Post-infarction ventricular septal defect: percutaneous or surgical management in the UK national registry.

AIMS: Post-infarction ventricular septal defect (PIVSD) is a mechanical complication of acute myocardial infarction (AMI) with a poor prognosis. Surgical repair is the mainstay of treatment, although percutaneous closure is increasingly undertaken. METHODS AND RESUTS: Patients treated with surgical or percutaneous repair of PIVSD (2010-2021) were identified at 16 UK centres. Case note review was undertaken. The primary outcome was long-term mortality. Patient groups were allocated based upon initial management (percutaneous or surgical). Three-hundred sixty-two patients received 416 procedures (131 percutaneous, 231 surgery). 16.1% of percutaneous patients subsequently had surgery. 7.8% of surgical patients subsequently had percutaneous treatment. Times from AMI to treatment were similar [percutaneous 9 (6-14) vs. surgical 9 (4-22) days, P = 0.18]. Surgical patients were more likely to have cardiogenic shock (62.8% vs. 51.9%, P = 0.044). Percutaneous patients were substantially older [72 (64-77) vs. 67 (61-73) years, P < 0.001] and more likely to be discussed in a heart team setting. There was no difference in long-term mortality between patients (61.1% vs. 53.7%, P = 0.17). In-hospital mortality was lower in the surgical group (55.0% vs. 44.2%, P = 0.048) with no difference in mortality after hospital discharge (P = 0.65). Cardiogenic shock [adjusted hazard ratio (aHR) 1.97 (95% confidence interval 1.37-2.84), P < 0.001), percutaneous approach [aHR 1.44 (1.01-2.05), P = 0.042], and number of vessels with coronary artery disease [aHR 1.22 (1.01-1.47), P = 0.043] were independently associated with long-term mortality. CONCLUSION: Surgical and percutaneous repair are viable options for management of PIVSD. There was no difference in post-discharge long-term mortality between patients, although in-hospital mortality was lower for surgery.

Left ventricular apical masses: distinguishing benign tumours from apical thrombi.

Differential diagnoses for cardiac left ventricular apical masses presenting following acute myocardial infarction include thrombi and cardiac tumours. We present two such cases and the multidisciplinary assessment that is required to assist with diagnosis.

Total arterial revascularisation: effect of avoiding cardiopulmonary bypass on in-hospital mortality and morbidity in a propensity-matched cohort.

OBJECTIVE: The combination of total arterial revascularisation and avoidance of cardiopulmonary bypass may provide additional benefits to patients receiving complete arterial grafting with cardiopulmonary bypass. We performed a propensity-matched cohort study of complete arterial off-pump and on-pump coronary surgery and examined differences in in-hospital mortality and morbidity. METHODS: Three hundred and sixty patients who underwent off-pump coronary surgery with complete arterial grafting between April 1997 and September 2002 were matched to 360 patients who received coronary surgery with cardiopulmonary bypass and complete arterial grafting. To match off-pump with unique on-pump patients, logistic regression was used to develop a propensity score for off-pump surgery. The C statistic for this model was 0.79. Off-pump patients were matched to unique on-pump patients with an identical 5-digit propensity score. If this could not be done, we then proceeded to a 4-, 3-, 2-, or 1-digit match. RESULTS: Patient characteristics were well matched. There was no difference in in-hospital mortality between the groups. Off-pump patients were less likely to develop sternal wound infections compared to the on-pump group (2.5 versus 5.8%; P=0.03), and had significantly lower blood loss (675 versus 780 ml; P<0.001), red blood cell unit transfusion (8.6 versus 38.9%; P<0.001), enzyme rises (13 versus 23 U/l; P<0.001), inotrope support (11.9 versus 28.9%; P<0.001), and ventilation times (5 versus 8 h; P<0.001). Intensive care unit and hospital stay were also significantly lower in the off-pump patients. CONCLUSIONS: Off-pump coronary surgery with complete arterial revascularisation can significantly reduce in-hospital morbidity and lengths of stay compared to conventional on-pump coronary surgery.

