Decline in serum hemoglobin in the 7 days after cardiac catheterization.

OBJECTIVES: Bleeding is an established complication following cardiac catheterization and lower preoperative hemoglobin concentration is a potentially modifiable risk factor for adverse outcomes after cardiac surgery. However, typical changes in serum hemoglobin concentration after cardiac catheterization are poorly defined. The authors sought to identify the pattern of change in serum hemoglobin concentration within 7 days after cardiovascular catheterization, factors associated with this change and any association with adverse outcomes. DESIGN: Retrospective observational study over a 1-year period. SETTING: U.S. academic medical institution. PARTICIPANTS: Participants were 284 adult patients with baseline hemoglobin concentration≥12 g/dL undergoing nonemergent cardiac surgery after cardiovascular catheterization via the femoral arterial route. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Lowest daily hemoglobin concentration was recorded where available for up to 7 days after catheterization and before surgery. Generalized estimating equations identified the pattern of change in serum hemoglobin while regression models identified factors associated with hemoglobin decline. Following cardiovascular catheterization average serum hemoglobin declined over time, reaching a nadir 1.4 g/dL (95% CI 1.0-1.8) below baseline 6 days after catheterization. A higher baseline hemoglobin concentration and lower body mass index were associated with greater maximal decline in hemoglobin concentration after catheterization. Acute preoperative hemoglobin decline was not associated with acute kidney injury (AKI) or a composite adverse outcome that may reflect organ ischemia. CONCLUSIONS: In a cohort of patients before cardiac surgery serum hemoglobin declines during the week after cardiac catheterization, with maximal average decline observed 5 to 7 days after catheterization.

Caregiver status: a simple marker to identify cardiac surgery patients at risk for longer postoperative length of stay, rehospitalization, or death.

BACKGROUND: Patients who have undergone cardiac surgery, especially those with greater comorbidities, may be cared for by family members or paid aides. OBJECTIVE: The purpose of this study was to evaluate the association between having a caregiver among patients who underwent cardiac surgery and clinical outcomes at 1 year. We hypothesized that patients with a caregiver would have longer lengths of stay and higher rehospitalization or death rates 1 year after surgery. METHODS: We studied 665 patients consecutively admitted for cardiac surgery as part of the Family Cardiac Caregiver Investigation To Evaluate Outcomes sponsored by the National Heart, Lung, and Blood Institute. The participants (mean age, 65 years; women, 35%; racial/ethnic minorities, 21%) completed an interviewer-assisted questionnaire to determine caregiver status. Outcomes were documented by a hospital-based information system; demographics/comorbidities, by electronic records. Associations between having a caregiver and outcomes were evaluated by logistic regression, adjusted for demographic and comorbid conditions. RESULTS: At baseline, 28% of the patients (n = 183) had a caregiver (8%, paid; 20%, informal only). Having a caregiver was associated with longer (>7 days) postoperative length of stay in univariate analysis among the patients with paid (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.57-5.74) or informal (OR, 1.55; 95% CI, 1.04-2.31) caregivers versus none; the association remained significant for the patients with paid (OR, 2.13; 95% CI, 1.00-4.55) but not with informal (OR, 1.12; 95% CI, 0.70-1.80) caregivers after adjustment. Having a paid caregiver was significantly associated with rehospitalization/death at 1 year in univariate analysis (OR, 2.09; 95% CI, 1.18-3.69); having an informal caregiver was not (OR, 1.39; 95% CI, 0.94-2.06). Increased odds of rehospitalization/death associated with having a paid caregiver attenuated after adjustment (OR, 1.39; 95% CI, 0.74-2.62). CONCLUSIONS: The patients who underwent cardiac surgery who had a paid caregiver had a significantly longer length of stay independent of comorbidity. The increased risk of rehospitalization/death associated with having a paid caregiver was explained by demographics and comorbidity. These data suggest that caregiver status assessment may be a simple method to identify cardiac surgery patients at increased risk for adverse clinical outcomes.

Incorporating oliguria into the diagnostic criteria for acute kidney injury after on-pump cardiac surgery: impact on incidence and outcomes.

