The effects of high-sensitivity C-reactive protein on the clinical outcomes in obstructive sleep apnea patients undergoing off-pump coronary artery bypass grafting.

PURPOSE: To investigate the relationship between obstructive sleep apnea (OSA) severity and high-sensitivity C-reactive protein (Hs-CRP), and their respective impact on the clinical outcomes in patients undergoing off-pump cardiac artery bypass grafting (OPCABG). METHODS: We enrolled consecutive eligible patients listed for elective OPCABG who underwent cardiorespiratory polygraphy before surgery between January 2019 and December 2019 in this prospective observational single-center study. Baseline, intraoperative, and postoperative clinical data were compared between absent-mild and moderate-severe OSA groups. Regression analysis investigated the relationship between Hs-CRP level and severity of OSA, and further assessed the factors influencing postoperative atrial fibrillation, duration of hospitalization, and hospital cost. RESULTS: Patients with moderate-severe OSA accounted for 42.3% (52/123) of the cohort. Partial pressure of carbon dioxide (PCO2), Hs-CRP, apnea hypopnea index (AHI), mean apnea time, maximum apnea time, and oxygen desaturation index ODI ≥ 3% were significantly higher in the moderate-severe OSA group than in the absent-mild OSA group. Left ventricle ejection fraction (LVEF), lowest arterial oxygen saturation (SaO2), and mean SaO2 were significantly lower in the moderate-severe OSA group. Moderate-severe OSA was associated with elevated Hs-CRP level (OR = 2.356, 95% CI 1.101-5.041, P = 0.027). Hs-CRP was an independent risk factor for post-CABG atrial fibrillation (POAF) (OR = 1.212, P = 0.01). Hs-CRP level independently correlated with duration of hospitalization (B = 0.456, P = 0.001) and hospital cost (B = 1.111, P = 0.044). CONCLUSION: Hs-CRP level was closely related to OSA severity and have potential utility in predicting POAF, duration of hospitalization, and hospital costs in patients undergoing OPCABG.

Economic Analysis of Surgical and Interventional Treatments for Patients with Complex Coronary Artery Disease: Insights from a One-Year Single-Center Study.

BACKGROUND Surgical treatment methods for patients with complex coronary artery disease (CAD) who have undergone vascular reconstruction mainly include coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). The purpose of the study aimed to compare a 1-year follow-up for the patient clinical outcomes and costs between PCI and CABG treatment. MATERIAL AND METHODS There were 840 patients enrolled in this study from July 2015 to September 2016. Among the study participants, 420 patients underwent PCI treatment and 420 patients underwent off-pump CABG. Patients costs were assessed from the perspective of the China healthcare and medical insurance system. EuroQOL 5-dimension 3 levels (EQ-5D-3L) questionnaire was used to evaluate the general health status, and the Seattle Angina Questionnaire (SAQ) was used to assess the disease-specific health status. RESULTS After a 1-year follow-up, the all-cause mortality (P=0.0337), the incidence of major adverse cardiac and cerebrovascular events (P<0.001), and additional revascularization (P<0.001) in PCI group were significantly higher than those in CABG group. Both groups have significant sustained benefits in the SAQ subscale. The CABG group had a higher score on the frequency of angina than the PCI group. In addition, the quality-adjusted life year value of PCI and CABG resulted was 0.8. The average total cost for PCI was $14 643 versus CABG cost of $13 842 (P=0.0492). CONCLUSIONS In the short-term, among the CAD patients with stable triple-vessel or left-main, costs and clinical outcomes are substantially higher for CABG than PCI. Long-term, economic, and health benefits analysis, is warranted.

OPCAB surgery is cost-effective for elderly patients.