Effect of preoperative aspirin use in off-pump coronary artery bypass operations.

BACKGROUND: The effect of preoperative aspirin use until the day of operation on mortality rate and bleeding risks in patients who had on-pump coronary artery bypass operation has been well documented. However, the effect of aspirin use in patients undergoing off-pump coronary artery bypass operation (OPCAB) with regard to postoperative blood loss and morbidity has not been studied. We aimed to determine the effects of continuing aspirin therapy preoperatively. METHODS: We performed a retrospective study of 340 patients who had first-time OPCAB between January 1998 and September 2001. A propensity score for receiving aspirin until the day of operation was constructed from core patient characteristics. All aspirin users (n = 170) were matched with unique 170 nonaspirin users by identical propensity score. The primary outcome measures were in-hospital mortality rate and hemorrhage-related outcomes (postoperative blood loss in the intensive care unit, reexploration for bleeding, and blood product requirements). Secondary outcome measures were stroke, myocardial infarction, gastrointestinal bleeding, and sternal wound infections. RESULTS: There were no differences in patient characteristics between aspirin users and nonaspirin users. The average postoperative blood loss (845 mL versus 775 mL; p = 0.157) and the rate of reexploration for bleeding (3.5% versus 3.5%; p > 0.99) were similar in aspirin users and nonaspirin users. We found no significant difference between blood product requirements for the two groups. Similarly, we found no significant difference in the incidence of the secondary outcomes. CONCLUSIONS: Preoperative aspirin did not increase bleeding-related complications, mortality rate, or other morbidities in patients who had off-pump coronary artery operation.

Coronary surgery in patients with peripheral vascular disease: effect of avoiding cardiopulmonary bypass.

BACKGROUND: An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. METHODS: Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke (p = 0.007), and had shorter postoperative hospital stays (p < 0.001). However, the incidence of new atrial arrhythmia was higher (p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay (p = 0.001). CONCLUSIONS: Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

Neurological outcomes in coronary surgery: independent effect of avoiding cardiopulmonary bypass.

BACKGROUND: Recent studies examining neuroprotective effects of off-pump coronary artery bypass grafting (CABG) have shown inconsistent results. We examined our database to quantify the independent effects of avoidance of cardiopulmonary bypass (CPB) and aortic manipulation on neurologic outcomes after CABG. METHODS: A total of 2,327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified at our two institutions. Patients were divided into three groups: on CPB, off-pump with aortic manipulation, and off-pump without aortic manipulation. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, redo operations, diabetes, chronic obstructive pulmonary disease, neurologic disease, peripheral vascular disease, ejection fraction, and priority of operation. RESULTS: A total of 1,210 cases were performed on CPB, compared with 520 off-pump with aortic manipulation, and 597 off-pump without aortic manipulation. The incidence of focal neurologic deficit was 1.6% (n = 19) in the on-pump group, 0.4% (n = 2) in the off-pump with aortic manipulation group, and 0.5% (n = 3) for the off-pump without aortic manipulation group (p for trend = 0.027). The results of the multivariate logistic regression analysis demonstrated that use of CPB was a risk factor for focal neurologic deficit, with an odds ratio of 3.82 (95% confidence interval, 1.41 to 10.34; p = 0.005). Aortic manipulation did not significantly influence neurologic outcome in off-pump patients. CONCLUSIONS: Off-pump operation, with or without aortic manipulation, reduces adverse neurologic outcomes compared with on-pump procedures.

'Shunt shuffle'-a simple technique of introducing intracoronary shunts for off-pump coronary artery bypass.

Intracoronary shunting is a useful method for maintaining distal perfusion as well as providing a bloodless field during off-pump coronary revascularization. Intracoronary shunts require insertion of both ends through a limited arteriotomy, which sometimes can be troublesome. We describe the 'shunt shuffle' as a simple technique, which allows rapid, atraumatic and easy insertion of intracoronary shunts.

