Gender is Independently Associated With Red Blood Cell and Platelet Transfusion in Patients Undergoing Coronary Artery Bypass Grafting: Data From the Netherlands Heart Registration.

OBJECTIVES: The aim of this study was to evaluate the incidence of transfusions, including red blood cells (RBC), platelets, and fresh frozen plasma (FFP) during and after coronary artery bypass grafting (CABG) in the Netherlands. Furthermore, the authors aimed to identify the impact of sex on blood product transfusion. DESIGN: A retrospective multicenter cohort study. Data were collected from January 2013 to December 2021 from the Netherlands Heart Registration (NHR) database. SETTING: The NHR receives its data from 16 heart centers in the Netherlands. PARTICIPANTS: Patients older than 18 years who underwent CABG in the Netherlands. INTERVENTIONS: Coronary artery bypass grafting with extracorporeal circulation or off-pump coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: The incidence of blood transfusion, defined as transfusions intraoperatively and during the length of the hospital admission after CABG. In addition, a differentiation was made according to the type of transfusion (packed RBC, platelets, and FFP). In the overall cohort (N = 42,388), the number of patients who received a transfusion of any type was 27.0% (n = 11,428). Women received more often RBC transfusions compared with men (45.4% v 15.6%, respectively, p < 0.001). There was a significant difference between the 2 sexes regarding platelet transfusion (women 10.0% v men 11.1%, p = 0.005) but not in FFP transfusion. Female sex was independently associated with RBC transfusion, using the multivariate logistic regression analysis. CONCLUSIONS: The incidence of any blood transfusion was 27.0%, and was higher in women than in men. The female sex was independently associated with receiving RBC during and after CABG.

Long-term Outcome of Reexploration for Bleeding After Coronary Artery Bypass Grafting.

OBJECTIVES: This study aimed to determine the influence of reexploration for bleeding and blood product requirement after coronary artery bypass grafting (CABG) on long-term mortality. DESIGN: A retrospective cohort study. SETTING: A single-center institution. PARTICIPANTS: All patients who underwent CABG between January 1998 and December 2019 were included. INTERVENTIONS: The parameters were analyzed to assess the association between reexploration for bleeding and long-term mortality. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was all-cause mortality up to the end of follow-up (June 1, 2021). The secondary endpoints were 30-day mortality, duration of admission, blood product transfusion, postoperative use of an intra-aortic balloon pump, deep sternal wound infection, myocardial infarction, and neurologic complications. The Cox proportional hazards model was used to assess the association between reexploration and blood product use and all-cause mortality. Median follow-up was 9.7 years (IQR 5.1-14.6). In total, 576 out of 21,346 (2.7%) patients were reexplored for bleeding. Thirty-day mortality was 6.2% v 1.6% for the reexplored versus not reexplored patients. Reexploration for bleeding was not significantly correlated with long-term mortality (hazard ratio [HR] 1.029; p = 0.068). On the other hand, blood product transfusion (HR = 1.135; p < 0.001), and in particular, packed red blood cell (pRBC) transfusion (HR = 1.139; p < 0.001), was significantly associated with higher long-term mortality. After multivariate Cox regression using ≥5 pRBC transfused as a cut-off point, reexploration for bleeding was not significantly associated with long-term mortality (HR 0.982; p = 0.813). Receiving ≥5 pRBCs was significantly associated with higher long-term mortality (HR 1.249; p < 0.001). CONCLUSION: Reexploration for bleeding was significantly associated with higher 30-day mortality but not with long-term mortality. Poorer long-term mortality was attributed to patient characteristics and higher use of postoperative blood products.

Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients.

OBJECTIVE: Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed in the Catharina Hospital (Eindhoven). PARTICIPANTS: All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. INTERVENTIONS: Isolated CABG. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. CONCLUSIONS: Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.

Sex Difference in Long-Term Survival After Coronary Artery Bypass Grafting Is Age-Dependent.

