RESUMO
Prospective data of 3,120 consecutive patients who had elective coronary artery bypass were analyzed to identify patient profile, cost, outcome and predictors of those readmitted to the intensive care unit. Group A (n=3,002) had a single intensive care unit admission and group B (n=118) were readmitted within 30 days after surgery. Parsonnet score, EuroSCORE, age, body mass index, chronic obstructive airway disease, peripheral vascular disease, renal dysfunction, unstable angina, congestive cardiac failure, and poor left ventricular function were higher in group B. Bypass and crossclamp times were longer, and the prevalence of inotropic and balloon pump support, arrhythmias, myocardial infarction, re-exploration, blood loss and transfusion, cerebrovascular accident, wound infection, sternal dehiscence, and multisystem failure were higher in group B. Despite a 4-fold increase in cost of care, the mortality rate (32.4%) of patients readmitted to intensive care was 23-times higher than routine patients (1.4%). Crossclamp time>80 min, Parsonnet score>10, EuroSCORE>9, sternal dehiscence, ventricular arrhythmias, and renal failure predicted readmission.
Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Procedimentos Cirúrgicos Eletivos , Unidades de Terapia Intensiva , Readmissão do Paciente , Complicações Pós-Operatórias/etiologia , Idoso , Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
OBJECTIVE: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.
Assuntos
Ponte de Artéria Coronária/enfermagem , Revascularização Miocárdica , Consultores , Inglaterra , Feminino , Humanos , Masculino , Auditoria Médica , Corpo Clínico Hospitalar , Pessoa de Meia-Idade , Recursos Humanos de Enfermagem Hospitalar , Complicações Pós-Operatórias/etiologia , Estudos ProspectivosRESUMO
Congestive heart failure complicating aortic valve disease has been reported to increase the operative mortality associated with aortic valve replacement. To determine whether this adverse effect remains late after aortic valve replacement, we analyzed prospectively collected and survival data of 849 patients who underwent aortic valve replacement between 1999 and 2008. There were 243 (29%) cases of heart failure preoperatively (138 current and 105 prior). Both operative and late mortality rates (up to 10 years) were significantly higher in heart failure patients. Current congestive heart failure caused a 3-fold increase in operative mortality and an 86% increase in late mortality, whereas previous history of heart failure caused a doubling of late mortality. Preoperative heart failure still compromises early and late survival after aortic valve replacement. Surgery should be considered early in patients with aortic valve disease and deferred, when possible, in those with frank heart failure.
Assuntos
Insuficiência da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/cirurgia , Insuficiência Cardíaca/complicações , Implante de Prótese de Valva Cardíaca , Idoso , Idoso de 80 Anos ou mais , Insuficiência da Valva Aórtica/complicações , Insuficiência da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/mortalidade , Distribuição de Qui-Quadrado , Inglaterra , Feminino , Insuficiência Cardíaca/mortalidade , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Small coronary size and extensive atherosclerosis pose operative challenges during coronary artery bypass grafting. We investigated the influence of coronary characteristics on early operative outcome. METHODS: Prospectively collected data for 5171 patients undergoing first-time coronary artery bypass grafting from April 1, 1999, to December 31, 2007, were analyzed. Coronary diameter estimated or probe-gauged intraoperatively was regarded as small if 1.25 mm or less. Coronary atherosclerosis was graded as none/mild or moderate/severe. Their influence on postoperative major adverse cardiac events, myocardial infarction or reintervention for graft failure, post-cardiotomy shock, and operative mortality, was investigated. RESULTS: Of 14,019 coronary anastomoses, 4417 coronaries (31.5%) were small and 5895 coronaries (43.4%) had moderate/severe atherosclerosis. All grafted coronaries were small in 1091 patients (21.1%). Left anterior descending, circumflex, and right coronary arteries received grafts in 94.8% of patients (n = 4903), 74.3% of patients (n = 3842), and 72.5% of patients (n = 3751), with corresponding rates of 31.7%, 31.7%, and 32.6% for small-caliber arteries, 44.4%, 33.3%, and 47.2% for moderate/severe atherosclerosis, and 0.6%, 0.5%, and 3.4% for endarterectomy. Postoperative major adverse cardiac events occurred in 236 patients (4.6%). There was no clear evidence that small caliber of half or more distal anastomoses in a patient (odds ratio, 1.36; 95% confidence interval, 0.97-1.94; P = .07) increased the risk of a major adverse cardiac event, but incomplete revascularization (odds ratio, 1.87; 95% confidence interval, 1.03-3.39; P = .04) and moderate/severe atherosclerosis of the left anterior descending artery (odds ratio 1.37; 95% confidence interval, 1.01-1.87; P = .04) did increase the risk. CONCLUSION: Grafting small coronaries did not significantly increase the risk of an early postoperative major adverse cardiac event, but incomplete revascularization did increase the risk. Our findings support grafting small coronaries when technically feasible to prevent incomplete revascularization.