Effect of avoiding cardiopulmonary bypass in non-elective coronary artery bypass surgery: a propensity score analysis.

OBJECTIVE: Non-elective coronary artery surgery (emergent/salvage or urgent) carries an increased risk in most risk-stratification models. Off-pump coronary surgery is increasingly used in non-elective cases. We aimed to investigate the effect of avoiding cardiopulmonary bypass on outcomes following non-elective coronary surgery. METHODS: Of the 3771 consecutive coronary artery bypass procedures performed by five surgeons between April 1997 and March 2002, 828 (22%) were non-elective and 417 (50.4%) of these patients had off-pump surgery. Multivariate logistic regression was used to assess the effect of off-pump on in-hospital outcomes, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics, which was the probability of avoiding cardiopulmonary bypass. The C statistic for this model was 0.8. RESULTS: Off-pump patients were more likely to be hypertensive, stable, had less extensive disease and better left ventricular function. The left internal mammary artery was used in 91.8% (n=383) of off-pump patients compared to 79.3% (n=326) of on-pump cases (P<0.001). After adjusting for the propensity score, no difference in in-hospital mortality was observed between off-pump and on-pump (adjusted odds ratio (OR) 0.83 (95% confidence intervals (CI) 0.36-1.93); P=0.667). Off-pump patients were less likely to require intra-aortic balloon pump support (adjusted OR 0.44 (95% CI 0.21-0.96); P=0.039), less likely to have renal failure (adjusted OR 0.44 (95% CI 0.22-0.90); P=0.025), and have shorter lengths of stay (adjusted OR 0.51 (95% CI 0.37-0.70); P<0.001). Other morbidity outcomes were similar in both groups. CONCLUSIONS: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery.

Off-pump coronary artery bypass surgery does not reduce gastrointestinal complications.

OBJECTIVES: Gastrointestinal (GI) complications following on-pump coronary artery bypass grafting (CABG) are rare, but carry a high mortality rate. Prolonged cardiopulmonary bypass (CPB) has been associated with a higher incidence of such complications. Little is known about the effect of avoiding CPB on GI complications. Our hypothesis was that off-pump CABG might reduce such complications. METHODS: A total of 2327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified from four consultants' practice at the two cardiothoracic centres involved in this study. We performed a multivariable logistic regression analysis to identify the risk factors for development of post-operative GI complications. Potential risk factors considered in the logistic model were age, sex, angina, ejection fraction, peripheral vascular disease, renal dysfunction, redo operations, previous GI complications, priority of surgery and the use of CPB. RESULTS: A total of 1210 cases were performed on CPB, compared to 1117 off-pump. The incidence of GI complications was 1.2% (n = 14) in the on-pump group and 1.6% (n = 18) in the off-pump group (P = 0.347). The incidence of in-hospital mortality, in the patients who had a GI complication, was 28.6% (n = 4) and 22.2% (n = 4), respectively (P = 0.681). The results of the logistic regression analysis showed that renal dysfunction, advancing age and previous history of GI surgery are significant risk factors for GI complications after coronary bypass surgery whether CPB is used or not. CONCLUSIONS: Our study suggests that off-pump and on-pump techniques are similar in the rates of GI complications. We suggest that a properly designed randomized control trial is needed to verify our findings.

Comparison of the EuroSCORE II and Society of Thoracic Surgeons 2008 risk tools.