OBJECTIVES: Consensus definitions represent an important step toward defining the epidemiology of acute kidney injury (AKI). However, the oliguric component of these definitions remains of uncertain impact and utility after cardiac surgery. The authors sought to define the specific impact of oliguric criteria, both alone and in combination with serum creatinine criteria, on the observed incidence of AKI and associated adverse outcomes following adult cardiac surgery. DESIGN: Retrospective observational study over a 1-year period. SETTING: Academic medical institution. PARTICIPANTS: A total of 311 adult patients undergoing elective valve and/or coronary artery bypass graft surgery with cardiopulmonary bypass. INTERVENTIONS: No interventions were performed as part of the study. MEASUREMENTS AND MAIN RESULTS: Hourly urine output and daily serum creatinine were recorded in the 2 days following surgery. AKI was defined by Acute Kidney Injury Network oliguric and serum creatinine criteria. Defined by serum creatinine criteria alone, the incidence of AKI was 17.7% and was associated strongly with in-hospital mortality (odds ratio 6.6, 95% confidence interval 1.4-30.5, p = 0.02) and renal replacement therapy (odds ratio 12.7, 95% confidence interval 2.4-67.3, p = 0.003) as well as time to discharge from the intensive care unit and hospital. Defined by oliguric criteria alone through 48 hours following surgery, the incidence of AKI dramatically increased to 55.6% but was not associated with mortality, renal replacement therapy, or time to discharge. CONCLUSIONS: Acute Kidney Injury Network oliguric criteria applied over 48 hours after surgery dramatically increased the measured incidence of AKI after cardiac surgery, but was not associated with adverse outcomes.

Acute kidney injury after cardiac surgery: does the time interval from contrast administration to surgery matter?

OBJECTIVE: The authors sought to evaluate the association between the time interval from contrast administration to cardiac surgery and postoperative acute kidney injury (AKI). DESIGN: A retrospective observational study over a 1-year period. SETTING: A US academic medical institution. PARTICIPANTS: Six hundred forty-four adult patients undergoing nonemergent cardiac surgery. INTERVENTIONS: No interventions were performed as part of the study. MEASUREMENTS AND MAIN RESULTS: AKI was defined as an increase in serum creatinine by ≥0.3 mg/dL or ≥50% above baseline within the first 2 postoperative days or the commencement of renal replacement therapy within the same period. Using a contrast-to-surgery time interval >7 days as the baseline, multivariable logistic regression analysis determined the association between a contrast-to-surgery time interval ≤1 day or 2 to 7 days and postoperative AKI adjusting for potential confounding variables. The incidence of AKI within the study cohort was 21.9%. After adjusting for other covariates, there was no association between the contrast-to-surgery time and AKI (odds ratio [OR] ≤1 day = 0.93; 95% confidence interval [CI], 0.52-1.66; p = 0.81; OR = 2-7 days = 1.28; 95% CI, 0.78-2.11; p = 0.34). CONCLUSIONS: In an appropriately selected population, cardiac surgery can be performed within 1 day of cardiovascular catheterization and contrast administration without an increase in the incidence of postoperative AKI. Recommendations to delay cardiac surgery for a specified period after contrast administration to reduce the risk of postoperative AKI are premature. Additional evidence is required before making recommendations on optimal surgical timing after contrast exposure.

Association between having a caregiver and clinical outcomes 1 year after hospitalization for cardiovascular disease.

Caregivers might represent an opportunity to improve cardiovascular disease outcomes, but prospective data are limited. We studied 3,188 consecutive patients (41% minority, 39% women) admitted to a university hospital medical cardiovascular service to evaluate the association between having a caregiver and rehospitalization/death at 1 year. The clinical outcomes at 1 year were documented using a hospital-based clinical information system supplemented by a standardized questionnaire. Co-morbidities were documented by hospital electronic record review. At baseline, 13% (n = 417) of the patients had a paid caregiver and 25% (n = 789) had only an informal caregiver. Having a caregiver was associated with rehospitalization or death at 1 year (odds ratio [OR] 1.68, 95% confidence interval [CI] 1.45 to 1.95), which varied by paid (OR 2.46, 95% CI 1.96 to 3.09) and informal (OR 1.40, 95% CI 1.18 to 1.65) caregiver status. Having a caregiver was significantly (p <0.05) associated with age ≥65 years, racial/ethnic minority, lack of health insurance, medical history of diabetes mellitus or hypertension, a Ghali co-morbidity index >1, chronic obstructive pulmonary disease, or taking ≥9 prescriptions medications. The relation between caregiving and rehospitalization/death at 1 year was attenuated but remained significant after adjustment (paid, OR 1.64, 95% CI 1.26 to 2.12; and informal, OR 1.20, 95% CI 1.00 to 1.44). In conclusion, the risk of rehospitalization/death was significantly greater among cardiac patients with caregivers and was not fully explained by the presence of traditional co-morbidities. Systematic determination of having a caregiver might be a simple method to identify patients at a heightened risk of poor clinical outcomes.

