An Easy and Reliable Way to Prevent Electrocardiographic Deteriorations of Patients Undergoing Off-Pump Coronary Artery Bypass Surgery: Preoperative Anxiolytic Treatment.

OBJECTIVE: To investigate the effects of preoperative anxiety relieving on electrophysiological changes in patients undergoing off-pump coronary artery bypass surgery. METHODS: A total of 61 patients at ASA III risk group in the age range of 18-65 years were enrolled in the present study. Patients were randomly divided into two groups. Group S (Sedation group) was administered 0.04 mg/kg lorazepam per os (PO) twice before the operation. Group C (control group) was not administered with any anxiolytic premedication. State Trait Anxiety Inventory (STAI-I) and Beck Anxiety Inventory (BAI) were used to evaluate the level of anxiety. Electrocardiography (ECG), pulse oximeter and standard monitoring were performed for each patient. QT and P dispersions in each derivation of all ECGs were calculated. RESULTS: Preoperative STAI-I scores were significantly lower in sedation group compared to the controls. Mean values of QT dispersion measured before induction, at the 1st minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.024; P=0.027; P=0.001; P=0.033, respectively). The mean values of P dispersion measured before induction, at the 3rd minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.001; P=0.020; P=0.023; P=0.005, respectively). CONCLUSION: Elevated anxiety levels in patients undergoing coronary bypass surgery have a negative effect through prolonged QT and P-wave dispersion times. Anxiolytic treatment before surgery may be useful to prevent ventricular and atrial arrhythmias and associated complications through decreasing the QT and P-wave dispersion duration.

An easy and reliable way to prevent electrocardiographic deteriorations of patients undergoing off-pump coronary artery bypass surgery: preoperative anxiolytic treatment

Abstract Objective: To investigate the effects of preoperative anxiety relieving on electrophysiological changes in patients undergoing off-pump coronary artery bypass surgery. Methods: A total of 61 patients at ASA III risk group in the age range of 18-65 years were enrolled in the present study. Patients were randomly divided into two groups. Group S (Sedation group) was administered 0.04 mg/kg lorazepam per os (PO) twice before the operation. Group C (control group) was not administered with any anxiolytic premedication. State Trait Anxiety Inventory (STAI-I) and Beck Anxiety Inventory (BAI) were used to evaluate the level of anxiety. Electrocardiography (ECG), pulse oximeter and standard monitoring were performed for each patient. QT and P dispersions in each derivation of all ECGs were calculated. Results: Preoperative STAI-I scores were significantly lower in sedation group compared to the controls. Mean values of QT dispersion measured before induction, at the 1st minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.024; P=0.027; P=0.001; P=0.033, respectively). The mean values of P dispersion measured before induction, at the 3rd minute of induction, 30th second of intubation and 4th minute of intubation in sedation group were significantly reduced compared to controls (P=0.001; P=0.020; P=0.023; P=0.005, respectively). Conclusion: Elevated anxiety levels in patients undergoing coronary bypass surgery have a negative effect through prolonged QT and P-wave dispersion times. Anxiolytic treatment before surgery may be useful to prevent ventricular and atrial arrhythmias and associated complications through decreasing the QT and P-wave dispersion duration.

Assessment of long-term cognitive impairment after off-pump coronary-artery bypass grafting and related risk factors.

