixed venous saturation. Using these parameters, we found four clusters that were significantly different by CPB performance (first cluster, 389 patients; second cluster, 431 patients; third cluster; and fourth cluster, 229 patients). The frequency of postoperative neurologic complications was 0.3% in the first cluster and increased to 3.9% in the fourth cluster. Importantly, the impact of common clinical risk factors for postoperative neurologic complications was affected by the performance of the CPB procedure. For example, the frequency of neurologic complications among patients with cerebrovascular disease in their medical history was 22% in the fourth cluster, whereas it was zero in the second cluster. CONCLUSIONS: This study shows that apparently normal CPB procedures affect the impact of common clinical risk factors on postoperative neurologic complications. Patients who underwent CPB procedures with large fluctuations in hemodynamic parameters particularly showed an increased risk for the development of postoperative neurologic complications.

Evaluation of "new" cardiac markers for ruling out myocardial infarction after coronary artery bypass grafting.

STUDY OBJECTIVES: This study was conducted to evaluate the value of serum troponin T, myoglobin, and creatine kinase (CK)-MB mass concentrations for ruling out perioperative myocardial infarction (poMI) early after cardiac surgery. DESIGN: Retrospective study. SETTING: Cardiothoracic surgery department in a university hospital. PATIENTS: One hundred eighty-one patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass were included. METHODS: Serum concentrations of troponin T, myoglobin, and CK-MB mass were measured preoperatively (baseline), on arrival at the cardiosurgical ICU (CICU), and at 2, 4, 8, 12, 16, and 20 h after arrival at the CICU. The strength of markers studied for ruling out poMI was studied using receiver operating characteristics curves. Based on these curves, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for each marker at every time point were calculated. RESULTS: poMI developed in 14 patients. On arrival at the CICU, all markers were significantly increased from baseline concentrations in both patient groups. In patients with poMI, serum concentrations of troponin T, myoglobin, and CK-MB mass were significantly higher than in control patients from 8, 2, and 0 h after arrival on the CICU, respectively. CK-MB mass was the earliest marker, and its NPV reached 98.6% 12 h after arrival at the CICU. On arrival at the CICU, the NPV for CK-MB mass already reached 96.7%. The NPV for myoglobin reached 98.4% 12 h after arrival at the CICU. Troponin T was not an early marker for ruling out poMI, with an NPV reaching 98.6% 12 h after arrival on the CICU. During the first 8 h after arrival at the CICU, sensitivity, specificity, PPV, and NPV of CK-MB mass exceeded those of myoglobin and troponin T. In later measurements (until 20 h after arrival at the CICU), troponin T gave the most sensitive definition of poMI. CONCLUSIONS: For ruling out poMI on the CICU after CABG, CK-MB mass is a better marker than myoglobin and troponin T during the first 12 h after arrival on the CICU. Using these markers, postoperative treatment of cardiac surgical patients might be further improved.

Prestorage leucocyte reduction of red cell components prevents release of bactericidal permeability increasing protein and defensins.

BACKGROUND AND OBJECTIVES: In this study we examined whether prestorage leucocyte reduction prevents the accumulation of bioreactive substances in red cell units. MATERIALS AND METHODS: Measurements were performed in the supernatants of buffy-coat-depleted (standard red cells) and leucocyte-reduced (filtered red cells) red cell units. The effect of storage was evaluated by taking repetitive samples up to 35 days after donation. We determined the concentrations of polymorphonuclear neutrophil (PMN)-derived bactericidal permeability increasing protein (BPI), defensins and annexin A5. In addition, leucocyte counts (using nageotte chamber) were performed on days 0 and 35. RESULTS: During storage, the concentrations of BPI, defensins and annexin A5 in standard red cells gradually increased. However, in the filtered red cells BPI and defensins were found in only a few samples, whereas the annexin A5 concentration in these units did not change during storage. Haemolysis data in both types of red cell components were similar at all time-points, except prestorage. Significant correlations were found between the release of BPI, defensins and annexin A5 into red cell units and the loss of leucocytes during storage. CONCLUSIONS: PMNs lose their membrane integrity during cold storage and release their contents into red cell components. Prestorage leucocyte reduction of red cell components prevents the accumulation of BPI, defensins and annexin A5.