Patterns of caregiving among patients hospitalized with cardiovascular disease.

BACKGROUND AND OBJECTIVES: Cardiac caregivers may represent a novel low-cost strategy to improve patient adherence to medical follow-up and guidelines and, ultimately, patient outcomes. Prior work on caregiving has been conducted primarily in mental health and cancer research; few data have systematically evaluated caregivers of cardiac patients. The purpose of this study was to evaluate the patterns of caregiving and characteristics of caregivers among hospitalized patients with cardiovascular disease (CVD) to assess disparities in caregiver burden and to determine the potential for caregivers to impact clinical outcomes. SUBJECTS AND METHODS: Consecutive patients admitted to the cardiovascular service line at a university medical center during an 11-month period were included in the Family Cardiac Caregiver Investigation To Evaluate Outcomes (FIT-O) study. Patients (n=4500; 59% white, 62% male, 93% participation rate) completed a standardized interviewer-assisted questionnaire in English or Spanish regarding assistance with medical care, daily activities, and medications in the past year and plans for posthospitalization. In univariate and multiple variable analyses, caregivers were categorized as either paid/professional (eg, nurse/home aide) or nonpaid (eg, family member/friend). RESULTS AND CONCLUSIONS: Among CVD patients, 13% planned to have a paid caregiver and 51% a nonpaid caregiver at discharge. Planned paid caregiving was more prevalent among racial/ethnic minority versus white patients (odds ratio, 1.5; 95% confidence interval, 1.2-1.8); planned nonpaid caregiving prevalence did not differ by race/ethnicity. Most nonpaid caregivers were female (78%). Patients who had nonpaid caregivers in the year prior to hospitalization (28%) reported grocery shopping/meal preparation (32%), transport to/arranging doctor visits (30%), and medication adherence/medical needs (25%) as top tasks caregivers assisted with. Following hospitalization, a majority of patients expect nonpaid caregivers, primarily women, to assist with tasks that have the potential to improve CVD outcomes such as medical follow-up, medication adherence, and nutrition, suggesting that these are important targets for caregiver education.

Eight-year experience with minimally invasive cardiothoracic surgery.

BACKGROUND: Over the past decade, minimally invasive cardiac surgery (MICS) has emerged as an accepted approach for the management of cardiac disease that requires a surgical solution. We report the results of an 8-year, single-institution experience with MICS. METHODS: Between January 1, 2000 and December 31, 2007, a total of 910 patients underwent MICS. Major cases included aortic valve procedures (71, 7.8%), coronary artery bypass grafting (96, 10.5%), atrioseptal defect repair (103, 11.3%), and mitral valve procedures (507, 55.7%). Major outcomes of interest included the complication and mortality rates. RESULTS: The mean age of the patients was 57 +/- 15 years; the mean ejection fraction was 55% +/- 11%; and the mean body mass index was 26.1 +/- 4.9. Overall, 782 cases (85.9%) were performed through a mini-thoracotomy. Most of the cases were accomplished through central cannulation (765, 84.0%), and venous drainage was most commonly performed in a bicaval fashion (percutaneous superior vena cava and percutaneous inferior vena cava). The mean aortic cross-clamp and cardiopulmonary bypass (CPB) times were 58.1 +/- 44.9 and 101.9 +/- 66.8 min, respectively. Conversion to full sternotomy occurred in 10 patients, and the median length of stay in hospital was 6 days. The overall complication rate was 8.8%, and the 30-day mortality rate was 2.9%. In the multivariate logistic regression analysis, risk factors associated with in-hospital complications included age, CPB time, arterial cannulation location, conversion from off-CPB to on-CPB, hepatic insufficiency, and diabetes. In the multivariate hazards regression analysis, risk factors associated with mortality included postoperative stroke, renal failure, and sternal wound infection; CPB time; and previous surgery. CONCLUSIONS: In our experience, minimally invasive approaches are effective and reproducible for a variety of cardiac operations, with acceptable operating time durations, morbidity, and mortality.