Prediction of major complications after isolated coronary artery bypass grafting: the CGMH experience.

BACKGROUND: The in-hospital mortality of coronary artery bypass grafting (CABG) is low but can be significant if catastrophic complications occur. To increase the safety of CABG, we aimed to establish a predictive model of major postoperative complications that incorporated patient characteristics and operative strategies. METHODS: A retrospective study was performed which included all consecutive patients receiving isolated CABG from August 2006 to February 2008 (n = 319). Patient characteristics were quantified by the additive EuroSCORE. Operative strategies were classified as cardioplegic arrest, on-pump beating, and off-pump. RESULTS: Four major complications were identified to be connected to the in-hospital mortality: (1) requirement of mechanical circulatory supports > 72 h (odds ratio [OR] 28.9, 95% confidence interval [CI] 6.0-139.9), (2) requirement of mechanical ventilator supports > 72 h (OR 9.5., 95%, CI 2.2- 42.7), (3) acute renal failure requiring dialysis (OR 9.2, 95% CI 2.2-38.3), (4) major gastrointestinal complications (OR 5.4., 95% CI 1.1-26.7). An increase of additive EuroSCORE (OR 1.2, 95% CI 1.1-1.4) and the cardioplegic strategy (OR 2.7, 95% CI 1.2-6.0) were independent risk factors for major complications. The probability of one or more major complication was > 50% for patients receiving cardioplegic CABG with an additive EuroSCORE > 8. CONCLUSION: Dependence on the mechanical ventilator or circulatory supports > 72 h, acute renal failure requiring dialysis, and major gastrointestinal complications were major complications of CABG. The individual risk of having at least one of these complications could be predicted by the patient's preoperative EuroSCORE and operative strategy. A surgical plan tailored by institutional experiences on specific risk factors and aggressive therapeutic plans for major complications are helpful in improving the overall results of CABG.

Using extracorporeal life support to resuscitate adult postcardiotomy cardiogenic shock: treatment strategies and predictors of short-term and midterm survival.

BACKGROUND: Postcardiotomy extracorporeal life support (ECLS) is a resource-demanding therapy with varied results among institutions. An organized protocol was necessary to improve the effectiveness of this therapy. METHODS AND RESULTS: A total of 110 patients received ECLS due to refractory postcardiotomy cardiogenic shock between January 2003 and June 2009, and were eligible for inclusion in this retrospective study. Preoperative, perioperative, and postoperative variables were collected, including the European system for cardiac operative risk evaluation (EuroSCORE) and markers of ECLS-related organ injuries. All variables were analyzed for possible associations with mortality in hospital, and after hospital discharge. The mean age, additive EuroSCORE, and left ventricular ejection fraction (LVEF) for all patients was 60 (+/-14) years, 9 (+/-6), and 43% (+/-20%) respectively. Sixty-seven patients were weaned from ECLS and 46 survived to hospital discharge. The mean duration of ECLS support was 143 h (+/-112 h). Multivariate analysis revealed that an age of >60 years, a necessity for postoperative continuous arteriovenous hemofiltration, a maximal serum total bilirubin >6 mg/dL, and a need for ECLS support for >110 h were independent predictors of in-hospital mortality. In addition, persistent heart failure with LVEF <30% was an independent predictor of mortality after hospital discharge. A risk-predicting score for in-hospital mortality associated with postcardiotomy ECLS was developed for clinical application. CONCLUSION: Based on the abovementioned findings, a comprehensive protocol for postcardiotomy ECLS was designed. The primary objective was to achieve adequate hemodynamics within the first 24h of initiating ECLS. Other objectives of the protocol included a consistent approach to safe anticoagulation while on ECLS, a process to make decisions within 7 days of initiating ECLS, and patient follow-up after hospital discharge.

Postcardiotomy extracorporeal life support in adults: the optimal duration of bridging to recovery.

Extracorporeal life support (ECLS) is a temporary support of postcardiotomy cardiogenic shock (PCS). Mortality of postcardiotomy ECLS often results from inability to recognize appropriate patients and bridge them to the next therapy before complications. A two-gated strategy for the second bridge transferring was suggested. From January 2003 to January 2008, 72 patients (mean 60 years) received ECLS for PCS. Indicators of cardiac recovery were identified from the physiological responses to ECLS. The optimal ECLS duration for myocardial recovery was defined as the supporting time of survivors. Forty-one patients weaned off ECLS and 29 survived to discharge. The mean duration of ECLS was 130 hours. Twenty- eight of the 29 survivors weaned off ECLS within 7 days. ECLS >100 hours and a refractory phenomenon of persistent hypotension (mean arterial pressure < 70 mm Hg) with a high adrenergic demand (inotropic equivalent score > 35) under a sufficient ECLS (flow > 50 ml x kg x min, SvO(2) > 80%) >24 hours were independent risk factors of ECLS nonweaning. The benefits of adult postcardiotomy ECLS are controversial after a 7-day support. Bridging should be considered in suitable patients having ECLS >7 days or showing instabilities under an adequate ECLS >24 hours. Continuing ECLS poses a higher risk of mortality.

Impact of preexisting organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure.

BACKGROUND: Extracorporeal life support (ECLS) is associated with a high mortality rate in patients with preexisting multiple organ failure. To achieve better outcomes of ECLS in this high risk group, an understanding of the real impact of preexisting organ dysfunction on ECLS-associated mortality is necessary. METHODS: From January 2003 to March 2007, a total of 45 patients (mean age: 48 years) were placed on ECLS for acute cardiopulmonary failure and survived longer than 24h. The medical records of these 45 patients were retrospectively reviewed. The indications for ECLS were acute respiratory distress syndrome (n=23), acute myocarditis (n=10) and acute myocardial infarction (n=12). Organ failure was assessed based on the Sequential Organ Failure Assessment (SOFA) score, which was calculated daily until ECLS termination. The demographic variables, SOFA score variables, and ECLS-related complications, including renal dialysis, severe brain damage and limb ischemia, were analysed. RESULTS: Twenty-seven patients (60%) were weaned from ECLS and 21 (47%) survived to discharge. Multivariate analysis revealed that the necessity of renal dialysis was an independent risk factor associated with failure to wean and non-survival, and the necessity of cardiopulmonary resuscitation (CPR) before ECLS was an independent risk factor for non-survival. Preexisting organ dysfunction, quantified by the pre-ECLS SOFA score, was predictive of survival to discharge. A pre-ECLS SOFA score greater than 14 predicted mortality in this study. CONCLUSIONS: SOFA score is a practical assessment tool and is predictive of ECLS-associated mortality in non-postcardiotomy patients. Patients having cardiac arrest requiring CPR or acute renal failure requiring dialysis before ECLS may have inferior ECLS outcomes.

A novel technique of coronary revascularization in porcelain aorta: report of two cases.

Severe atherosclerosis of the distal ascending aorta increases the risk of intraoperative stroke during coronary artery bypass. More than one in situ arterial graft is required to avoid aortic manipulation during proximal anastomosis. The application of bilateral internal thoracic arteries is a good choice, but it also carries the risk of sternal wound complications. Using a composite graft constructed with a partially harvested in situ right internal thoracic artery graft and another vascular conduit prevents extreme ischemia of the sternum. This study describes the experience of successful coronary revascularization using bilateral internal thoracic arteries and modified with a composite graft in two patients with a severely atherosclerotic ascending aorta.