Assuntos
Doenças Cardiovasculares/etiologia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Vasos Coronários/cirurgia , Idoso , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/terapia , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/patologia , Vasos Coronários/patologia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Razão de Chances , Seleção de Pacientes , Reoperação , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Choque Cardiogênico/etiologia , Fatores de Tempo , Resultado do TratamentoRESUMO
OBJECTIVE: Studies of postoperative morbidity in diabetics have focussed on infection; however, autonomic and cardiovascular complications of diabetes potentially increase the risk for non-infective morbidity. We sought to investigate major non-infective early postoperative complications in diabetic patients. METHODS: We identified diabetics who underwent CABG and/or valve operation from 1998 through 2007, and compared their clinical characteristics and outcome with a contemporaneous cohort of non-diabetic patients. RESULTS: The demographic characteristics of 1145 diabetics were similar to 5534 non-diabetic patients (mean age 66+/-9 years vs 66+/-10 years, p=0.45, female 27.5% vs 26.7%, p=0.59, respectively). Class III/IV angina symptoms (43.9% vs 34.9%, p<0.0001), intravenous nitrates therapy (10.4% vs 6.6%, p<0.0001), heart failure (24.8% vs 20.4%, p=0.001), prior myocardial infarction (37% vs 31%, p<0.0001), ejection fraction =0.50 (34.5% vs 23.0%, p<0.0001), triple vessel disease (66.3% vs 54.8%, p<0.0001), renal insufficiency (3.6% vs 1.5%, p<0.0001) and peripheral vascular disease (16.1% vs 8.7%) were prevalent amongst diabetics. The predominant operation was CABG (diabetic 84.8% vs non-diabetic 73.9%). Low cardiac output (28.3% vs 24.0%, p=0.002), renal dialysis (2.0% vs 0.8%, p<0.0001) and cerebrovascular events (5.1% vs 3.8%, p=0.04) more often complicated recovery of diabetic patients, but operative mortality was similar for both groups. However, postoperative myocardial infarction was less common in diabetics (0.5% vs 1.4%, p=0.02). Diabetes was not a risk factor for the composite endpoint of major non-infective morbidity and operative mortality (OR 1.15, 95% CI 0.97-1.37, p=0.10). Diabetic patients were prone to longer postoperative hospitalisation (9.7+/-10.5 days vs 8.4+/-6.7 days, p<0.0001) and discharge to a convalescence facilities (9.8% vs 6.9%, p<0.0001). CONCLUSIONS: Diabetic patients present for surgery with higher prevalence of cardiovascular risk factors and are more likely to develop major non-infective complications, including cardiac, renal and neurological dysfunction, even though diabetes does not directly influence non-infective postoperative morbidity following CABG and/or valve operations.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Complicações do Diabetes/complicações , Valvas Cardíacas/cirurgia , Idoso , Angiopatias Diabéticas/complicações , Nefropatias Diabéticas/complicações , Métodos Epidemiológicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Insuficiência Renal/complicações , Resultado do TratamentoRESUMO
BACKGROUND: Aggressive nonsurgical revascularization results in high-risk patients presenting for operation at a later stage of coronary artery disease (CAD). This study investigated the effect of temporal changes in operative characteristics on outcomes of surgical revascularization. METHODS: We compared preoperative, intraoperative, and postoperative variables of 5633 patients who underwent surgical revascularization for CAD between April 1998 and January 2007, divided into early (1998 to 2002, n = 2746) and late (2004 to 2007, n = 2887) eras. End points were major adverse outcomes (postoperative myocardial infarction, stroke, new dialysis) and operative mortality. RESULTS: Median age (66 vs 68 years, p < 0.0001), prevalence of left ventricular systolic dysfunction, left main stem disease, prior angioplasty, diabetes mellitus, concomitant valve operation, and aprotinin use increased steadily over time. Severe symptoms, nonelective operations, mean number of grafts, postoperative bleeding, reopening for bleeding, and blood transfusion declined. Major complications were evenly distributed between the eras. Operative mortality for isolated coronary artery bypass grafting did not change (2.0% vs 1.8% p = 0.62) despite increasing operative risk (p < 0.0001); there was a 100% reduction in the absolute risk (110% to 210%) over time. The markers for operative difficulties, such as longer bypass times, were determinants of operative mortality and, in addition to other predictors like age and left ventricular systolic dysfunction, were more prevalent in the late era. CONCLUSIONS: Coronary operations are increasingly performed in higher-risk patients; however, surgical revascularization is nearly twice as safe in current practice compared with a decade ago.
Assuntos
Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Doença das Coronárias/mortalidade , Doença das Coronárias/cirurgia , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Assistência Perioperatória , Resultado do TratamentoRESUMO
BACKGROUND: To evaluate the efficacy of ventral cardiac denervation as a prophylaxis against post-coronary artery bypass grafting (CABG) atrial fibrillation (AF). METHODS: Seventy consecutive patients who underwent CABG (group A) were compared to 70 consecutive subsequent patients who underwent CABG + ventral cardiac denervation (group B). Both groups were well-matched for age, gender, disease severity, LV function, Euro scores, Parsonnet scores, preoperative beta-blockers, Ca-channel blockers, digoxin, and angiotensin converting enzyme inhibitors. The same cardioplegia, bypass, and operation techniques were used in all cases. Denervation before initiating bypass increased operation time by approximately 5 minutes. Heart rate and rhythm were monitored by continuous telemetry until postoperative day 5 and then 4- hourly until discharge. RESULTS: The cross-clamp time (p = 0.6), bypass time (p = 0.1), number of grafts (p = 0.9), inotrope usage (p = 0.4), reexploration rate (p = 1), postoperative myocardial infarction (none in either group), blood loss (p = 0.7), and length of stay (p = 0.8) were comparable in both groups. There was no significant difference in the incidence of AF; 34% in group A versus 29% in group B (p = 0.3). CONCLUSIONS: Ventral cardiac denervation failed to significantly reduce the incidence of AF following coronary revascularization in our study.
Assuntos
Fibrilação Atrial/prevenção & controle , Ponte de Artéria Coronária/efeitos adversos , Coração/inervação , Denervação Muscular/métodos , Idoso , Fibrilação Atrial/etiologia , Feminino , Humanos , Masculino , Estudos ProspectivosRESUMO
The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.