OBJECTIVES: Risk stratification in cardiac surgery is uniquely detailed, led latterly by the EuroSCORE and the Society of Thoracic Surgeons (STS) risk calculators. The recently published EuroSCORE II (ES2) algorithms update estimated mortality in a broad spectrum of cardiac procedures. The 2008 STS tool, in comparison, predicts multiple outcomes for specific procedures. We sought to identify and compare the external validity of both contemporaneous tools in our population. METHODS: Data from our hospital database were collated for the period February 2001 to March 2010. Logistic regression coefficients from the risk calculations were applied to the data and the results presented as receiver-operating characteristic (ROC) curves. Statistical analyses were performed using the area under the ROC curve (AUROC) and the Hosmer-Lemeshow (H-L) goodness-of-fit test, with comparisons using the DeLong method. RESULTS: A total of 15 497 procedures were identified, of which 14 432 were appropriate for STS risk scoring (i.e. valve and/or graft procedures with no tricuspid valve operations etc.). For all procedures, ES2 and STS were equivalent (AUROC 0.818 vs 0.805, respectively, P = 0.343). For procedures appropriate for STS risk scoring, results were similar (AUROC ES2 vs STS, 0.816 vs 0.810, P = 0.714), whereas for procedures excluded by STS, the result was marginally worse (AUROC ES2 vs STS, 0.773 vs 0.784, P = 0.751). Goodness of fit in all cases was poor, primarily where risk was higher than 15% (H-L P < 0.0001). CONCLUSIONS: EuroSCORE II and STS both provide equivalent discrimination in predicting mortality in a British population, including those undergoing procedures for which the STS does not normally predict. Accounting for decile-grouped Hosmer-Lemeshow tests not being ideal for the assessment of calibration, both tools show good calibration for patients with low to moderate risk, with divergence from ~15% predicted risk.

Outcomes and predictors of prolonged ventilation in patients undergoing elective coronary surgery.

OBJECTIVES Despite the seriousness of prolonged mechanical ventilation (PMV) as a postoperative complication, previously proposed risk prediction models were met with limited success. The purpose of this study was to identify perioperative variables associated with PMV in elective primary coronary bypass surgery. PMV was defined as the need for intubation and mechanical ventilation for >72 h, after completion of the operation. METHODS Between April 1997 and September 2010, 10 ,977 consecutive patients were retrospectively reviewed. A series of two multivariate logistic regression analyses were carried out to identify preoperative predictors of prolonged ventilation and the impact of operative variables. RESULTS PMV occurred in 215 (1.96%) patients; 119 (55.3%) of these underwent tracheostomy. At multivariate analysis, predictors included NYHA higher than class II (odds ratio [OR], 1.77; 95% confidence intervals [CI], 1.34-2.34), renal dialysis (OR, 5.5; 95% CI, 2.08-14.65), age at operation (OR, 1.04; 95% CI, 1.02-1.06), reduced FEV(1) (OR, 0.99; 95% CI, 0.98-0.99), body mass index >35 kg/m(2) (OR, 1.73; 95% CI, 1.14-2.63). On serial logistic regression analyses, operative variables added little to the discriminatory power of the model. Kaplan-Meier survival curves showed reduced survival among PMV patients (P < 0.001) with an improved survival in the tracheostomy subgroup. CONCLUSIONS PMV after coronary bypass is associated with a reduction in early and mid-term survival. Risk modelling for PMV remains problematic even when examining a more homogenous lower risk group.

Monitoring cardiac output trends with end-tidal carbon dioxide pressures in off-pump coronary bypass.

The optimum method of intraoperative monitoring in patients undergoing off-pump coronary bypass remains debatable. Using capnography and end-tidal carbon dioxide pressure may be a helpful method of monitoring cardiac output trends, especially when grafting posterior and lateral vessels. After repositioning the heart, End-tidal carbon dioxide pressures that continue to trend down usually indicate decreased cardiac output and precede hemodynamic and electrical instability. The advantages of this method include simplicity, universal availability, and a short response time to changes in cardiac output.

Mitral valve involvement in Wegener's granulomatosis.

Wegener's granulomatosis is an autoimmune condition resulting in the granulomatous vasculitis of small-to-medium-sized vessels, and is characterized by granulomatous lesions in the renal and respiratory systems. Cardiac involvement in Wegener's granulomatosis has been previously reported. However, involvement of cardiac valves is extremely rare. We present a patient with Wegener's granulomatosis with an extensive mitral mass extending to the aortic valve.