OBJECTIVE: To determine the cost-effective operative strategy for coronary artery bypass surgery in patients above 70 years. DESIGN: Randomized, controlled trial of 900 patients above 70 years of age subjected to coronary artery bypass surgery. Patients were randomized to either on-pump or off-pump coronary artery bypass surgery. Data on direct and indirect costs were prospectively collected. Preoperatively and six months postoperatively, quality of life was assessed using EuroQol-5D questionnaires. Perioperative in-hospital costs and costs of re-intervention were included. RESULTS: The Summary Score of EuroQol-5D increased in both groups between preoperatively and postoperatively. In the on-pump group, it increased from 0.75 (0.16) (mean (SD)) to 0.84 (0.17), while the increase in the off-pump group was from 0.75 (0.15) to 0.84 (0.18). The difference between the groups was 0.0016 QALY and not significantly different. The mean costs were 148.940 D.Kr (CI, 130.623 D.Kr-167.252 D.Kr) for an on-pump patient and 138.693 D.Kr (CI, 123.167 D.Kr-154.220 D.Kr) for an off-pump patient. The ICER base-case point estimate was 6,829,999 D.Kr/QALY. The cost-effectiveness acceptability curve showed 89% probability of off-pump being cost-effective at a threshold value of 269,400 D.Kr/QALY. CONCLUSIONS: Off-pump surgery tends to be more cost-effective than on-pump surgery. Long-term comparisons are warranted.

Rationale and design of the coronary artery bypass grafting surgery off or on pump revascularization study: a large international randomized trial in cardiac surgery.

BACKGROUND: Uncertainty remains regarding the benefits and risks of the technique of operating on a beating heart (off pump) for coronary artery bypass grafting (CABG) surgery versus on-pump CABG. Prior trials had few events and relatively short follow-up. There is a need for a large randomized, controlled trial with long-term follow-up to inform both the short- and long-term impact of the 2 approaches to CABG. METHODS: We plan to randomize 4,700 patients in whom CABG is planned to undergo the procedure on pump or off pump. The coprimary outcomes are a composite of total mortality, myocardial infarction (MI), stroke, and renal failure at 30 days and a composite of total mortality, MI, stroke, renal failure, and repeat revascularization at 5 years. We will also undertake a cost-effectiveness analysis at 30 days and 5 years after CABG surgery. Other outcomes include neurocognitive dysfunction, recurrence of angina, cardiovascular mortality, blood transfusions, and quality of life. RESULTS: As of May 3, 2011, CORONARY has recruited >3,884 patients from 79 centers in 19 countries. Currently, patient's mean age is 67.6 years, 80.7% are men, 47.0% have a history of diabetes, 51.4% have a history of smoking, and 34.4% had a previous MI. In addition, 20.9% of patients have a left main disease, and 96.6% have double or triple vessel disease. CONCLUSIONS: CORONARY is the largest trial yet conducted comparing off-pump CABG to on-pump CABG. Its results will lead to a better understanding of the safety and efficacy of off-pump CABG.

An observational study of intraoperative transfusion management in a cardiac surgical unit in Trinidad and Tobago.

OBJECTIVE: To investigate the intraoperative transfusion requirements in off-pump coronary artery bypass grafting (OPCABG) and the cost implication of blood products and cell savers on a background of limited resources. METHODS: Prospective data collection identified 60 patients undergoing OPCABG surgery at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. Data relating to these patients (including preoperative haemoglobin (Hb), graft number, presence of diabetes, ejection fraction, preoperative serum creatinine, intraoperative blood use and blood loss) and costing for cell saver disposables and prepared donor (or allogenic) blood were obtained. RESULTS: Twenty units of packed red blood cells (pRBCs) were given in theatre to 27% (16 of 60) of patients. Transfusion requirement was significantly lower in patients with fewer grafts, higher preoperative Hb level and non-diabetic patients. Cell saver disposables and one unit of pRBCs were estimated to cost TT$5000 and TT$1700, respectively. Each patient's transfusion cost TT$2125.00 per unit. CONCLUSION: The study demonstrates the financial implications of routine cell saver use in OPCABG in a setting of limited resources. The cost-effectiveness of routine cell saver use remains to be elucidated, but we recommend the selective use of cell savers in patients who are at a higher risk for transfusion.