OBJECTIVES: Women undergoing coronary artery bypass grafting (CABG) demonstrate higher rates of postoperative morbidity and mortality than men. The aim of this study was to compare the patient profile and long-term outcomes of men and women undergoing isolated CABG. DESIGN: A retrospective patient record study and propensity score-matched analysis. SETTING: This single-center study was performed at Catharina Hospital in Eindhoven, The Netherlands. PARTICIPANTS: The study comprised 17,483 patients, of whom 13,564 (77.6%) were men and 3,919 (22.4%) were women. INTERVENTIONS: Coronary artery bypass grafting was performed between January 1998 and December 2015. MEASUREMENTS AND MAIN RESULTS: The mean follow-up period was 8.8 ± 5.0 years. Women were older than men (67.7 ± 9.4 years v 63.9 ± 9.6 years, p < 0.001) and had lower preoperative hemoglobin levels. Early mortality (30-day) (2.8% v 1.9%; p < 0.001) and one-year mortality (5.2% v 3.8%; p < 0.001) rates were significantly higher in women than in men. Women demonstrated worse long-term survival than men only in the population younger than 70 years. After propensity score matching, female sex was not identified as an independent risk factor for long-term survival. CONCLUSIONS: In the patient population, propensity score-matched analysis showed that female sex was not an independent risk factor for long-term survival after CABG. Poorer survival in women after CABG only was observed in patients <70 years of age.

Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG): A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial (The Effect of Ticagrelor on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting Surgery) investigated whether ticagrelor added to standard aspirin improves SVG patency at 1 year after CABG. METHODS: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80 mg or 100 mg). The primary outcome was SVG occlusion at 1 year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was 1-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG, or sudden death. RESULTS: Among 499 randomly assigned patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was acute coronary syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), odds ratio, 1.29 [95% CI, 0.73-2.30]; P=0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (odds ratio, 1.22 [95% CI, 0.72-2.05]). CONCLUSIONS: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at 1 year after CABG. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02352402.

Recent trends in aortic valve interventions: Data of the Netherlands heart registration.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve implantation (TAVI) has evolved from bailout for inoperable patients to an alternative to surgical aortic valve replacement (SAVR) in higher-risk groups. The aim of this study is to describe these clinical trends in TAVI and SAVR in patients with aortic valve disease. METHODS: We analyzed data of the Netherlands Heart Registration (NHR) up to 2018 to explore the trends in TAVI and SAVR among 14 cardiac centers in the Netherlands. RESULTS: Between 2013 and 2017, a total of 7432 isolated SAVR and 5929 TAVI procedures have been performed. A 43.9% increase in the total number of procedures was observed, mainly due to the considerable increase in the number of TAVI procedures. In 2017, there was a decrease in the number of SAVR procedures. In the TAVI group, 30- and 120-day mortality decreased significantly from 7.2% and 10.6% in 2013 to 3.4% and 5.7% in 2017, respectively. In the SAVR group, 30- and 120-day mortality decreased from 1.7% and 2.9% in 2013 to 1.2% and 1.7% in 2017, respectively. Outcomes showed a significant decrease in vascular complications after TAVI. The risk profile of TAVI patients has changed over time. CONCLUSIONS: The recent developments in TAVI have contributed to the increasing numbers of aortic valve interventions in the Netherlands. Mortality rates after SAVR and TAVI decreased as did the rate of complications after TAVI. Furthermore, a trend towards decrease of preoperative risk was observed.

Sex Difference in Coronary Artery Bypass Grafting: Preoperative Profile and Early Outcome.

OBJECTIVE: According to the available risk-stratification systems, women have a higher risk of mortality than men after coronary artery bypass grafting (CABG). In this study, the authors investigated the authors' CABG database to trace factors contributing to this difference in outcome between sexes. DESIGN: A retrospective patient record study. SETTING: This single-center study was performed at the Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 17,919 patients, of whom 4,016 (22.4%) were women and 13,903 (77.6%) were men. INTERVENTIONS: Coronary artery bypass grafting was performed between January 1998 and July 2016. MEASUREMENTS AND MAIN RESULTS: Early mortality was significantly higher in women than in men (2.7% v 1.9%; p = 0.001). Regarding the baseline characteristics, women were older and had a lower hemoglobin level and a lower creatinine level than men. Women more often had hypertension, diabetes, underweight (body mass index [BMI] <20 kg/m2), and obesity (BMI >30 kg/m2). The mean number of grafts per patient was less in women than in men (3.2 ± 1.1 v 3.5 ± 1.1; p < 0.001). However, the mean cross-clamp time per graft was longer in female patients than in male patients (11.6 ± 8.7 min. v 11.2 ± 7.0 min.; p = 0.013). Logistic regression analyses showed that chronic obstructive pulmonary disease, peripheral vascular disease, cross-clamp time, and underweight were independent risk factors for early mortality only in men. CONCLUSION: The preoperative patient profile is significantly different between men and women undergoing CABG. The predictive value of well-known risk factors for early mortality is different between the 2 sexes.

Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles.

OBJECTIVE: The aim of this study was to compare the patient profiles and outcomes of men and women undergoing isolated aortic valve replacement. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed at Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 2,362 patients, of whom 1,040 (44%) were women and 1,322 were men (56%). INTERVENTIONS: Isolated aortic valve replacement was performed between January 1998 and December 2016. MEASUREMENTS AND MAIN RESULTS: The mean follow-up was 8.3 ± 5.1 years. Women were relatively older (69.9 years v 64.6 years; p < 0.001); more of them were underweight, obese, and diabetic; and they had lower hemoglobin values and worse renal function than did men. However, fewer women than men experienced chronic obstructive pulmonary disease, aortic regurgitation, left ventricular dysfunction, and endocarditis. Early mortality did not differ significantly between men and women (p = 0.238). Overall survival was worse in women (p < 0.001). After correction for potential risk factors, female sex was not associated with worse survival. During the study period, the mean age of patients undergoing aortic valve replacement increased. In addition, the mean age at the time of death increased, following the trend of national statistics. CONCLUSIONS: Although women undergoing aortic valve replacement have relatively more risk factors than do men, early mortality in women is not significantly higher than in men. Overall survival is worse in women than in men; however, after adjustment for preoperative risk factors, there is no difference in overall survival between women and men.

A case of right ventricular outflow tract obstruction after minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement is commonly used to treat aortic valve disease through smaller incisions and upper hemisternotomy. No major differences in postoperative outcomes have been reported compared with full sternotomy aortic valve replacement. In this case report, we present a rare complication of right ventricular outflow tract obstruction after minimally invasive aortic valve replacement.

Preventing spasm of the radial artery conduit during coronary artery bypass grafting: Nicardipine versus verapamil.

BACKGROUND AND AIM OF THE STUDY: In vitro studies have shown a reduction in radial artery spasm with the use of calcium antagonists. The purpose of this study was to evaluate the efficacy of topical treatment of the radial artery conduit using either verapamil or nicardipine before the anastomoses. METHODS: This prospective randomized study included 131 patients, who underwent coronary artery bypass grafting surgery with the use of the radial artery as a conduit. In 65 patients, the harvested radial artery was topically treated with verapamil and in 66 patients with nicardipine. After harvesting the radial artery, the direct flow through the conduit was measured in vitro before 5-minute incubation in nicardipine or verapamil and measured again after incubation. The flow before and after incubation was compared. Postincubation flow was also compared in the two groups. After performing the anastomosis, the flow through the radial artery was measured in vivo. RESULTS: The mean flow after NaCl incubation was 19.93 ± 12.66 mL/min and after incubation in the Ca+ channel blocker 47.16 ± 14.58 mL/min (P < .001). No significant difference in postincubation free flow was found between verapamil (46.29 ± 15.43 mL/min) and nicardipine (48.01 ± 13.77 mL/min; P = .503). CONCLUSION: Topical treatment with Ca+ channel blockers reduces radial artery spasm and significantly increases the free flow through the radial artery conduit. Nicardipine is a safe and effective alternative of verapamil in preventing spasm of radial artery conduit.

Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery.

OBJECTIVES: In the present study, the authors investigated the predictive value of postoperative peak arterial lactate levels for early and late mortality after cardiac surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Single-center study in an academic hospital. PARTICIPANTS: Adult patients who underwent cardiac surgery between 2004 and 2014 (n = 16,376). INTERVENTIONS: Different cardiac surgical procedures. MEASUREMENTS AND RESULTS: Patients were classified according to the peak arterial lactate level (PALL) within 3 days postoperatively. Logistic regression analysis and Cox regression analysis were performed to identify postoperative peak arterial lactate level as a predictor for early and late mortality respectively. In 8460 patients (51.7%), lactate was not measured postoperatively because these patients were managed according to the fast-track protocol. These patients constituted group 1 in our population but were excluded from the regression analysis. The remaining patients (n = 7,916; 48.3%) were divided according to the postoperative peak arterial lactate level (PALL): PALL<5 mmol/L (group 2), PALL 5 to 10 mmol/L (group 3), and PALL of>10 mmol/L (group 4). Early mortality was 3.7%, 20.4%, and 62.9% in groups 2, 3, and 4 respectively (p<0.0001). This mortality rate was significantly higher than that of group 1 (1.6%); p<0.0001. Multivariate regression analyses revealed postoperative peak arterial lactate as a significant predictor of 30-day mortality (odds ratio = 1.44 [1.39-1.48], p<0.001) as well as for late mortality (hazard ratio = 1.05 [1.01-1.10], p<0.025). CONCLUSIONS: Postoperative peak arterial lactate level in patients undergoing cardiac surgery is an independent predictor for both early and late mortality.

