Mortality and morbidity of patients on the waiting list for coronary artery bypass graft surgery.

OBJECTIVES: The public health care system in Brazil has extensive waiting lists of patients requiring complex operations such as coronary artery bypass grafting (CABG). The purpose of this study was to identify the mortality and morbidity rates of the patients awaiting CABG and identify predictors of adverse events and their association with perioperative outcomes. METHODS: We conducted a retrospective analysis of outpatient medical records of patients referred for this elective procedure in Rio de Janeiro, Brazil. Excluded from the study were records of patients with any of the following: an indication for urgent surgery, unstable angina or concomitant surgical valvular disease or subsequent transfer to clinical or percutaneous therapy. RESULTS: A total of 274 patients were identified and met the inclusion criteria, with a median waiting time for an operation of 142.7 days. While waiting for CABG surgery, 31 (11.3%) patients died of any cause and 42 (15.3%) patients had a serious cardiac event (death, myocardial infarction or unstable angina). Of the 22 (8%) incidents of acute myocardial infarction, 8 (2.9%) were non-fatal and 14 (5.1%) were fatal. There was a greater risk of death awaiting CABG surgery in patients with a left ventricular ejection fraction below 45% (hazard ratio = 2.33, 95% confidence interval 1.02-5.32; P = 0.039). The operative mortality rate was 5.8%. Although there was no evidence of worse perioperative outcomes in patients with prolonged waiting times for an operation, there was an association between waiting more than 16 weeks for an operation and death while on the list. CONCLUSIONS: Extensive waiting periods for CABG contribute to higher mortality and morbidity rates, especially in patients with left ventricular dysfunction.

Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

A idade influencia os desfechos em pacientes com idade igual ou superior a 70 anos submetidos à cirurgia de revascularização miocárdica isolada / Age influences outcomes in 70-year or older patients undergoing isolated coronary artery bypass graft surgery

OBJETIVO: Analisar os resultados da cirurgia de revascularização miocárdica (CRVM) isolada com circulação extracorpórea em pacientes com idade > 70 anos em comparação àqueles com < 70 anos. MÉTODOS: Pacientes submetidos consecutivamente à CRVM isolada. Os pacientes foram agrupados em G1 (idade e" 70 anos) e G2 (idade < 70 anos). Os desfechos analisados foram letalidade hospitalar, infarto agudo miocárdio (IAM), acidente vascular encefálico (AVE), reoperação para revisão de hemostasia (RRH), necessidade de balão intra-aórtico (BIA), complicações respiratórias, insuficiência renal aguda (IRA), mediastinite, sepse, fibrilação atrial (FA) e bloqueio atrioventricular total (BAVT). RESULTADOS: Foram estudados 1033 pacientes, 257 (24,8%) do G1 e 776 (75,2%) do G2. A letalidade hospitalar foi significantemente maior no G1 quando comparado ao G2 (8,9% vs. 3,6%, P=0,001), enquanto a incidência de IAM foi semelhante (5,8% vs. 5,5%; P=0,87). Maior número de pacientes do G1 necessitou de RRH (12,1% vs. 6,1%; P=0,003). Da mesma forma, no G1 houve maior incidência de complicações respiratórias (21,4% vs. 9,1%; P<0,001), mediastinite (5,1% vs. 1,9%; P=0,013), AVE (3,9% vs. 1,3%; P=0,016), IRA (7,8% vs. 1,3%, P<0,001), sepse (3,9% vs. 1,9%; P=0,003), fibrilação atrial (15,6% vs. 9,8%; P=0,016) e BAVT (3,5% vs. 1,2%; P=0,023) do que o G2. Não houve diferença significante na necessidade de BIA. Na análise regressão logística multivariada "forward stepwise", a idade >70 anos foi fator preditivo independente para maior letalidade operatória (P=0,004) e para RRH (P=0,002), sepse (P=0,002), complicações respiratórias (P<0,001), mediastinite (P=0,016), AVE (P=0,029), IRA (P<0,001), FA (P=0,021) e BAVT (P=0,031) no pós-operatório. CONCLUSÃO: Este estudo sugere que pacientes com idade > 70 anos estão sob maior risco de morte e outras complicações no pós-operatório de CRVM em comparação aos pacientes mais jovens.