Increasing long-term major vascular events and resource consumption in patients receiving off-pump coronary artery bypass: a single-center prospective observational study.

BACKGROUND: Despite its widespread use and short-term efficacy, substantial uncertainty remains about the long-term outcomes and cost-effectiveness of off-pump coronary artery bypass (OPCAB). METHODS AND RESULTS: A retrospective review of prospectively collected data was conducted of 6665 consecutive patients undergoing isolated coronary artery bypass graft (CABG) at our institution during 1999 to 2006. All patients were followed up until September 30, 2008. Short- and long-term outcomes were compared between OPCAB and conventional CABG. The 2 main long-term outcome measures were repeat revascularization and the composite outcome of major vascular events. Cost comparison at 2 years in a propensity-matched sample during follow-up was also a study interest. The overall mean baseline age was 60.3+/-8.6 years, and 17.0% were women. Compared with conventional CABG, patients who underwent OPCAB had lower rates of atrial fibrillation (P=0.003) and requirements for blood transfusion (P=0.03) and ventilation time >24 hours (P<0.001). After an average of 4.5 years of follow-up, the rates of repeat revascularization (adjusted hazard ratio, 1.40; 95% confidence interval, 1.03 to 1.89) and major vascular events (adjusted hazard ratio, 1.23; 95% confidence interval, 1.09 to 1.39) were significantly higher in the OPCAB than the conventional CABG group. At 2 years, OPCAB was associated with increased additional direct costs per patient compared with conventional CABG and had a similar survival rate. CONCLUSIONS: Compared with conventional CABG, OPCAB is associated with small short-term gain but increased long-term risks of repeat revascularization and major vascular events, especially among high-risk patients. Moreover, OPCAB consumes more resources and is less cost-effective in the long run.

Mid-term results and costs of coronary artery bypass vs drug-eluting stents for unprotected left main coronary artery disease.

BACKGROUND: The optimal revascularization strategy for unprotected left main coronary artery (ULMCA) disease in the era of drug-eluting stents (DES) has become more controversial between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). METHODS AND RESULTS: Since April 2004, 89 patients underwent CABG, including 82 (92.1%) off-pump procedures and 63 patients underwent PCI with DES for ULMCA disease. Major adverse cardiac and cerebrovascular events (MACCE: death, acute myocardial infarction, stroke and repeat revascularization) and hospitalization costs were compared. Patients in the CABG group were likely to have multivessel disease and higher euroSCORE. The mean follow-up was 2.2+/-1.1 years in the CABG group and 1.6+/-0.8 years in the DES group (P<0.001). The overall survival rate did not differ (P=0.288) between the groups (CABG: 93.4% and DES: 91.9% at 2 years). The MACCE-free survival rate was better (P=0.033) in the CABG group (CABG: 82.2% and DES: 62.6% at 2 years). Total hospitalization costs were lower (P=0.013) in the CABG group (median: 3,225 thousand yen) than in the DES group (median: 4,192 thousand yen). CONCLUSIONS: CABG might be associated with cost-effectiveness and could be still the first revascularization strategy for ULMCA disease.

[Advantages of off-pump coronary bypass surgery over conventional coronary bypass surgery]. / Vantagens da cirurgia coronária sem CEC sobre a cirurgia coronária convencional.