Predictive accuracy of EuroSCORE: is end-diastolic dysfunction a missing variable?

OBJECTIVE: Left-ventricular function has been shown to be an important prognostic factor in estimating operative risk in cardiac surgery. As such, left-ventricular ejection fraction (LVEF) is included in the EuroSCORE. However, left-ventricular function is more comprehensively assessed by measures of both systolic and diastolic dysfunction. We hypothesised that end-diastolic dysfunction is an additional independent indicator for predicting outcome following coronary artery bypass grafting (CABG). METHODS: We retrospectively assessed all patients undergoing isolated off-pump CABG between October 2000 and September 2004 by two surgeons. Left-ventricular end-diastolic pressure (LVEDP), measured during cardiac catheterisation, was used as a measure of left-ventricular diastolic dysfunction. Logistic regression was used to assess the association between LVEDP (a continuous and dichotomous variable) and mortality, while adjusting for EuroSCORE. RESULTS: A total of 925 patients with complete LVEDP data were identified and stratified as follows: group 1 (LVEF >30% and LVEDP <20 mmHg), group 2 (LVEF <30% and LVEDP <20 mmHg), group 3 (LVEF >30% and LVEDP >20 mmHg) and group 4 (LVEF <30% and LVEDP >20 mmHg). Mortality increased progressively from group 2 (1.9%, odds ratio (OR) 1.22, RR 1.21, p 0.58) to group 3 (5.6%, OR 3.81, RR 3.66, p 0.07) and was highest in group 4 (7.4%, OR 5.18, RR 4.87, p 0.08). Receiver operating characteristic (ROC) curve c-characteristic improved from 0.7 to 0.78 when EuroSCORE was combined with LVEDP, identifying LVEDP as an independent predictor of mortality after adjusting for EuroSCORE. Logistic equation: odds of death = exp(-6.3283+[EuroSCORE x 0.1813]+[EDP x 0.0954]). CONCLUSIONS: LVEDP as a marker of diastolic dysfunction seems an important variable in predicting patient-specific risk and should be considered for incorporation in future risk models.

Logistic risk model for prolonged ventilation after adult cardiac surgery.

BACKGROUND: The aim of this study was to develop a multivariate risk prediction model for prolonged ventilation after adult cardiac surgery. METHODS: This is a retrospective analysis of prospectively collected data on 12,662 consecutive patients undergoing adult cardiac surgery between April 1997 and March 2005. Data were randomly split into a development dataset (n = 6,000) and a validation dataset (n = 6,662). A multivariate logistic regression analysis was undertaken using a forward stepwise technique to identify independent risk factors for prolonged ventilation (defined as ventilation greater than 48 hours). The area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow goodness-of-fit statistic were calculated to assess the performance and calibration of the model, respectively. Patients were split into low-, medium-, and high-risk groups based on their predicted probability of prolonged ventilation. RESULTS: Three hundred thirty-three patients had prolonged ventilation (5.5%). Independent variables, identified with prolonged ventilation, are shown with relevant coefficient values and p values as follows: (1) age 65 to 75 years, 0.7831, p < 0.001; (2) age 75 to 80 years, 1.5605, p < 0.001; (3) age greater than 80 years, 1.7115, p < 0.001; (4) forced expiratory volume less than 70% predicted, 0.3707, p = 0.013; (5) current smoker, 0.5315, p = 0.001; (6) serum creatinine 125 to 175 micromol/L, 0.6371, p < 0.001; (7) serum creatinine greater than 175 micromol/L, 1.3817, p < 0.001; (8) peripheral vascular disease, 0.6212, p < 0.001; (9) ejection fraction less than 0.30, 0.7839, p < 0.001; (10) myocardial infraction less than 90 days, 0.7415, p < 0.001; (11) preoperative ventilation, 1.3540, p = 0.004; (12) prior cardiac surgery, 0.8946, p < 0.001; (13) urgent surgery, 0.4414, p = 0.004; (14) emergency surgery, 0.7421, p = 0.005; (15) mitral valve surgery, 0.7715, p < 0.001; (16) aortic surgery, 1.7043, p < 0.001; and (17) use of cardiopulmonary bypass, 0.4052, p = 0.025; intercept, -4.7666. The ROC curve for the predicted probability of prolonged ventilation was 0.79, indicating a good discrimination power. The prediction equation was well-calibrated, predicting well at all levels of risk. A simplified additive scoring system was also developed. In the validation dataset, 5.1% of patients had prolonged ventilation compared with 5.4% expected. The ROC curve for the validation dataset was 0.75. CONCLUSIONS: We developed a contemporaneous multivariate prediction model for prolonged ventilation after cardiac surgery. This tool can be used in day-to-day practice to calculate patient-specific risk by the logistic equation or a simple scoring system with an equivalent predicted risk.

Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting.

OBJECTIVE: Patients who have prolonged stay in intensive care unit (ICU) are associated with adverse outcomes. Such patients have cost implications and can lead to shortage of ICU beds. We aimed to develop a preoperative risk prediction tool for prolonged ICU stay following coronary artery surgery (CABG). METHODS: 5,186 patients who underwent CABG between 1st April 1997 and 31st March 2002 were analysed in a development dataset. Logistic regression was used with forward stepwise technique to identify preoperative risk factors for prolonged ICU stay; defined as patients staying longer than 3 days on ICU. Variables examined included presentation history, co-morbidities, catheter and demographic details. The use of cardiopulmonary bypass (CPB) was also recorded. The prediction tool was tested on validation dataset (1197 CABG patients between 1st April 2003 and 31st March 2004). The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of the prediction tool. RESULTS: 475 (9.2%) patients had a prolonged ICU stay in the development dataset. Variables identified as risk factors for a prolonged ICU stay included renal dysfunction, unstable angina, poor ejection fraction, peripheral vascular disease, obesity, increasing age, smoking, diabetes, priority, hypercholesterolaemia, hypertension, and use of CPB. In the validation dataset, 8.1% patients had a prolonged ICU stay compared to 8.7% expected. The ROC curve for the development and validation datasets was 0.72 and 0.74 respectively. CONCLUSION: A prediction tool has been developed which is reliable and valid. The tool is being piloted at our institution to aid resource management.

On-pump versus off-pump surgical revascularization for left main stem stenosis: risk adjusted outcomes.

BACKGROUND: Recent publications have shown coronary surgery is safe and effective in patients with critical left main stem stenosis when using off-pump coronary surgery techniques. However, these studies were small and did not adjust for differences in case mix. METHODS: Between April 1997 and March 2003, 1,197 consecutive patients with critical left main stem stenosis (> 50%) underwent coronary surgery. Two hundred and fifty-nine (21.6%) of these patients had off-pump coronary surgery, while 938 (78.4%) received on-pump coronary surgery. Multivariate logistic regression and Cox proportional hazards analysis were used to assess the effect of off-pump coronary surgery on outcomes, while adjusting for patient characteristics (treatment selection bias). Treatment selection bias was controlled by constructing a propensity score from core patient characteristics. The propensity score was the probability of receiving off-pump coronary surgery and was included along with the comparison variable in the multivariable analyses of outcome. RESULTS: After adjusting for the propensity score, the requirement for inotropic support (22.4% versus 35.3%; p < 0.001) or a prolonged length of stay (5.3% versus 9.3%; p = 0.034) were significantly reduced after receiving off-pump coronary surgery. There was a trend to suggest that off-pump patients had a lower incidence of stroke and chest infection. The adjusted freedom from death in off-pump patients at 2 years was 94.6% compared with 93.6% for on-pump patients (p = 0.54). CONCLUSIONS: After risk adjustment, patients with critical left main stem stenosis can undergo off-pump coronary surgery safely, with results comparable with on-pump coronary surgery.