OBJECTIVE: To analyze the results of isolated on-pump coronary artery bypass graft surgery (CABG) in patients >70 years-old in comparison to patients <70 years-old. METHODS: Patients undergoing isolated CABG were selected for the study. The patients were grouped in G1 (age > 70 years-old) and G2 (age <70 years-old). The endpoints were in-hospital mortality, acute myocardial infarction (AMI), stroke, reexploration for bleeding, intra-aortic balloon for circulatory shock, respiratory complications, acute renal failure, mediastinitis, sepsis, atrial fibrillation, and complete atrioventricular block (CAVB). RESULTS: 1,033 patients were included, 257 (24.8%) in G1 and 776 (75.2%) in G2. Patients in G1 were more likely to have in-hospital mortality than G2 (8.9% vs. 3.6%, respectively; P=0.001), while the incidence of AMI was similar (5.8% vs. 5.5%; P=0.87) than G2. More patients in G1 had re-exploration for bleeding (12.1% vs. 6.1%; P=0.003). G1 had more incidence of respiratory complications (21.4% vs. 9.1%; P<0.001), mediastinitis (5.1% vs. 1.9%; P=0.013), stroke (3.9% vs. 1.3%; P=0.016), acute renal failure (7.8% vs. 1.3%; P<0.001), sepsis (3.9% vs. 1.9%;P=0.003), atrial fibrillation (15.6% vs. 9.8%; P=0.016), and CAVB (3.5% vs. 1.2%; P=0.023) than G2. There was no significant difference in the use of intra-aortic balloon. In the forward stepwise multivariate logistic regression analysis age > 70-year-old was an independent predictive factor for higher in-hospital mortality (P=0.004), reexploration for bleeding (P=0.002), sepsis (P=0.002), respiratory complications (P<0.001), mediastinitis (P=0.016), stroke (P=0.029), acute renal failure (P<0.001), atrial fibrillation (P=0.021) and CAVB (P=0.031). CONCLUSION: This study suggests that patients > 70 years-old were at increased risk of death and other complications in the CABG's postoperative period in comparison to younger patients.

Quem vê coronária não vê coração / Coronary artery no mirror for the heart

Oclusão de uma ou mais artérias coronárias se associa, em geral, a importante comprometimento da função ventricular. Relata-se o caso de um paciente de 64 anos sem história ou eletrocardiograma de infarto agudo do miocárdio prévio, com oclusão proximal de duas importantes artérias coronárias e função ventricular preservada.

In general, occlusion of one or more coronary arteries is associated with significant weakening of the leftventricular function. This case study describes a 64-year old man with no history or electrocardiographic signs ofprior acute myocardial infarction, with proximal occlusion of two main coronary arteries and preserved left ventricular function.

Disfunção sistólica do ventrículo esquerdo e prognóstico após cirurgia de revascularização do miocárdio / Left ventricular systolic dysfunction and prognosis after coronary artery bypass graft surgery

Fundamentos: A cirurgia de revascularização miocárdica (CRVM) promove uma melhora da sobrevivência de pacientes com doença arterial coronariana (DAC) e disfunção ventricular esquerda (DFVE).Objetivo: Analisar se a CRVM é capaz de igualar a sobrevivência de pacientes portadores de doença arterialcoronariana com DFVE e sem DFVE. Métodos: Pacientes (n=259) que sobreviveram à CRVM realizada entre 1/10/2001 e 31/1/2004 foramacompanhados por três anos após a cirurgia. A DFVE foi caracterizada por uma fração de ejeção do ventrículoesquerdo (FE) ≤40%. Foram formados dois grupos de acordo com a presença (G1; n=45) ou não (G2; n=214) deDFVE. Resultados: O G1 apresentava mais síndromes coronarianas agudas antes da CRVM (64,4% vs 40,2%;p=0,005); insuficiência cardíaca congestiva (17,8% vs 1,9%; p<0,0001); história prévia de infarto agudo do miocárdio (80% vs 60,3%; p=0,016) e doença pulmonarobstrutiva crônica (11,1% vs 2,3%; p=0,016) do que o G2. A sobrevivência cumulativa em três anos de seguimentofoi significantemente menor no G1 do que no G2 (88,8±4,7% vs 95,7±1,3%, respectivamente; p=0,05). ADFVE, no entanto, não foi fator independente para a menor sobrevivência no seguimento (p=0,119).Conclusão: Este estudo sugere que a CRVM não é capaz de igualar a sobrevivência de pacientes portadores de DAC e DFVE com a de pacientes com DAC sem DFVE.