UNLABELLED: Comparison between off-pump coronary bypass surgery ( OP-CABG )and conventional CABG ( C-CABG ) remains a controversial issue. OBJECTIVE: To compare short and long term OP-CABG and C-CABG results in high-risk patients ( pts ), in absence of usual bias. MATERIAL AND METHODS: A prospective observational study of 752 pts ( 252 pts with C-CABG and 500 with OP-CABG ) consecutively operated throughout 23 months by 4 surgeons largely experienced in both CABG modalities. For comparison of results, two groups ( Gr ) of pts were constituted - GrA, with 252 C-CABG pts, and GrB, with 252 OP-CABG pts - being the pts blindly matched for gender ( female sex - 51 pts ), age ( mean of 65 vs 64 yrs ), angiographic data ( 3 - VD ÷ left main - 92 % vs 90 % ), additive Euroscore ( mean of 4.6 vs 4.6 ), prior myocardial infarction ( 58 % vs 59 % ), history of diabetes ( 48 % vs 49 % ) or hypertension ( 83 % vs 83 % ). Other clinical data ( GrA vs GrB ): left ventricular dysfunction - 39 % vs 34 % ( NS ); logistic Euroscore - mean of 5.4 % vs 5.9 % ( NS ). Surgical results, in-hospital clinical evolution, in-hospital costs ( intra-operative and major post-operative costs ), and short-term ( mean of 50 days ) and long-term ( mean of 5 years ) follow-up were object of evaluation. Results ( GrA vs GrB ): 1 ) Nr of bypasses ÷ pt 2.9 vs 2.4 ( p < 0.01 ); nr of arterial conduits ÷ pt 1.2 vs 1.2; complete revascularization 60 % vs 60 %; surgical total time 155 ± 49 vs 136 ± 42 min ( p < 0.001 ); surgical total time in pts with 3 bypasses 157 ± 41 vs 156 ± 37 min ( NS ). 2 ) In-hospital post-operative evolution: inotropic support ( IS ) 46 % vs 29 % ( p < 0.001 ); heavy IS 14 % vs 6 % ( p < 0.025 ) ; uncomplicated post-operative course 18 % vs 26 % ( p < 0.025 ); significant CV events ( excluding atrial tachyarrhythmias ) 33 % vs 20 % ( p < 0.01 ); infection 22 % vs 14 % ( p < 0.05 ); severe complications 22 % vs 9.5 % ( p < 0.001 ); mean intensive care length of stay 4 vs 3 days ( p < 0.01 ); surgery-to-discharge length of stay 11.3 vs 9.8 days ( p ⋝ 0.05 ); in-hospital mortality ( HM ) 4.4 % vs 2.0 % ( NS ); HM + disabling chronic morbidity 7.5 % vs 3.2 % ( p < 0.05 ) . 3 ) In-hospital costs: intra-operative - superposable; post-operative - excess of about 900 euro ÷ pt in GrA. 4 ) Short-term follow-up: asymptomatic pts - 75 % vs 85 % ( p < 0.025 ); post-discharge complications - 8.3 % vs 7.7 % ( NS ); probability of being alive and asymptomatic + 17 % in GrB ( p < 0.01 ); mortality 0 % vs 0 %. 5 ) Long-term-follow-up ( 87 % vs 90 % pts ), at 5 years: pts alive with no clinical evidence of active coronary artery disease 72 % vs 75 % ( NS ); significant ÷ severe cardiac events of coronary origin 18.8 % vs 9.3 % ( p < 0.025 ); elective PTCA 4.8 % vs 2.3 % ( NS ); all-cause mortality 11.8 % vs 11.9 %; coronary mortality 6.9 % vs 4.4 % ( NS ). CONCLUSIONS: In experienced hands and before high-risk pts, OP-CABG offers lesser post-operative risks than C-CABG, with clear and positive consequences on in-hospital costs and short-term follow-up. During long-term follow-up, the revascularization benefits obtained by OP-CABG are not inferior to those conferred by C-CABG, and a significant reduction of the incidence of severe cardiac events can even be seen in a particular subset of pts.

Costs Five Years After Off-Pump or On-Pump Coronary Artery Bypass Surgery.

