Social and emotional factors as predictors of poor outcomes following cardiac surgery.

OBJECTIVES: Existing risk prediction models in cardiac surgery stratify individuals based on their predicted risk, including only medical and physiological factors. However, the complex nature of risk assessment and the lack of parameters representing non-medical aspects of patients' lives point towards the need for a broader paradigm in cardiac surgery. Objectives were to evaluate the predictive value of emotional and social factors on 4 outcomes; death within 90 days, prolonged stay in intensive care (≥72 h), prolonged hospital admission (≥10 days) and readmission within 90 days following cardiac surgery, as a supplement to traditional risk assessment by European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHODS: The study included adults undergoing cardiac surgery in Denmark 2014-2017 including information on register-based socio-economic factors, and, in a nested subsample, self-reported symptoms of anxiety and depression. Logistic regression analyses were conducted, adjusted for EuroSCORE, of variables reflecting social and emotional factors. RESULTS: Amongst 7874 included patients, lower educational level (odds ratio 1.33; 95% confidence interval 1.17-1.51) and living alone (1.25; 1.14-1.38) were associated with prolonged hospital admission after adjustment for EuroSCORE. Lower educational level was also associated with prolonged intensive care unit stay (1.27; 1.00-1.63). Having a high income was associated with decreased odds of prolonged hospital admission (0.78; 0.70-0.87). No associations or predictive value for symptoms of anxiety or depression were found on any outcomes. CONCLUSIONS: Social disparity is predictive of poor outcomes following cardiac surgery. Symptoms of anxiety and depression are frequent especially amongst patients with a high-risk profile according to EuroSCORE. SUBJ COLLECTION: 105, 123.

Supplementing prediction by EuroSCORE with social and patient-reported measures among patients undergoing cardiac surgery.

OBJECTIVES: The risk of poor outcomes is traditionally attributed to biological and physiological processes in cardiac surgery. However, evidence exists that other factors, such as emotional, behavioral, social, and functional, are predictive of poor outcomes. Objectives were to evaluate the predictive value of several emotional, social, functional, and behavioral factors on four outcomes: death within 90 days, prolonged stay in intensive care, prolonged hospital admission, and readmission within 90 days following cardiac surgery. METHODS: This prospective study included adults undergoing cardiac surgery 2013-2014, including information on register-based socioeconomic factors and self-reported health in a nested subsample. Logistic regression analyses to determine the association and incremental value of each candidate predictor variable were conducted. Multiple regression analyses were used to determine the incremental value of each candidate predictor variable, as well as discrimination and calibration based on the area under the curve (AUC) and Brier score. RESULTS: Of 3217 patients, 3% died, 9% had prolonged intensive care stay, 51% had prolonged hospital admission, and 39% were readmitted to hospital. Patients living alone (odds ratio, 1.19; 95% confidence interval, 1.02-1.38), with lower educational levels (1.27; 1.04-1.54) and low health-related quality of life (1.43; 1.02-2.01) had prolonged hospital admission. Analyses revealed living alone as predictive of prolonged intensive care unit (ICU) stay (Brier, 0.08; AUC, 0.68), death (0.03; 0.71), and prolonged hospital admission (0.24; 0.62). CONCLUSION: Living alone was found to supplement EuroSCORE in predicting death, prolonged hospital admission, and prolonged ICU stay following cardiac surgery. Low educational level and impaired health-related quality of life were, furthermore, predictive of prolonged hospital admission.

Updating EuroSCORE by including emotional, behavioural, social and functional factors to the risk assessment of patients undergoing cardiac surgery: a study protocol.