OBJECTIVES: To assess cognitive impairment after off-pump coronary-artery bypass grafting, with a particular emphasis on long-term follow-up and related risk factors. DESIGN: Prospective study. SETTING: Virgen de la Victoria University Hospital, Málaga, Spain. PARTICIPANTS: Participants were 36 patients undergoing off-pump coronary-artery bypass grafting. MEASUREMENTS: Changes in the neuropsychological test battery administered from before to after surgery (1, 6, and 12 months). Postoperative cognitive impairment was defined by a significant decrease. RESULTS: A significantly multidomain (attention-executive functions, P < .01; immediate and delayed memory, P < .001; and verbal fluency, P < .05) postoperative cognitive impairment was shown, being maximum at 6 months (more than 50% of patients) and still presented at 12 months (more than 30% of patients), but partially recovered. Related risk factors as smoking (P < .01), diabetes mellitus (P < .01), peripheral arteriopathy (P < .01), obesity (P < .05), lower hematocrit (P < .01), and hemoglobin (P < .05) levels and diastolic blood pressure (P < .05) were identified as predictors of cognitive impairment. Better New York Heart Association class (P < .01) and less severity of angina (P < .01) were associated with partial postoperative recovering. CONCLUSION: A multidomain long-term postoperative cognitive impairment and a partial neurocognitive recovering were detected after off-pump coronary-artery bypass grafting and were associated with several nonspecific surgery factors. These findings may be useful when counseling patients before surgery and suggest the importance of long-term neurocognitive evaluation.

Perioperative and long-term development of anxiety and depression in CABG patients.

BACKGROUND: The high incidence of symptomatic anxiety and depression in coronary artery bypass graft (CABG) patients may lead to impaired quality of life and increased morbidity and mortality. This prospective longitudinal study on CABG patients should provide data for future preoperative and postoperative psychotherapeutic interventions. METHODS: From 2009 to 2010, 135 consecutive patients who were able and prepared were consulted by one interviewer immediately before 1 week (early) and 6 months (late) after surgery to complete the "Hospital Anxiety and Depression Scale" questionnaire. RESULTS: Compared with the standard population, anxiety scores (AS) were preoperatively elevated in 39.3% of the patients. Early and late after surgery, AS had decreased to 34.4% (not significant [n.s.]) and 28.9% (p < 0.01). Before surgery, depression scores (DS) were elevated in 20.7%. Early and late after surgery, DS further increased to 24.0% (n.s.) and 28.0% (n.s.).Preoperative elevated DS appeared to correlate with increased complications. Mortality was not associated with elevated AS or DS. Both scores were not affected by on- or off-pump surgery. CONCLUSION: Remarkably high AS and elevated DS late postoperatively require psychotherapeutic support even after seemingly successful CABG.

Patient preference for coronary artery bypass graft surgery performed on the arrested or beating heart: a questionnaire study.

OBJECTIVE: Patient choice is now a major facet of health-care policy within the National Health Service. Our objective was to determine whether the patient would like to choose if the 'beating heart' technique or the 'arrested heart' technique is employed for their coronary artery bypass graft (CABG) surgery. METHODS: We undertook a cross-sectional, self-reported questionnaire survey of patients referred to a regional cardiac surgical unit for elective coronary artery surgery between October 2008 and July 2009. The questionnaire was split into five sections as follows: (1) the patients' awareness of 'beating heart' and 'arrested heart' techniques for CABG surgery, (2) an information sheet detailing both techniques, (3) patients' preference of technique to be used for CABG surgery, (4) whether the patient would like to choose their surgeon according to the surgeons' preferred technique and (5) demographics, including age, sex, and educational qualifications. Data are expressed as counts (percentages). RESULTS: The questionnaire was sent to 120 people; 88 returned a completed questionnaire, representing a response rate of 73%. Awareness of 'beating heart' and 'arrested heart' techniques for CABG surgery was reported by 35 respondents (40%). Of these, 74% respondents had no preference of technique used for CABG surgery. After reading the information sheet, 78 (89%) respondents reported no preference of technique used for CABG surgery. As many as 71 (81%) respondents reported that they did not want to be given an opportunity to choose the technique used for CABG surgery, and all respondents preferred to let the surgeon decide the appropriate technique. A binary logistic regression analysis showed that gender, age and level of education were not significant predictors of whether patients wanted to choose the technique to be used for their CABG surgery. CONCLUSION: Cardiac surgical patients prefer to allow the surgeon to determine the technique to be used for their coronary artery operation and do not want to be offered the chance to choose their surgeon according to the surgeons' preferred technique. Involvement of the patient in determining the operative technique is not always desired.