BACKGROUND: Coronary artery bypass grafting (CABG) is a common surgical treatment for ischemic heart disease. Little is known about the long-term costs of conducting the surgery on-pump or off-pump. METHODS: As part of the Randomized On/Off Bypass follow-up study, we followed 2,203 participants randomized to on-pump (n = 1,099) and off-pump (n = 1,104) CABG for 5 years using Department of Veterans Affairs and Medicare administrative data. We examined annual costs through 5 years, standardized to 2016 dollars, using multivariate regression models, controlling for site and baseline patient factors. RESULTS: In the first year, including the CABG surgery, annual average costs were $66,599 (SE, $1,946) for the on-pump group and $70,552 (SE, $1,954) for the off-pump group. In years 2 to 5, average costs ranged from $15,000 to $20,000 per year. There was no significant difference between on-pump and off-pump across the 5 years. We explored differences among high-risk subgroups (diabetes, chronic obstructive pulmonary disease, peripheral vascular disease, cerebrovascular disease, renal dysfunction, ejection fraction < 35%, over age 70 years), and found no treatment assignment by time interactions, except for a nonsignificant trend in patients with diabetes. CONCLUSIONS: At 5 years, the average costs of off-pump and on-pump CABG patients did not statistically differ. Costs do not favor one approach and the decision should be based on clinical risks, especially in subgroups. Future research is warranted to examine post-CABG costs and outcomes for diabetic patients over time.

Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques.

BACKGROUND: Minimally invasive coronary artery bypass grafting (miniCABG) decreases in-hospital morbidity versus traditional sternotomy CABG. We performed a prospective cohort study (NCT00481806) to assess the impact of miniCABG on costs and metrics that influence quality of life after hospital discharge. METHODS: One hundred consecutive miniCABG cases performed using internal mammary artery (IMA) grafting +/- coronary stenting were compared with a matched group of 100 sternotomy CABG patients using IMA and saphenous veins, both treating equivalent number of target coronaries (2.7 vs. 2.9), off-pump. We compared perioperative costs, time to return to work/normal activity, and risk of major adverse cardiac/cerebrovascular events (MACCE) at 1 year: myocardial infarction (elevated troponin or EKG changes), target vessel occlusion (CT angiography at 1 year), stroke, or death. RESULTS: For miniCABG, robotic instruments and stents increased intraoperative costs; postoperative costs were decreased from significantly less intubation time (4.80 +/- 6.35 vs. 12.24 +/- 6.24 hours), hospital stay (3.77 +/- 1.51 vs. 6.38 +/- 2.23 days), and transfusion (0.16 +/- 0.37 vs. 1.37 +/- 1.35 U) leading to no significant differences in total costs. Undergoing miniCABG independently predicted earlier return to work after adjusting for confounders (t = -2.15; P = 0.04), whereas sternotomy CABG increased MACCE (HR, 3.9; 95% CI, 1.4-7.6), largely from lower target-vessel patency. CONCLUSIONS: MiniCABG shortens patient recovery time, minimizes MACCE risk at 1 year, and showed superior quality and outcome metrics versus standard-of-care CABG. These findings occurred without increasing costs and with superior target vessel graft patency.

Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial.

The objective of this study is to evaluate the costs and health benefits of coronary artery bypass grafting (CABG) surgery with and without cardiopulmonary bypass (CPB). Randomized controlled clinical trial is used as the design. The setting is in a single tertiary cardiothoracic center in Middlesex, UK. Participants were 168 patients (27 females) requiring primary isolated CABG surgery. Patients were randomized to have the procedure performed by a single surgeon either with CPB (n = 84) or by an off-pump coronary artery bypass (OPCAB) surgery (n = 84). Health-related quality of life was assessed at baseline, 6 weeks, and 6 months using the World Health Organization Quality-of-Life (WHOQOL-100) questionnaire. Mean total costs of patient management by either technique were calculated using different available key sources. A utility measure, derived from WHOQOL-100, was used to calculate quality-adjusted life year (QALY) gained in each group, on basis of which a cost-effectiveness analysis was performed. The mean total costs of an OPCAB patient was 5859 pounds , whereas for a CPB patient it was 7431 pounds with a mean difference of 1572 pounds (standard error [SE] 674 pounds ; P = 0.02). Three patients died in the CPB group and two in the OPCAB group during the 6-month follow-up period. Mean QALYs over 6 months was 0.379 in the OPCAB group and 0.362 in the CPB group, but the difference was not significant (mean difference 0.017; SE 0.016; P = 0.305). OPCAB surgery offered patients in this randomized trial similar health benefits to CPB over a 6-month period, but at a significantly less cost.