Impaired Left Ventricular Function Does Not Predict Worse Late Outcome after Isolated Mitral Valve Surgery.

BACKGROUND AND AIM OF THE STUDY: The best timing for mitral valve surgery remains controversial. Decreased left ventricular function (LVF) is considered to be a predictor for increased mortality and is therefore an indication for surgery. The study aim was to investigate the independent effect of preoperative LVF on early and late mortality after mitral valve surgery. METHODS: Patients undergoing isolated mitral valve surgery between January 1998 and December 2010 at a single center were included for the analysis. Patients without recorded LVF, with active endocarditis, or patients lost to follow up were excluded. Patients were allocated to three groups based on their left ventricular ejection fraction (LVEF) measured using echocardiography as good (>50%), moderate (35-50%) or poor (<35%). A Cox regression analysis was performed to identify independent risk factors for late survival. RESULTS: A total of 549 patients underwent isolated mitral valve surgery. The 30-day mortality was not statistically different between groups (p = 0.579), and late survival was similar in all groups (log-rank, p = 0.130). A moderate or poor LVF was not identified as a risk factor for late mortality (HR 1.4 [0.9-2.2], p = 0.179; HR 1.8 [0.7-4.4], respectively, p = 0.213). The difference remained insignificant after correction for other risk factors (HR 1.4 [0.8-2.3], p = 0.192; HR 2.4 [0.9-6.7], respectively, p = 0.09). CONCLUSION: A reduced LVF is not an independent risk factor for short- and long-term all-cause mortality in patients undergoing isolated mitral valve surgery for non-ischemic mitral valve disease.

Conventional Aortic Valve Replacement after Displacement of a Percutaneously Implanted Aortic Prosthesis: Case Report.

A case is described of aortic stenosis that was initially treated with transcatheter aortic valve implantation (TAVI) due to a high-risk profile. Following dysfunction of the TAVI prosthesis, conventional aortic valve replacement (AVR) was successfully performed; the subsequent postoperative course was uneventful. In conclusion, the target population for TAVI must be more accurately specified, with further research helping to define whether AVR or TAVI is the best treatment option for 'intermediate-risk' patients.

Impact of postoperative renal replacement therapy on long-term outcome after cardiac surgery increases with age.

BACKGROUND AND AIM OF THE STUDY: In the present study, we investigated the survival of patients who received postoperative renal replacement therapy (RRT) after cardiac surgery. We specifically focused on factors predicting long-term outcome in elderly patients. METHODS: Data of all patients that received unintentional renal replacement therapy following cardiac surgery between 2004 and 2010 were analyzed. Logistic- and Cox regression analyses were performed to detect the predictors of early and late mortality, respectively. RESULTS: During the study period, 11,899 patients underwent cardiac surgery in our center. Post-operative RRT was performed in 138 patients (1.2%). In this group of patients, 30-day mortality included 72 patients (52%) and the total overall mortality included 107 patients (77.5%). Regression analyses revealed that age predicted 30-day mortality (odds ratio = 1.08 [1.03 to 1.12]) as well as late mortality (odds ratio = 1.05 [1.02 to 1.07]. CONCLUSIONS: Patients requiring RRT after cardiac surgery have a poor prognosis with a high mortality. Older age predicted both 30-day and late mortality in these patients.

Preoperative hemoglobin level as a predictor of mortality after aortic valve replacement.