INTRODUCTION: Conventional risk assessment in cardiac surgery focus on medical and physiological factors and have been developed to predict mortality. Other relevant risk factors associated with increased risk of poor outcomes are not included. Adding non-medical variables as potential prognostic factors to risk assessments direct attention away from specific diagnoses towards a more holistic view of the patients and their predicament. The aim of this paper is to describe the method and analysis plan for the development and validation of a prognostic screening tool as a supplement to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality, readmissions and prolonged length of admission in patients within 90 days after cardiac surgery, as individual outcomes. METHODS AND ANALYSIS: The development of a prognostic screening tool with inclusion of emotional, behavioural, social and functional factors complementing risk assessment by EuroSCORE will adopt the methods recommended by the PROGnosis RESearch Strategy Group and report using the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis statement. In the development stage, we will use data derived from three datasets comprising 1143, 3347 and 982 patients for a prospective cohort study of patients undergoing cardiac surgery, respectively. We will construct logistic regression models to predict mortality, prolonged length of admission and 90-day readmissions. In the validation stage, we will use data from a separate sample of 333 patients planned to undergo cardiac surgery to assess the performance of the developed prognostic model. We will produce validation plots showing the overall performance, area under the curve statistic for discrimination and the calibration slope and intercept. ETHICS AND DISSEMINATION: The study will follow the requirements from the Ethical Committee System ensuring voluntary participation in accordance with the Helsinki declarations. Data will be filed in accordance with the requirements of the Danish Data Protection Agency.

Tricuspid annular plane systolic excursion is significantly reduced during uncomplicated coronary artery bypass surgery: A prospective observational study.

OBJECTIVES: Longitudinal shortening constitutes most of the right ventricle (RV) contraction in the normal heart. However, after even uncomplicated cardiac surgery with preserved RV function a significant and sustained decrease in longitudinal contraction expressed as a reduction in tricuspid annular plane systolic excursion (TAPSE) has been observed. Why and exactly when this happens remains unsettled. The aim of this study was to evaluate the magnitude and timing of changes in TAPSE in relation to sternotomy, pericardial opening, cardiopulmonary bypass (CPB), and chest closure. METHODS: Fifty patients with normal preoperative ejection fraction and no valvulopathy, who underwent coronary artery bypass grafting with the use of CPB, were included. TAPSE was assessed using transthoracic echocardiography (TTE) at baseline and immediately after chest closure. Transesophageal echocardiography was performed at the following time points: after (1) anesthesia induction and transthoracic echocardiography; (2) sternotomy; (3) pericardiotomy; (4) completion of CPB; and (5) chest closure. RESULTS: TAPSE was significantly reduced to approximately half of its initial value in all patients (from 22 [95% confidence interval, 21-23 mm] after anesthesia induction to 9 [95% confidence interval, 8-10 mm] after chest closure). No change was seen after pericardiotomy. The most prominent reduction (30%-40%) was observed after weaning from CPB. An additional significant decrease of 13% to 16% was seen after chest closure. CONCLUSIONS: TAPSE was consistently reduced to approximately half of its initial value after uncomplicated coronary artery bypass grafting surgery. The reduction happened mainly after weaning from CPB, possibly reflecting conformational change of the RV.

Time to expand risk evaluation systems for cardiac surgery? Looking beyond physiological parameters.

Risk assessment in cardiac surgery traditionally consists of medical and physiological parameters. However, non-physiological factors have also been found to be predictive of poor outcomes following cardiac surgery. Therefore, the isolated focus on physiological parameters is questionable. This paper describes the emotional, behavioural, social and functional factors that have been established to play a role in outcomes following cardiac surgery. This forms a basis for future research, testing the value of these factors above and beyond the physiological parameters. By including such non-physiological factors, the accuracy of the existing risk scoring systems could potentially be improved.

Transit-time flow measurement as a predictor of coronary bypass graft failure at one year angiographic follow-up.

BACKGROUND: Transit-time flow measurement (TTFM) is a commonly used intraoperative method for evaluation of coronary artery bypass graft (CABG) anastomoses. This study was undertaken to determine whether TTFM can also be used to predict graft patency at one year postsurgery. METHODS: Three hundred forty-five CABG patients with intraoperative graft flow measurements and one year angiographic follow-up were analyzed. Graft failure was defined as more than 50% stenosis including the "string sign." Logistic regression analysis was used to analyze the risk of graft failure after one year based on graft vessel type, anastomatic configuration, and coronary artery size. RESULTS: Nine hundred eighty-two coronary anastomoses were performed of which 12% had signs of graft failure at one year angiographic follow-up. In internal mammary arteries (IMAs), analysis showed a 4% decrease in graft failure odds for every 1 mL/min increase in TTFM (OR = 0.96, CI = [0.93; 0.99], p = 0.005). ROC analysis showed good discriminative ability for TTFM alone AUC = 69.5% in IMA grafts. For single-vein grafts the decrease in graft failure odds was 2% for every 1 mL/min increase in TTFM (OR = 0.98; CI = [0.97; 1.00], p = 0.059) and AUC of 59.9%. There were no significant relationships between TTFM and graft failure in other graft types or graft configurations. CONCLUSION: The TTFM method has good discriminative ability for assessing the risk of graft failure in certain graft types within the first year after CABG surgery and is a valuable instrument for intraoperative quality assessment of bypass grafts.