Safety, efficacy, and cost-effectiveness of intraoperative blood salvage in OPCABG with different amount of bleeding: a single-center, retrospective study.

BACKGROUND: We sought to evaluate the safety, efficacy, and cost-effectiveness of intraoperative blood salvage (IBS) in off-pump coronary artery bypass grafting (OPCABG) surgery with different amount of bleeding. METHODS: We retrospectively reviewed the medical records of 321 patients who underwent OPCABG between December 2012 and December 2016 at our hospital. Patients treated with IBS or allogeneic blood (AB) transfusions were divided into three groups depending on the amount of bleeding respectively: IBS1 or AB1 group (400-600 ml); IBS2 or AB2 group (600-1000 ml); IBS3 or AB3 group (1000-1500 ml). The intraoperative and postoperative conditions, blood transfusion volume, clinical and hematological outcomes, and total blood transfusion cost were examined. RESULTS: The amount of allogeneic red blood cell (RBC) transfusion in the IBSs groups were significantly lower than that in the ABs groups (P < 0.01). Furthermore, drainage volume 24 h post-surgery (P < 0.05) and white blood cell count (WBC) 2 day post-surgery (P < 0.01) in IBS3 group were significantly higher compared with the AB3 group. Additionally, when IBS cost was 230 USD per set, the total blood transfusion cost in the IBSs groups was significantly higher than that in the ABs groups (P < 0.01); however, when 199 or 184 USD, only the IBS1 group, rather than IBS2 or IBS3, showed significantly higher cost of the total blood transfusion compared with the AB1 group (P < 0.05). CONCLUSIONS: When the amount of bleeding was 600-1000 ml, IBS can significantly reduce the demand for allogeneic blood, and has no direct adverse effects on coagulation function and recuperation, and is cost-effective in OPCABG.

Cost-effectiveness of on-pump and off-pump coronary artery bypass grafting for patients with coronary artery disease: Results from the MASS III trial.

BACKGROUND: Recent trials have reported similar clinical outcomes between on-pump and off-pump coronary artery bypass graft (CABG). However, long-term cost-effectiveness of these strategies is unknown. METHODS: A prespecified economic study was performed based on the MASS III trial. Costs were estimated for all patients based on observed healthcare resource usage over a 5-year follow-up. Health state utilities were evaluated with the SF-6D questionnaire. Cost-effectiveness was assessed as cost per quality-adjusted life-year (QALY) gained using a Markov model. Probabilistic sensitivity analysis with the Monte-Carlo simulation and cost-effectiveness acceptability curve were used to address uncertainty. RESULTS: Quality of life improved significantly in both groups during follow-up compared with baseline. At 5 years, when comparing on-pump and off-pump CABG groups, no differences were found in cumulative life-years (4.851 and 4.766 years, P = .319) and QALY gained (4.150 and 4.105 QALYs, P = .332). Mean cost in US dollars per patient during the trial did not differ significantly between the on-pump and off-pump groups ($5890.29 and $5674.75, respectively, P = .409). Over a lifetime horizon, the incremental cost-effectiveness ratio of on-pump versus off-pump CABG was $12,576 per QALY gained, which is above the suggested cost-effectiveness threshold range (from $3210 to 10,122). In the sensitivity analysis, the probability that on-pump CABG is cost-effective compared to off-pump surgery for a willingness-to-pay threshold of $3212 per QALY gained was <1%. For the $10,122 per QALY threshold, the same probability was 35%. CONCLUSION: This decision-analytic model suggests that on-pump CABG is not cost-effective when compared to off-pump CABG from a public health system perspective.