OBJECTIVES: The predictive value of preoperative hemoglobin (HB) level on the outcome of patients undergoing valve surgery is not well established. This study evaluated the predictive value of preoperative HB level on survival after aortic valve replacement (AVR). DESIGN: This was a retrospective analysis of prospectively collected data. SETTING: A single-center study performed in an educational hospital. PARTICIPANTS: All consecutive patients (n = 1,808) who underwent AVR between January 1998 and December 2010. INTERVENTIONS AVR MEASUREMENTS AND MAIN RESULTS: Patients were classified into 4 groups according to the preoperative HB level: very low (HB of <12 g/dL in men and <11 g/dL in women), low (HB of 12-13 g/dL in men and 11-12 g/dL in women), normal (HB of 13-14.5 g/dL in men and 12-13.5 g/dL in women), and high normal (HB of ≥14.5 g/dL in men and ≥13.5 g/dL in women). The mean follow-up duration was 5.58±3.5 years, and the median follow-up duration was 5.38 years. The mean preoperative HB was 14±1.6 g/dL for men and 13.0±2.1 g/dL for women. Early mortality (≤30 days) was 6.1% in the very-low-HB group, 5.4% in the low-HB group, 3.2% in the normal HB group, and 2.3% in the high-normal-HB group (p = 0.37). Late mortality (>30 days) was 26.1% in the very-low-HB group, 23.7% in the low-HB group, 17.1% in the normal-HB group, and 12.6% in the high-normal-HB group (p<0.0001). The multivariate logistic regression model did not identify low HB as an independent predictor for early mortality. Cox regression multivariate analysis revealed both HB level, as a continuous variable, (p = 0.006), and very-low-HB level (p<0.0001), as independent predictors of late mortality. Cox regression analyses, corrected for confounders, demonstrated that low-HB level is an independent predictor for higher overall mortality (hazard ratio = 2.00, CI 1.41-2.85, p≤0.0001). CONCLUSIONS: In patients undergoing AVR, preoperative low-HB level is an independent risk factor for late mortality, but not for early mortality.

Introduction of a New Method to Monitor Patient-Relevant Outcomes and Costs: Using a Quality Improvement Project in Transcatheter Aortic Valve Implantation Care as an Example.

BACKGROUND AND OBJECTIVE: Routine outcome monitoring is becoming standard in care evaluations, but costs are still underrepresented in these efforts. The primary aim of this study was therefore to assess if patient-relevant cost drivers can be used alongside clinical outcomes to evaluate an improvement project and to provide insight into (remaining) areas for improvement. METHODS: Data from patients who underwent transcatheter aortic valve implantation (TAVI) between 2013 and 2018 at a single center in the Netherlands were used. A quality improvement strategy was implemented in October 2015, and pre- (A) and post-quality improvement cohorts (B) were distinguished. For each cohort, clinical outcomes, quality of life (QoL), and cost drivers were collected from the national cardiac registry and hospital registration data. The most appropriate cost drivers in TAVI care were selected from hospital registration data using a novel stepwise approach with an expert panel of physicians, managers, and patient representatives. A radar chart was used to visualize the clinical outcomes, QoL and the selected costs drivers. RESULTS: We included 81 patients in cohort A and 136 patients in cohort B. All-cause mortality at 30 days was borderline significantly lower in cohort B than in cohort A (1.5% vs 7.4%, P = .055). QoL improved after TAVI for both cohorts. The stepwise approach resulted in 21 patient-relevant cost drivers. Costs for pre-procedural outpatient clinic visits (€535, interquartile range [IQR] = 321-675, vs €650, IQR = 512-890, P < .001), costs for the procedure (€1354, IQR = 1236-1686, vs €1474, IQR = 1372-1620, P < .001), and imaging during admission (€318, IQR = 174-441, vs €329, IQR = 267-682, P = .002) were significantly lower in cohort B than in cohort A. Possible improvement potential was seen in 30-day pacemaker implantation and 120-day readmission. CONCLUSION: A selection of patient-relevant cost drivers is a valuable addition to clinical outcomes for use in evaluation of improvement projects and identification of room for further improvement.

Can the EuroSCORE predict midterm survival after aortic valve replacement?