Long-term internal thoracic artery bypass graft patency and geometry assessed by multidetector computed tomography.

The left internal thoracic artery (LITA) undergoes vascular remodelling when used for coronary artery bypass grafting. In this study we tested the hypothesis that the extent of the LITA remodelling late after coronary artery bypass grafting assessed by multidetector computed tomography is related to the severity of stenosis in the native coronary vessel. One hundred and forty-two patients who had undergone coronary artery bypass grafting including implantation of LITA as conduit to the left anterior descending artery were studied 5 years after surgery. Arterial graft patency and geometry was assessed with 64-slice multidetector computed tomography. Quantitative volumetric assessment of the LITA was performed to measure the average vessel lumen area (mm(2)/m(2)). The native coronary vessel subtended by the LITA was evaluated by multidetector computed tomography and defined as a high-grade stenosis patient group, when the diameter stenosis was >70% and an intermediate grade stenosis patient group when <70%. Among patients with intermediate-grade stenosis of the native vessel 11 out of 65 patients (17%) had a totally occluded LITA, as opposed to none among the 77 patients with a high-grade stenosis. In patients with intermediate-grade stenosis of the proximal native vessel, the LITA lumen area was 4.9 compared to 5.3 mm(2)/m(2) in patients with a high-grade stenosis of the proximal native vessel (P = 0.0043). Lumen area of the LITA when used as a conduit in patients with coronary artery disease seems to be inversely correlated with the severity of disease in the native coronary vessel proximal to the anastomosis. Volumetric vessel multidetector computed tomography appears to be useful for evaluation of coronary bypass remodelling.

Comparably improved health-related quality of life after total arterial revascularization versus conventional coronary surgery--Copenhagen arterial revascularization randomized patency and outcome trial.

OBJECTIVE: We compared health-related quality of life up to 11 months after coronary artery bypass grafting using total arterial revascularization versus conventional coronary surgery. METHODS: In this randomized single-center trial, 161 patients underwent total arterial revascularization using single or bilateral internal thoracic artery (ITA) and radial artery grafts versus 170 patients conventionally revascularized using left ITA and saphenous vein grafts. Preoperatively, and at 3 and 11 months, postoperatively, patients filled in the generic questionnaire Short Form-36 (SF-36). RESULTS: The mean age was 59±8 years and 39 were women (12%). Median EuroSCORE (European System for Cardiac Risk Evaluation) was 2 (interquartile range 1-4). More than 90% of patients filled in the questionnaire at all three time points. Preoperatively, all scores were lower (P<0.001) than for a sample of the general Danish population. On all scales of the SF-36, there was statistically significant improvement at 3 and 11 months in both groups. For 'social functioning', the improvement following total arterial revascularization was significantly higher than following conventional revascularization (P=0.01). For total arterial revascularization, there were also not statistically significant improvements for 'physical component summary' (P=0.09), 'bodily pain' (P=0.07) and 'vitality' (P=0.08). CONCLUSION: Health-related quality of life up to 1 year after total arterial revascularization is equal or slightly better than results after conventional coronary surgery.

Cell saver for on-pump coronary operations reduces systemic inflammatory markers: a randomized trial.