A cost comparison of off-pump CABG versus on-pump CABG at one-year: The Canadian off-pump CABG registry.

BACKGROUND: Evidence suggests that off-pump coronary artery bypass graft surgery (CABG) is as safe and effective as on-pump CABG, and the cost of initial hospitalization for off-pump CABG is less expensive than on-pump CABG. However, it is uncertain whether the cost savings are sustained over a longer period of time. OBJECTIVE: To assess in-hospital and one-year direct medical costs of off-pump CABG versus on-pump CABG in the context of the Canadian health care system. METHODS AND RESULTS: From March 2001 to December 2002, 1657 consecutive patients enrolled in the Canadian Off-Pump CABG Registry were compared with 1693 consecutive on-pump patients from Hamilton Health Sciences CABG database. At one year, patients of both groups were followed by telephone interview. An economic analysis was conducted from the perspective of the Ontario Ministry of Health and Long-Term Care, and the data analysis was based on propensity score-matched registry patients (1233 pairs) to ensure the comparability of the two study groups. Clinical event and resource use information was collected from all patients. Unit costs from the Hamilton Health Sciences case-costing system were used to estimate hospital costs; all costs were reported in 2003 Canadian dollars. Sensitivity analyses were performed to account for uncertainties. The cost of initial hospitalization for off-pump CABG was significantly less than on-pump CABG (11,744 dollars versus 13,720 dollars, P < 0.001). Although follow-up costs were similar between the groups, the one-year total cost per patient for off-pump CABG remained significantly less than on-pump CABG (12,063 dollars versus 14,141 dollars, P < 0.001). CONCLUSION: Off-pump CABG offers significant savings during initial hospitalization that are also sustained after one year.

Beating heart versus conventional cardiopulmonary bypass: the octopus experience: a randomized comparison of 281 patients undergoing coronary artery bypass surgery with or without cardiopulmonary bypass.

In the Octopus Study, 281 coronary artery bypass surgery patients were randomized to surgery with or without cardiopulmonary bypass. The primary objective was to compare cognitive outcome between off-pump and on-pump coronary artery bypass surgery. Before and after surgery, psychologists administered a battery of 10 neuropsychological tests to the patients. Cognitive decline was defined as a decrease in an individual's performance of at least 20% from baseline, in at least 20% of the main variables. According to this definition, cognitive decline was present in 21% in the off-pump group and 29% in the on-pump group, 3 months after the procedure (P = .15). At 12 months, cognitive decline was present in 31% in the off-pump group and 34% in the on-pump group (P = .69). These results indicated that patients undergoing coronary artery bypass surgery without cardiopulmonary bypass had improved cognitive outcomes 3 months after the procedure, but the effects were limited and became negligible at 12 months. The same definition of cognitive decline was also applied to 112 volunteers not undergoing surgery. The definition labeled 28% of the control subjects as suffering from cognitive decline, 3 months after their first assessment. This suggests that the natural fluctuations in performance during repeated neuropsychological testing should be included in the statistical analysis of cognitive decline. Using an alternative definition of cognitive decline that takes these natural fluctuations in performance into account, the proportions of coronary artery bypass surgery patients displaying cognitive decline were substantially lower. This indicates that the incidence of cognitive decline after coronary artery bypass surgery has been overestimated.

Outcome improvement and cost reduction in an increasingly morbid cardiac surgery population.

