Initial impact of drug-eluting stents on coronary artery bypass graft surgery.

BACKGROUND: Drug-eluting stents (DES) reduce the incidence of restenosis after percutaneous coronary intervention and have been predicted to decrease the number of patients referred for coronary artery bypass grafting (CABG). The purpose of this study was to determine the impact of DES on the number and characteristics of patients referred for CABG. METHODS: Drug-eluting stents were introduced at our hospital in April 2003 and reached maturity by June 2003. We compared our isolated CABG patients from the 12 months before the introduction of DES (year 1) with those from the 12 months after full implementation of DES (year 2). RESULTS: In year 1, of 4,348 cardiac catheterization patients, 2,144 (49.3%) underwent percutaneous coronary intervention, and 432 (9.9%) had CABG. In year 2, of 3,986 cardiac catheterization patients, 2,027 (50.9%) had percutaneous coronary intervention, and 337 (8.5%) had CABG, representing a 14% reduction in proportion of cardiac catheterization patients referred for CABG (p = 0.021). Among CABG patients, there was no change in age, prevalence of diabetes, or prevalence of three-vessel disease; however, patients in year 2 were more likely to have left main coronary artery disease (year 1, 36% versus year 2, 44.5%; p < 0.02) and left ventricular ejection fraction greater than 0.50 (year 1, 45% versus year 2, 52%; p < 0.02). CONCLUSIONS: The clinical introduction of DES was associated with a modest decrease in the percentage of cardiac catheterization patients referred for CABG. Of those referred for surgery, an increasing proportion had left main coronary artery disease and preserved left ventricular systolic function. Defining the role of DES versus CABG for coronary revascularization will require elucidation of the long-term outcomes of DES compared with CABG.

Implementing tight glucose control after coronary artery bypass surgery.

BACKGROUND: The clinical benefit of tight glucose control has been demonstrated in diabetic patients. In adopting an approach of tight glucose control for all cardiac surgery patients at Beth Israel Deaconess Medical Center, we encountered several challenges, including defining good glucose control, meaningfully measuring control, and assessing the impact of variables that may affect control. METHODS: An interdisciplinary team used an insulin protocol to achieve tight glucose control of cardiac surgery patients in the operating room and intensive care unit as part of an effort to reduce sternal wound infections. Good control was defined as glucose less than 130 mg/dL for more than 50% of measured time. RESULTS: Eight hundred eighteen patients underwent coronary artery bypass grafting between November 2002 and August 2004. Seven hundred thirty-seven (90%) received insulin. Fifty-seven percent did not have a preoperative diagnosis of diabetes. The trigger for insulin initiation was decreased sequentially from 150 mg/dL to 110 mg/dL, but the measure of good control remained the same: glucose less than 130 mg/dL. The factor most highly predictive of glucose being well controlled was the protocol with the 110 mg/dL trigger for insulin (p < 0.001). Patient factors such as age, ejection fraction, preoperative angiotensin-converting enzyme inhibitor or beta-blocker use, or time on cardiopulmonary bypass were not significantly associated with glucose control. During the course of the protocols, the rate of mediastinitis decreased from 1.6% to 0%. CONCLUSIONS: Key elements to implementing tight glucose control include having a standard protocol and metrics to track protocol performance. This practice improved control and was associated with a marked reduction in mediastinitis.