BACKGROUND: This study investigated whether intraoperative use of a cell saver reduces the systemic inflammatory response after coronary operations using cardiopulmonary bypass (CPB). METHODS: The study randomized 29 patients, 15 to cell saving of pericardial suction blood and residual blood in the CPB circuit after perfusion (cell saver group) vs 14 who received direct retransfusion of the suction blood and the CPB circuit blood (control group). Outcome measures were plasma concentrations of the inflammatory markers interleukin (IL)-1beta, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-alpha, soluble tumor necrosis factor receptors I and II, and procalcitonin at 6, 24, and 72 hours postoperatively. RESULTS: At 6 hours postoperatively, the cell saver group displayed significantly reduced plasma levels of IL-6 and IL-8 (p < 0.05). A reduction in IL-10 was also found (p = 0.05), along with nonsignificant reductions in the remaining markers. At 24 and 72 hours, significant differences between groups no longer existed. In the cell saver group, the suction blood and CPB circuit blood were cleared for tumor necrosis factor receptors (p < 0.005), and IL-6, IL-8, IL-10, and procalcitonin were significantly reduced (p < 0.05). Median intraoperative blood loss was 250 mL in the cell saver group vs 475 mL (p < 0.02). Immediately postoperatively the hemoglobin level was higher in the cell saver group (p < 0.03). Transfusion requirements were similar. CONCLUSIONS: The cell saver reduced the systemic levels of the proinflammatory markers IL-6 and IL-8 at 6 hours after CPB. The role of the anti-inflammatory molecules IL-10 and soluble tumor necrosis factor receptors is undefined in this setting.

One-year results of total arterial revascularization vs. conventional coronary surgery: CARRPO trial.

AIMS: To investigate clinical and angiographic outcomes after coronary surgery using total arterial revascularization (TAR). METHODS AND RESULTS: We randomized 331 patients with multivessel or isolated left main disease to TAR [internal thoracic (ITA) and radial arteries] vs. conventional revascularization (CR) using left ITA and vein grafts. The primary angiographic outcome was the patency index: number of patent grafts (<50% stenosed) divided by number of constructed grafts. One-year angiography was complete for 83% of patients. Mean patency index (+/-SD) was 87 +/- 22% in the TAR group and 88 +/- 18% in the conventional group (P = 0.52). In 72% of TAR patients and 67% of the conventional group, all grafts were patent (P = 0.45). Multiple imputation of missing angiographic data did not influence on results. Within 1 year, 37 (23%) TAR patients and 43 (25%) conventional group patients suffered cardiac events (HR 1.09, 95% CI 0.70-1.69, P = 0.70). One patient (0.6%) in the TAR group and two (1.2%) in the conventional group died (P = 1.00). CONCLUSION: Within 1 year post-operatively, TAR seems at least as safe and effective as CR. Prolonged follow-up will reveal whether this is sustained or superior results of TAR can justify a more general use.

Comparable three months' outcome of total arterial revascularization versus conventional coronary surgery: Copenhagen Arterial Revascularization Randomized Patency and Outcome trial.

OBJECTIVE: The in-hospital safety of total arterial revascularization for coronary artery bypass surgery seems to be comparable to conventional revascularization, but randomized trials evaluating this are few and data on complications in the postoperative months are sparse. METHODS: In a randomized single-center trial, 331 patients underwent total arterial revascularization using single or bilateral internal thoracic and radial arteries versus conventional revascularization using the left internal thoracic artery and saphenous vein grafts. We report the results from 3 months' follow-up. RESULTS: The mean age of patients was 59 +/- 8 years, and 39 were women (12%). The median EuroSCORE was 2 (interquartile range 1-4). The arterial group comprised 161 patients, and the conventional group comprised 170 patients. The mean number of bypasses in the arterial group was 2.9 +/- 0.9 versus 3.2 +/- 0.9 in the conventional group (P = .004). Three months' follow-up for the arterial versus conventional groups showed the following: deaths: 1 (0.6%) versus 0; stroke: 3 (1.9%) versus 3 (1.8%); myocardial infarction: 6 (3.7%) versus 4 (2.4%); sternal wound reoperation: 4 (2.5%) versus 0 (P = .054); arm and leg wound complications requiring hospitalization: 3 (1.9%) versus 6 (3.5%) (P = .50), respectively. CONCLUSION: These results confirm previous reports that total arterial revascularization can be performed with low in-hospital morbidity and mortality. Further, in the 3 postoperative months, total arterial revascularization did not lead to more complications or admissions than conventional surgery. Arterial grafting was performed with significantly fewer bypasses, but no differences in anginal status were seen after 3 months. A tendency toward more sternal complications after arterial grafting was observed, but clinical outcomes were comparable to conventional grafting.