Cognitive outcomes after on- versus off-pump coronary artery bypass surgery.

BACKGROUND: The Randomized On versus Off Bypass trial found no difference for a global cognitive outcome measure for patients receiving on-pump versus off-pump coronary artery bypass graft surgery (CABG). In this report, we present the baseline patient characteristics that were predictive of post-CABG cognitive decline as well as compare cognitive outcomes between treatment arms. METHODS: A neuropsychological battery was administered preoperatively and at 1 year after undergoing CABG. Stepwise regression was used to identify demographic or clinical risk factors associated with cognitive decline. Neuropsychological data were converted to demographically corrected T scores to provide impairment levels. RESULTS: Overall 1,156 patients (581 on-pump, 575 off-pump) completed match-paired neuropsychological assessments at baseline and 1-year follow-up. Baseline cognitive score, age, education level, and ethnicity predicted cognitive decline after CABG. Only 20% of either group had mild impairment at baseline on three of the test scores, and less than 10% had severe impairment on individual tests at either time. Few subjects in either group transitioned to clinically impaired levels at follow-up on individual tests. CONCLUSIONS: At baseline, lower cognitive function, older age, lower education, and ethnicity other than white were predictive of cognitive decline after CABG. Patients in both groups demonstrated low frequencies of cognitive impairment on individual tests at baseline and follow- up, and few patients in either group were classified as impaired at 1-year follow-up on individual tests. In general, the Randomized On versus Off Bypass study documented that neither on-pump nor off-pump CABG adversely impacts long-term brain function.

On vs off: perceptions of four patients' experiences of coronary artery bypass surgery.

The benefits of Off-Pump Coronary Artery Bypass surgery (OPCAB) are well documented, but little information is available that explores the patient's perception of the experience. The purpose of this study was to explore the differences in perceptions and experiences in patients who have undergone both OPCAB and on-pump Coronary Artery Bypass Grafting procedures. Guided by naturalistic inquiry, semistructured qualitative interviews were conducted and audio taped with 4 men living independently. Inductive analysis of the transcripts revealed 7 themes: general comparisons, health care seeking symptoms, loss of control, faith and trust, postoperative depression, interactions with health care professionals, and sharing the life-time experience. The findings from this study will help to guide future research in the area of cardiovascular surgery.

Comparison of the quality of life after conventional versus off-pump coronary artery bypass surgery.

PURPOSE: Numerous studies have focused on off-pump coronary artery bypass graft (off-pump CABG) morbidity and mortality outcomes, but few looked at the patient's perception of the technique and its effect on postoperative quality of life (QOL). We investigated and compared postoperative QOL in patients who had undergone either conventional or off-pump CABG myocardial revascularization. METHODS: During a six-month period, 191 patients who underwent CABG surgery were prospectively studied through preoperative and six-month postoperative short-form 36 (SF-36) general health status surveys. One hundred-sixteen (60.7%) off-pump CABG patients and 75 (39.3%) conventional on-pump CABG patients were enrolled. RESULTS: Sixteen (13.8%) off-pump patients reported improvement in physical score QOL, 84 (72.4%) reported no change, and 16 (13.8%) reported a decrease. In comparison, 20 (80.0%) patients in the on-pump CABG group reported an improvement in QOL, 42 (56.0%) were unchanged, and 13 (17.3%) reported deterioration (p = 0.28). For postoperative change in mental score, 19 (16.4%) off-pump patients reported an improvement, 85 (73.3%) stayed unchanged, and 12 (10.3%) reported a decrease compared with 8 (10.7%) conventional CABG patients reporting improvement, 60 (80.0%) showing no change, and 7 (9.3%), having a score decline (p = 0.52). In multivariate logistic regression analysis, hypertension (odds ratio [OR] 2.2, 95% confidence intervals [CI], 1.08 to 4.40, p = 0.03) and multivessel coronary artery disease (OR 2.1, 95% CI, 1.11 to 4.13, p = 0.02) emerged as independent predictors of worse physical score component score. Diabetes was associated with an improved physical score component score after CABG (OR 0.4, 95% CI, 0.17 to 0.76, p = 0.01), regardless of the surgical approach. CONCLUSION: This prospective study reveals no significant differences in the expected QOL at six months after either on-pump or off-pump CABG. Patients with hypertension and multivessel coronary artery disease were more likely to have worse, while patients with diabetes have improved physical score component scores six months after CABG.