Background: Coronary artery bypass graft (CABG) surgery prolongs the survival of patients with coronary artery disease (CAD) and left ventriculardysfunction (LVD). Objective: To verify whether CABG can match the survival times of CAD patients with and without LVD. Methods: 259 patients who survived CAGB performed between October 1, 2001 and January 31, 2004 were followed up for three years, with LVD characterized by a left ventricle ejection fraction of ≤40%. Two groups of patients were established, based on the presence (G1; n=45) or absence (G2; n=214) of LVD. Results: G1 patients presented more acute coronarysyndromes before CABG (64.4% vs 40.2%; p=0.005), congestive heart failure (17.8% vs 1.9%; p<0.0001),previous history of acute myocardial infarction (80% vs 60.3%; p=0.016), and chronic obstructive pulmonarydisease (11.1% vs 2.3%; p=0.016) than G2. The threeyear cumulative survival rate was significantly lowerin G1 than in G2 (88.8±4.7% vs 95.7±1.3%, respectively; p=0.05). However, LVD was not an independent factor for shorter survival times during the follow-up period (p=0.119).Conclusion: this study suggests that CABG is unable to match the survival of patients with CAD and LVD to the survival of patients with CAD without LVD.

Lesão não aterosclerótica do óstio do tronco da coronária esquerda / Non atherosclerotic left main coronary artery ostial lesion

Relata-se um caso de cardiopatia isquêmica como manifestação inicial da arterite de Takayasu (AT). Paciente internada para cirurgia de revascularização miocárdica(CRVM), devido à angina estável e lesão isolada do tronco de coronária esquerda, apresentava alterações vasculares ao exame físico que sugeriram o diagnóstico de AT. O presente caso leva à reflexão sobre a pesquisa de etiologias alternativas à doença aterosclerótica coronariana, especialmente em indivíduos jovens ou com poucos fatores de risco. O acometimento da artéria coronária na AT, embora infrequente se comparado a outras lesões vasculares encontradas nesta doença, determina elevada morbimortalidade.

Doença arterial coronariana acelerada em jovem submetido à radioterapia do mediastino / Accelerated coronary artery disease in a young patient submitted to mediastinal radiotherapy

Relata-se um caso de doença arterial coronariana (DAC) grave em paciente jovem submetido no passado à irradiação do mediastino para tratamento complementar de timoma linfoepitelial. O paciente de 32 anos de idade foi admitido no hospital com quadro de infarto agudo do miocárdio com supradesnivelamento do segmento ST, sendo tratado com angioplastia primária de artéria circunflexa. Ele apresentava história pregressa de irradiação do mediastino e 2 episódios de IAM aos 27 e 32 anos de idade. Como fatores de risco tradicionais, apresentava dislipidemia, com elevação dos n[iveis de colesterol total, LDL colesterol e triglicerideos, e ex-tabagismo. Na cinecoronariografia foi verificada a presença de doença multiarterial. Em razão da extensão e da gravidade das lesões arteriais coronarianas apresentadas pelo paciente atribuiu-se à radioterapia mediatinal o papel de acelerador da doença.

Functional assessment of coronary grafts on dobutamine pharmacological stress echocardiogram.

OBJECTIVE: To verify the sensitivity, specificity and diagnostic accuracy of dobutamine stress echocardiogram (DSE) when assessing the functional status of coronary grafts: sufficient (SUF) or insufficient (INS). METHODS: We carried out a prospective, observational study which included 25 patients submitted to coronary artery bypass grafting (CABG). The DSE and the coronary angiography were performed before the CABG and three months after the CABG. The left ventricle was divided into three territories per patient according to the three major coronary arterie: the anterior descending (AD), the circumflex (CX) and the right coronary (RC). Of the 75 possible territories, 54 were revascularized: 25 were specific to the AD artery and 29 of the CX/RC arteries. INS means luminal obstruction or occlusion greater than or equal to 50%. RESULTS: In 14 (26%) of the 54 revascularized territories the grafts were INS. The DSE detected ischemia in 16 (28%) territories; 10 of which had INS grafts. The DSE detected ischemia in 6 (15%) of the 40 territories whose grafts were SUF. Therefore, the DSE had a sensitivity of 71.4%, specificity of 85% and diagnostic accuracy of 81.4%. CONCLUSION: The DSE is a diagnostic method with high specificity and diagnostic accuracy, and good sensitivity for the functional assessment of coronary grafts.

Avaliação funcional dos enxertos coronarianos através do ecocardiograma sob estresse farmacológico com dobutamina / Functional assessment of coronary grafts on dobutamine pharmacological stress echocardiogram / Functional assessment of coronary grafts on dobutamine pharmacological stress echocardiogram