Two studies assessed initiatives to improve the quality and the cost-effectiveness of cardiac surgery. The first evaluated a system for access and stabilization (SAS), with coronary stabilization, and a clinical effectiveness quality initiative (CEQI) in off-pump coronary artery bypass grafting. The SAS + CEQI cohort showed significantly lower mortality, a lower percentage of patients requiring prolonged ventilation, and a shorter mean postoperative length of hospital stay than the pre-SAS cohort who underwent on-pump coronary artery bypass grafting. The second study assessed the potential for noninvasive cerebral oximetry to reduce strokes related to all cardiac surgery by optimizing cerebral oxygen delivery. The incidence of permanent stroke was significantly lower in the cerebral oximetry group than in an earlier control group in which cerebral oximetry was not used, despite the fact that the study group had a significantly greater number of patients in New York Heart Association classes III and IV. The proportion of patients requiring prolonged ventilation was significantly lower, and the length of postoperative hospital stay was significantly shorter in the study group than in the control group. The incidence of cerebrovascular accident in the study group was 0.97%, compared with 2.03% in the controls. This translated to a potential avoidance of 12 cerebrovascular accidents and approximately $254,214 in direct costs and more than $425,000 in total costs. The results show that specific measures can improve outcomes and reduce costs in cardiac surgery. Therefore, the use of a clinical effectiveness quality initiative and cerebral oximetry in all cardiac surgery, with the SAS system for off-pump surgery, should be advocated.

Safety, efficacy, and cost of intraoperative cell salvage and autotransfusion after off-pump coronary artery bypass surgery: a randomized trial.

OBJECTIVE: We evaluated, in a randomized controlled trial, the safety and effectiveness of intraoperative cell salvage and autotransfusion of washed salvaged red blood cells after first-time coronary artery bypass grafting performed on the beating heart. METHODS: Sixty-one patients undergoing off-pump coronary artery bypass grafting surgery were prospectively randomized to autotransfusion (n = 30; receiving autotransfused washed blood from intraoperative cell salvage) or control (n = 31; receiving homologous blood only as blood-replacement therapy). Homologous blood was given according to unit protocols. RESULTS: The groups were well matched with respect to demographic and comorbid characteristics. Patients in the autotransfusion group had a significantly higher 24-hour postoperative hemoglobin concentration (11.9 g/dL; SD, 1.41 g/dL) than those in the control group (10.5 g/dL; SD, 1.37 g/dL) (mean difference, 1.02 g/dL; 95% confidence interval, 1.60-0.44 g/dL; P = .0007), as well as a 20% reduction in the frequency of homologous blood product use (11/31 vs 5/30; P = .095). Autotransfusion of washed red blood cells was not associated with any derangement of thromboelastograph values or laboratory measures of clotting pathway function (prothrombin time, activated partial thromboplastin time, and fibrinogen levels), increased postoperative bleeding, fluid requirements, or adverse clinical events. There was no statistical difference between groups in the total operation, hospitalization, and management costs per patient (median difference, USD 1015.90; 95% confidence interval, -USD 2260 to USD 206; P = .11). Conclusions Intraoperative cell salvage and autotransfusion was associated with higher postoperative hemoglobin concentrations, a modest reduction in transfusion requirements, no adverse clinical or coagulopathic effects, and no significant increase in cost compared with controls. This study supports its routine use in off-pump coronary artery bypass grafting surgery.

[Influence of DPC on cardiovascular surgery].

After a new medical expense system "DPC (Diagnosis Procedure Combination)" had been introduced in 2003, the change in the medical treatment fee was evaluated according to each cardiovascular surgical field. Application of the DPC is limited to hospitalization fee in the general ward by a fixed daily amount The former payment system remains for operation, anesthesia, and some invasive examinations such as cardiac catheterization, therefore, the influence of the DPC introduction on cardiovascular surgery was minimum. A lot of problems are still left, however, for the classification of diagnosis, especially in a congenital heart disease, and the fee setting of intensive care. It is required also to reconsider serious cases, advanced complications and methods of life support. In the field of cardiovacular surgery, the treatment is so risky and so expensive, that more detailed analysis should be necessary by establishment of data base system.