[Depression before and after operation in coronary artery bypass grafting patients].

OBJECTIVE: To investigate the presence of depression in coronary artery bypass grafting (CABG) patients before and after the operation. METHODS: A questionnaire survey was conducted among 72 CABG patients, 21 of which, aged 65.30 +/- 1.15, underwent on-pump coronary artery bypass grafting (ONCAB) and 51 of which, aged 63.70 +/- 0.22, underwent off-pump CAB (OPCAB), using Beck Depression Inventory (BDI) one day before, and 3 and 6 months after the operation. RESULTS: Depressive disorders occurred in 49.2% of the patients preoperatively and 26.7% of the patients 6 months after the operation. The mean pre-operative BDI score was 5.77, and the post-operative BDI scores 3 and 6 months after operation were 4.12 and 3.06 respectively. At different post-operative time points the BDI scores of the depressive group were all lower than those of the non-depressive group, however, there was still a trend of lowering of BDI scores in the latter group. There were more patients who failed to resume their original work and more patients with angina and hypertension in the depression group. The proportion of females after operation was higher in the depression group. There was no significant difference in BDI score between the ONCAB and OPCAB groups both pre- and post-operatively. CONCLUSION: Depression at different degrees exists before CABG and can be improved post-operatively. Pre-operative BDI score is predictor of post-operative psychological outcome.

Health-related quality of life outcome after on-pump versus off-pump coronary artery bypass graft surgery: a prospective randomized study.

BACKGROUND: The clinical benefit of off-pump coronary artery bypass graft surgery over on-pump surgery is a matter of controversy. The aim of this study was to assess quality of life in patients after on-pump and off-pump coronary artery bypass graft surgery, and compare the data with an age-matched and sex-matched standard population. METHODS: Two hundred twelve patients admitted for elective coronary artery bypass graft surgery were randomized to on-pump (n = 104) and off-pump (n = 108) surgery. Quality-of-life assessments were made 6 and 18 months postoperatively using the standard form of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36, version 2). The questionnaire yields eight subscores of functional health and well being. The eight SF-36 raw scores were standardized using means and standard deviations from a random sample of adults in Great Britain. Mean on-pump and off-pump SF-36 scores were compared using two-sample Student's t tests. RESULTS: Questionnaires were completed for 72% (154 of 212) and 46% (98 of 212) of patients at the 6- and 18-month follow-up, respectively. There were no significant differences between on-pump and off-pump patients in any of the eight subscales at both stages. Fifty-six (72%) on-pump and 59 (75%) off-pump patients reported a better health status compared with the 6-month period before surgery (not significant). CONCLUSIONS: Patients who have undergone off-pump coronary artery bypass graft surgery have a similar quality of life to on-pump patients at 6 and 18 months after surgery. For both groups, the majority of patients reported improved health after coronary artery bypass graft surgery compared with their preoperative status.

Cognitive function after on or off pump coronary artery bypass grafting.