[Coronary subclavian steal syndrome: two cases after coronary artery bypass grafting]. / Coronary-subclavian steal syndrome: to tilfaelde efter koronar bypassoperation.

Reverse flow in the internal mammary artery (IMA) graft due to stenosis or occlusion of the proximal ipsilateral subclavian artery causes coronary subclavian steal syndrome (CSSS). We describe two patients who were diagnosed with CSSS following CABG. Patient A presented with angina pectoris, was diagnosed with CSSS and treated by transposition of the proximal IMA from the subclavian artery to the aorta. Patient B was diagnosed with CSSS by control angiography. Myocardial scintigraphy showed reversible silent ischemia. He was offered treatment, but refused as he was symptom-free.

Autotransfusion with cell saver for off-pump coronary artery bypass surgery: a randomized trial.

OBJECTIVES: Off-pump coronary surgery reduces transfusions, however, many patients still receive blood. This trial aims to clarify the effect of using a cell saver intraoperatively. DESIGN: In 60 patients shed blood was collected in the cell saver reservoir intraoperatively; randomization and processing or discharge were performed immediately after surgery. PRIMARY OUTCOME MEASURES: proportion of patients receiving allogeneic blood, and average number of units per patient. SECONDARY OUTCOME MEASURES: blood loss, hemoglobin levels, complications, and costs. RESULTS: Cell saver group versus control group; received transfusions: 17/30 vs. 14/29 (p = 0.28), allogeneic units: median 1 (interquartile range 0 - 2) vs. 2 (IQR 0 - 7) (p = 0.06), intraoperative net blood loss: median 300 ml (IQR 193 - 403) vs. 610 ml (IQR 450 - 928) (p < 0.001). Control group patients had more complications leading to transfusion. Hemoglobin levels and costs were comparable between groups. CONCLUSIONS: Use of cell saver reduced intraoperative net blood loss and seemed to reduce transfusions by 1 unit per patient, however, this was probably attributable to more complications leading to transfusion in the control group. In the future larger trials are necessary.

An update on internal mammary artery grafting for coronary artery disease.

PURPOSE OF REVIEW: To describe recent results regarding the use of the internal mammary artery for coronary artery bypass grafting with emphasis on bilateral internal mammary artery grafting, patency, resistance to atherosclerosis, skeletonisation, composite arterial grafts, flow measurement, vasodilatation, and non-invasive imaging techniques. RECENT FINDINGS: Coronary artery bypass grafting plays an important part in coronary revascularisation and seems to be associated with a survival benefit in comparison with percutaneous coronary intervention. After 10 years, internal mammary arteries demonstrate better patency than vein grafts except when grafting moderately stenosed right coronary arteries. Bilateral internal mammary artery grafting increases survival further, but carries a higher risk of sternal complications. Skeletonisation may reduce this risk. The internal mammary arteries are used increasingly as composite arterial grafts and this technical solution should no longer be considered experimental. Perioperative flow measurement by the transit-time method is recommended while postoperative echocardiography represents an accurate method for evaluation of flow in internal mammary artery grafts. Multi-detector computed tomography allows for accurate assessment of all types of bypass conduits and native coronary arteries. At present, magnetic resonance imaging of internal mammary artery patency and flow is possible. SUMMARY: Newer studies confirm earlier data with respect to improved long-term survival when using internal mammary artery grafting, and this survival benefit is superior to percutaneous coronary intervention treatment. Bilateral internal mammary artery grafting improves survival further. Skeletonisation of the internal mammary artery provides extra length of grafts for complete arterial revascularisation. Non-invasive imaging techniques are increasingly sophisticated and may change the referral pattern for patients with coronary artery disease to either percutaneous coronary intervention or coronary artery bypass grafting.