Does off-pump total arterial revascularization without aortic manipulation influence neurological outcome? A study of 226 consecutive, unselected cases.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) is increasingly reported to have better post-operative outcomes than on-pump coronary artery bypass (ONCAB). Most series report OPCAB in selected cases and therefore the results of such studies are affected by selection bias. We report our series of consecutive, unselected OPCAB cases representing an entire coronary revascularization practice and its effect on neurological outcome. METHODS: Between January and December 2000, 226 consecutive OPCAB cases were performed. These were compared with 258 consecutive ONCAB cases performed by same surgeons historically. There were no significant differences in major demographic characteristics between the two groups. Postoperative outcomes including operation time, ventilation time, inotrope requirement, focal strokes, peak CKMB, length of hospital stay and mortality formed the basis of this study. All OPCAB patients had a median sternotomy approach. Left and right internal mammary arteries and radial arteries were used in varying combinations using composite and sequential grafting techniques to achieve revascularization and completely avoid aortic manipulation. ONCAB cases were performed employing conventional cardiopulmonary bypass techniques and using the left internal mammary artery and saphenous vein grafts as appropriate. RESULTS: OPCAB cases had significantly lower peak CKMB levels, operative time, length of hospital stay and number of grafts. There was a significantly lower incidence of permanent focal neurological events in OPCAB patients (0.4%, n = 1) compared to the ONCAB group (3.9%, n = 10, p = 0.012). CONCLUSION: This study documents the safety of off pump total arterial revascularization without aortic manipulation as the routine technique for coronary bypass surgery. It also demonstrates a significant reduction in the incidence of focal strokes. We conclude that avoidance of both cardiopulmonary bypass and aortic manipulation are important factors in reducing the occurrence of neurological deficits.

Reexploration for bleeding after coronary artery bypass surgery: risk factors, outcomes, and the effect of time delay.

BACKGROUND: We aimed to identify risk factors for reexploration for bleeding after surgical revascularization in our practice. We also looked at the impact of resternotomy and the effect of time delay on mortality and other in-hospital outcomes. METHODS: In all, 2,898 consecutive patients undergoing coronary artery bypass grafting between April 1999 and March 2002 were retrospectively analyzed from our cardiac surgery registry. Multivariate logistic regression analysis was used to identify risk factors for reexploration for bleeding. To assess the effect of preoperative aspirin and heparin, reexploration patients were propensity matched with unique patients not requiring reexploration. We carried out a casenote review to ascertain the timing and causes for bleeding in patients undergoing resternotomy. RESULTS: Eighty-nine patients (3.1%) underwent reexploration for bleeding. Multivariate analysis revealed smaller body mass index (p = 0.003), nonelective surgery (p = 0.022), 5 or more distal anastomoses (p = 0.035), and increased age (p = 0.041) to have increased risks. Propensity-matched analysis showed that preoperative use of aspirin (p = 0.004) and heparin (p = 0.001) were associated with increased risk in the on-pump coronary surgery group only. Patients requiring resternotomy had a significantly greater need for inotropic agents (p < 0.001), and longer intensive care unit stay (p < 0.001) and postoperative stay (p < 0.001) than their propensity-matched controls. However, there was no significant difference in the mortality rate. Adverse outcomes were significantly higher when patients waited more than 12 hours after return to the intensive care unit for resternotomy. CONCLUSIONS: Risk factors for reexploration for bleeding after coronary artery bypass grafting include older age, smaller body mass index, nonelective cases, and 5 or more distal anastomoses. Preoperative aspirin and heparin were risk factors for the on-pump coronary artery surgery group. Patients needing reexploration are at higher risk of complications if the time to reexploration is prolonged. Policies that promote early return to the operating theater for reexploration should be encouraged.