OBJECTIVES: The EuroSCORE as a predictor for midterm survival after isolated aortic valve replacement (AVR) and combined AVR with coronary artery bypass graft (CABG) surgery was tested. Survival in different risk-stratification groups also was compared to the survival of the general Dutch population. DESIGN: A retrospective analysis of prospectively collected data. SETTING: A single-center study performed in an educational hospital. PARTICIPANTS: All patients (N = 1,652) who underwent AVR with (n = 711) or without (n = 941) CABG surgery from January 2004 through December 2009. INTERVENTIONS: AVR with or without CABG surgery. MEASUREMENTS AND MAIN RESULTS: Univariate Cox regression analyses were used to identify the additive and the logistic EuroSCOREs as independent predictors of midterm mortality. Kaplan-Meier survival curves were used to compare the survival of different patients' risk subgroups, based on both the additive and the logistic EuroSCOREs, with the normal Dutch population matched for age and sex. Both additive and logistic EuroSCOREs were significant predictors of midterm mortality after isolated AVR and AVR with CABG surgery. This was also true for the different risk-stratification groups. Except for survival after AVR with CABG surgery in the high-risk group based on the additive EuroSCORE, no difference was found between survival after surgery and survival of the age- and sex-matched normal population. CONCLUSIONS: Both EuroSCORE models can predict midterm survival after isolated AVR and combined AVR with CABG surgery. However, the EuroSCORE is not a predictor for midterm survival when comparing the patient groups with the general Dutch population matched for age and sex. Except for high-risk patients undergoing AVR with CABG surgery, other risk subgroups have similar midterm survival to that of their age- and sex-matched cohorts of the Dutch population.

Predictive value of the additive and logistic EuroSCOREs in patients undergoing aortic valve replacement.

OBJECTIVES: The purpose of this study was to evaluate the accuracy of the additive and logistic EuroSCOREs in predicting the operative mortality in patients undergoing aortic valve replacement (AVR) with or without coronary artery bypass graft (CABG) surgery. DESIGN: This was a retrospective analysis of prospectively collected data. SETTING: This was a single-center study performed in an educational hospital. PARTICIPANTS: All patients (n = 1,885) who underwent AVR with (n = 813) or without (n = 1,072) CABG surgery between 1998 and 2007. INTERVENTIONS: AVR with or without CABG surgery. MEASUREMENTS AND MAIN RESULTS: Variable life-adjusted display curves were constructed to compare the observed operative mortality with the additive and logistic EuroSCOREs. The receiver operating characteristics (ROC) curve was used to determine the discriminatory power of the additive and logistic EuroSCOREs. Calibration between the predicted and the observed operative mortality was checked by comparing the predicted probability of the mortality with the additive and logistic EuroSCORE. In the isolated AVR group, the additive EuroSCORE was 5.8% predicted mortality and the logistic EuroSCORE was 7.2%, whereas the observed operative mortality was 3.2%. In the AVR with CABG surgery group, the additive EuroSCORE was 7.2% and the logistic EuroSCORE was 8.8%, whereas the observed operative mortality was 5.3%. ROC curve analyses showed a high discriminatory power for both EuroSCOREs in both patient groups. CONCLUSIONS: Although the additive and the logistic EuroSCOREs had good discriminatory power, they were not able to predict the actual operative mortality accurately. Both EuroSCOREs overestimated the operative mortality, especially in low-risk patients.

Preoperative prediction of early mortality in patients with low ejection fraction undergoing coronary artery bypass grafting.

BACKGROUND AND AIM OF THE STUDY: Patients with low ejection fraction (EF) undergoing coronary artery bypass grafting (CABG) usually have a higher incidence of mortality and morbidity. In this retrospective study, we sought to detect significant preoperative predictors of early mortality in these patients. METHODS: Patients with an EF of ≤ 30% who underwent isolated CABG in Catharina Hospital, Eindhoven, the Netherlands, between January 1998 and December 2008 (n = 413) were included in this study. All the preoperative patient-related risk factors were entered into a logistic regression analysis model to detect the significant predictors of early mortality. RESULTS: Patients with an EF of ≤ 30% represent 4.1% of the whole CABG population. The overall early mortality in this patient group was 9.1%. Risk factors for early mortality as identified by the univariate analysis were age, chronic obstructive pulmonary disease (COPD), prior CABG, New York Heart association (NYHA) class, emergency operation, preoperative serum creatinine (SeCr), and preoperative hemoglobin (Hb) level. These factors were entered into the multivariate analysis and were all identified as independent risk factors for early mortality. CONCLUSIONS: This study confirmed the impact of some well-known preoperative risk factors on early outcome in patients with low EF undergoing CABG. In addition, we have shown the predictive value of preoperative SeCr and hemoglobin level that have not yet been described.

Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting.

OBJECTIVES: The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). METHODS: Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). RESULTS: A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29-9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58-3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11-11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83-5.38)]. Secondary end points were not significantly different among the main study groups and subgroups. CONCLUSIONS: Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.