OBJECTIVE: To investigate cognitive outcome after on and off pump coronary artery bypass grafting. METHODS: Seventy patients between 50 and 80 years with stable angina pectoris, ejection fraction >30%, serum creatinine <150 micromol/l, and lack of tight main stem stenosis were randomized to on or off pump coronary artery bypass grafting. Standardized neuropsychological tests evaluated attention, verbal and visuo-spatial short-term and working memory, verbal learning, delayed recall, visuo-motor speed, and aspects of executive functions. Levels of anxiety and depression were also investigated. Testing was performed before and at 1 week, 1 and 6 months after surgery. RESULTS: There was no difference in cognitive impairment (defined as a 20% reduction in at least 20% of the tests) between groups. The incidence at 1 week post-operatively was 57% in the on pump group and 58% in the off pump group, after 1 month 30% and 12% and after 6 months 19% and 15%, respectively (p for interaction=0.19). There was no difference between groups in anxiety (p=0.18) or depression (p=0.48). CONCLUSIONS: This prospective, randomized study showed no differences in post-operative cognitive function after on pump compared to off pump coronary artery bypass grafting in low risk patients.

Health-related quality of life following off-pump versus on-pump coronary artery bypass grafting in elderly moderate to high-risk patients: a randomized trial.

OBJECTIVE: Previous trials comparing coronary artery bypass grafting (CABG) with or without extracorporeal circulation have mainly enrolled selected patients at younger age and low risk. Patient-reported health-related quality of life has not been significantly different. We compared health-related quality of life in elderly moderate to high-risk patients randomized to either off-pump or on-pump surgery. METHODS: The study is a sub-study of the randomized Best Bypass Surgery Trial that compares off-pump to on-pump treatment, with respect to peri- and postoperative mortality and morbidity in patients with a moderate to high-predicted preoperative risk. After randomization and before heart surgery, 120 consecutive patients were asked to fill in the Medical Outcomes Study Short Form 36 (SF-36) and Major Depression Inventory (MDI) diagnostic scale for self-report of health-related quality of life. Three months after surgery, the same questionnaires were mailed to the patients. RESULTS: The response rate was 96.5%. At baseline, the groups were comparable except for a difference in educational level. Both groups improved in all eight SF-36 domains from baseline to 3 months. No statistical differences were seen between the groups except for changes in mean difference of role limitation due to emotional problems, which was significantly (P=.04) improved in favour of the on-pump group. Depression scores remained unchanged within and between the two surgical groups. CONCLUSIONS: Both on-pump and off-pump patients improved in health-related quality of life scores after CABG surgery. No clinically relevant difference between the groups could be demonstrated.

Comparison of the SF-6D and the EQ-5D in patients with coronary heart disease.

BACKGROUND: The SF-6D was derived from the SF-36. A single summary score is obtained allegedly preserving the descriptive richness and sensitivity to change of the SF-36 into utility measurement. We compared the SF-6D and EQ-5D on domain content, scoring distribution, pre-treatment and change scores. METHODS: The SF-6D and the EQ-5D were completed prior to intervention and 1, 3, 6 and 12 months post-intervention in a study enrolling 561 patients with symptomatic coronary stenosis. Patients were randomized to off-pump coronary artery bypass surgery (CABG), standard on-pump CABG, or percutaneous transluminal coronary angioplasty (PTCA). Baseline and change over time scores were compared using parametric and non-parametric tests. RESULTS: The relative contribution of similar domains measuring daily functioning to the utility scores differed substantially. SF-6D focused more on social functioning, while EQ-5D gave more weight to physical functioning. Pain and mental health had similar contributions. The scoring range of the EQ-5D was twice the range of the SF-6D. Before treatment, EQ-5D and SF-6D mean scores appeared similar (0.64 versus 0.63, p = 0.09). Median scores, however, differed substantially (0.69 versus 0.60), a difference exceeding the minimal important difference of both instruments. Agreement was low, with an intra-class correlation of 0.45.Finally, we found large differences in measuring change over time. The SF-6D recorded greater intra-subject change in the PTCA-group. Only the EQ-5D recorded significant change in the CABG-groups. In the latter groups changes in SF-6D domains cancelled each other out. CONCLUSION: Although both instruments appear to measure similar constructs, the EQ-5D and SF-6D are quite different. The low agreement and the differences in median values, scoring range and sensitivity to change after intervention show that the EQ-5D and SF-6D yield incomparable scores in patients with coronary heart disease.