OBJETIVO: Verificar a sensibilidade, a especificidade e a acúracia diagnósticas do ecocardiograma de estresse com dobutamina (EED) ao avaliar o estado funcional dos enxertos coronarianos: suficientes (SUF) ou insuficientes (INS). MÉTODOS: Estudo observacional, prospectivo, que incluiu 25 pacientes submetidos a cirurgia de revascularização miocárdica (CRVM). Foram realizados o EED e a coronariografia, antes e três meses após a CRVM. O ventrículo esquerdo foi dividido em três territórios por paciente, de acordo com as três principais artérias do coração: descendente anterior (DA), circunflexa (CX) e coronária direita (CD). Dos 75 territórios possíveis, 54 foram revascularizados: 25 específicos da artéria DA e 29 das artérias CX/CD. INS significa oclusão ou obstrução luminal maior ou igual a 50 por cento. RESULTADOS: Dos 54 territórios revascularizados, em quatorze (26 por cento) os enxertos estavam INS. O EED detectou isquemia em dezesseis (28 por cento) territórios; em dez desses os enxertos estavam INS.O EED detectou isquemia em seis (15 por cento) dos quarenta territórios cujos enxertos estavam SUF. Portanto, o EED teve sensibilidade de 71,4 por cento, especificidade de 85 por cento, e acurácia diagnóstica de 81,4 por cento. CONCLUSÃO: O EED é um método diagnóstico com alta especificidade e acurácia diagnóstica e boa sensibilidade, na avaliação funcional dos enxertos coronarianos.

OBJECTIVE: To verify the sensitivity, specificity and diagnostic accuracy of dobutamine stress echocardiogram (DSE) when assessing the functional status of coronary grafts: sufficient (SUF) or insufficient (INS). METHODS: We carried out a prospective, observational study which included 25 patients submitted to coronary artery bypass grafting (CABG). The DSE and the coronary angiography were performed before the CABG and three months after the CABG. The left ventricle was divided into three territories per patient according to the three major coronary arterie: the anterior descending (AD), the circumflex (CX) and the right coronary (RC). Of the 75 possible territories, 54 were revascularized: 25 were specific to the AD artery and 29 of the CX/RC arteries. INS means luminal obstruction or occlusion greater than or equal to 50 percent. RESULTS: In 14 (26 percent) of the 54 revascularized territories the grafts were INS. The DSE detected ischemia in 16 (28 percent) territories; 10 of which had INS grafts. The DSE detected ischemia in 6 (15 percent) of the 40 territories whose grafts were SUF. Therefore, the DSE had a sensitivity of 71.4 percent, specificity of 85 percent and diagnostic accuracy of 81.4 percent. CONCLUSION: The DSE is a diagnostic method with high specificity and diagnostic accuracy, and good sensitivity for the functional assessment of coronary grafts.

High mortality associated with precluded coronary artery bypass surgery caused by severe distal coronary artery disease.

BACKGROUND: Patients with extensive coronary artery disease (CAD) have better prognosis when treated with coronary artery bypass grafting surgery (CABG), especially when left ventricular dysfunction (LVD) is present. However, there are scanty data about the clinical course of patients not referred to CABG because of extensive and severe atherosclerotic involvement of distal coronary arteries (ENDCAD). The aim of this study was to evaluate patients with multivessel (MV) or left main CAD (LM) who had CABG precluded because of ENDCAD. METHODS AND RESULTS: Between August 1999 and July 2001, 51 patients who had clinical indication but were not eligible for CABG because of ENDCAD were followed for at least 12 months or until death. There were 32 men and 19 women (age 61+/-9 years). Previous acute myocardial infarction (AMI) was present in 31 (60.8%), diabetes mellitus (DM) in 28 (54.9%), systemic arterial hypertension in 37 (72.5%), LVD (left ventricular ejection fraction <40%) in 26 (51%), 3 vessel CAD in 31 (60.8%), and LM in 4 (7.8%). During follow-up there were 20 cardiac (39.2%) deaths, 19 (37.2%) AMI, and 3 (5.8%) patients developed congestive heart failure. There were 2 (3.9%) noncardiac deaths. Patients with DM (60.7% versus 13%; P=0.001; odds ratio [OR], 10.30; 95% confidence interval [CI], 2.46 to 43.09), LVD (76.9% versus 0%; P<0.0001; OR, 4.33; 95% CI, 2.14 to 8.74), 3-vessel CAD (51.6% versus 20%; P=0.039; OR, 4.26; 95% CI, 1.16 to 15.69), and LM (100% versus 34%; P=0.019; OR, 1.25; 95% CI, 1.004 to 1.556) were more likely to die. There was no deaths in patients with 2-vessel CAD but they had more nonfatal AMI (43.8% versus 14.3%; OR, 4.667; 95% CI, 1.188 to 18.332). CONCLUSIONS: Patients in whom CABG could not be performed because of ENDCAD had high mortality, especially in the presence of LVD. DM (particularly insulin-dependent), LM CAD, and 3-vessel CAD were independent markers of increased risk.