Early neurocognitive function of patients after off-pump coronary artery bypass surgery.

DESIGN: This was a prospective, descriptive study. SETTING: The study took place in cardiovascular units at a large urban metropolitan, midwestern tertiary care hospital. SAMPLE: Fifty-four patients undergoing off-pump coronary artery bypass surgery were included. OUTCOME MEASURES: Outcome measures were neurocognition preoperatively at baseline (within 72 hours of surgery) and postoperatively (at least 72 hours after surgery but before discharge). RESULTS: In neurocognitive tests of cognition (memory, language, and attention) there was an improvement in the cognitive composite from the preoperative baseline to the postoperative follow-up (P < .001). However, in tests of motor function (motor speed and information processing speed) there was a decline in the motor composite (P = .006). CONCLUSIONS: After off-pump coronary artery bypass surgery, patients had an overall improvement in tests of memory, language, and attention (cognitive composite), but a decline in tests of motor speed and information processing speed (motor composite).

Gender-specific practice guidelines for coronary artery bypass surgery: perioperative management.

Gender differences in coronary bypass surgery have been the focus of numerous publications in recent years. Unfortunately these publications have contradictions that leave surgeons with conflicting recommendations for care. To help resolve these inconsistencies, The Society of Thoracic Surgeons (STS) Workforce on Evidence-Based Surgery has carried out an objective review of published information in this field. The STS Workforce recognizes that there are important gender issues associated with referral bias, the impact of body size, psychosocial factors, and postoperative support, but the intent of this guideline is to focus specifically on perioperative management. As with all practice guidelines, our goal is to gather the most important information, analyze the information in a logical and unbiased fashion, and make recommendations based solely on the available evidence.

[Perioperative cortisol circadian secretion and neuropsychological states in patients undergoing coronary artery bypass grafting surgery].

OBJECTIVE: To investigate the relationship between the circadian rhythm of perioperative cortisol secretion and neuropsychological states in patients undergoing coronary artery bypass grafting surgery. METHODS: Forty male patients scheduled for elective coronary artery bypass grafting (CABG) under hypothermic cardio-pulmonary bypass (CPB) or off-pump were enrolled in this study. They were allocated into CPB group or off-pump group with 20 patients in each group. Blood samples were withdrawn during surgery at specific time-points and every 3 h for 24 h in the immediate postoperative period. Plasma cortisol was measured by radioimmunoassay. All subjects were investigated preoperatively as well as 7 to 10 d and 3 months postoperatively with a comprehensive neuropsychologic assessment, while depression and anxiety were assessed by Self-Rating Depression Scale and the State-Trait Anxiety Inventory respectively. RESULTS: During postoperative 24 h, three patients in the CPB group and 7 patients in the off-pump group were demonstrating a circadian secretion pattern, while they were disturbed in the remaining patients in both groups. Postoperative depression scores of patients in both groups were significantly higher than preoperative values. Postoperative anxiety scores of patients in the CPB group were significantly higher than those in the off-pump group. The CABG with CPB patients showed a significant deficit in the Digit Span subtest of the WAIS-R and the Stroop colour word interference test. The disturbed cortisol circadian secretion in the CPB group correlated with depression and the Stroop colour word interference test, whereas in the off-pump group it correlated with depression, Digit Span subtest (forward), symbol digit modalities test and the Stroop colour word interference test. Degree of depression correlated with some items of cognitive dysfunctions. CONCLUSION: Perioperative secretion rhythm of cortisol in patients undergoing CABG surgery with CPB or off-pump was disturbed. The disordered cortisol may correlate directly or indirectly through mood with neuropsychological deficits.