Coronary revascularization with or without cardiopulmonary bypass in patients with preoperative nondialysis-dependent renal insufficiency.

BACKGROUND: Preoperative renal insufficiency is a predictor of acute renal failure in patients undergoing conventional coronary artery bypass grafting. Off-pump coronary artery bypass operations have been shown to reduce renal dysfunction in patients with normal renal function, but the effect of this technique in patients with preoperative nondialysis-dependent renal insufficiency is unknown. METHODS: From June 1996 to December 1999, data of 3,250 consecutive patients undergoing coronary artery bypass grafting were prospectively entered into the Patient Analysis & Tracking Systems (PATS, Dendrite Clinical Systems, London, UK). Two hundred and fifty-three patients with preoperative serum creatinine more than 150 micromol/L were identified (202 patients on-pump, 51 patients off-pump), and clinical outcomes were analyzed. Serum creatinine and urea, in-hospital mortality, and morbidity were compared between groups. The association of perioperative factors with acute renal failure was investigated by multiple logistic regression analysis. RESULTS: Preoperative characteristics were similar between the groups. Mean number of grafts was 2.9 +/- 0.8 and 2.3 +/- 0.8 in the on-pump and off-pump groups, respectively (p < 0.0001). Comparison between groups showed a significantly higher incidence of stroke, inotropic requirement, blood loss, and transfusion of red packed cell and platelets in the on-pump group (all p < 0.05). Postoperative serum creatinine and urea were higher in the on-pump group with a significant difference at 12 hours postoperatively (p < 0.05). Logistic regression analysis identified cardiopulmonary bypass, serum creatinine level 60 hours postoperatively, inotropic requirement, need for intraaortic balloon pump, transfusion of red packed cell, and hours of ventilation as predictors of postoperative acute renal failure. CONCLUSIONS: This study suggests that off-pump coronary artery bypass operations reduce in-hospital morbidity and the likelihood of acute renal failure in patients with preoperative nondialysis-dependent renal insufficiency undergoing myocardial revascularization.

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients.

OBJECTIVE: There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time. METHODS: Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5+/-3.5 years) and 87 consecutive CPB patients (age 77.2+/-2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4+/-4.4 (OPCAB) versus 16.6+/-5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques. RESULTS: The length of stay in the intensive therapy unit (ITU) was 35.4+/-52.9h for OPCAB patients and 77.6+/-144.9h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011. CONCLUSIONS: Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.

An evaluation of existing risk stratification models as a tool for comparison of surgical performances for coronary artery bypass grafting between institutions.

OBJECTIVE: Risk stratification systems are used in cardiac surgery to estimate mortality risk for individual patients and to compare surgical performance between institutions or surgeons. This study investigates the suitability of six existing risk stratification systems for these purposes. METHODS: Data on 5471 patients who underwent isolated coronary artery bypass grafting at two UK cardiac centres between 1993 and 1999 were extracted from a prospective computerised clinical data base. Of these patients, 184 (3.3%) died in hospital. In-hospital mortality risk scores were calculated for each patient using the Parsonnet score, the EuroSCORE, the ACC/AHA score and three UK Bayes models (old, new complex and new simple). The accuracy for predicting mortality at an institutional level was assessed by comparing total observed and predicted mortality. The accuracy of the risk scores for predicting mortality for a patient was assessed by the Hosmer-Lemeshow test. The receiver operating characteristic (ROC) curve was used to evaluate how well a system ranks the patient with respect to their risk of mortality and can be useful for patient management. RESULTS: Both EuroSCORE and the simple Bayes model were reasonably accurate at predicting overall mortality. However predictive accuracy at the patient level was poor for all systems, although EuroSCORE was accurate for low to medium risk patients. Discrimination was fair with the following ROC areas: Parsonnet 0.73, EuroSCORE 0.76, ACC/AHA system 0.76, old Bayes 0.77, complex Bayes 0.76, simple Bayes 0.76. CONCLUSIONS: This study suggests that two of the scores may be useful in comparing institutions. None of the risk scores provide accurate risk estimates for individual patients in the two hospitals studied although EuroSCORE may have some utility for certain patients. All six systems perform moderately at ranking the patients and so may be useful for patient management. More results are needed from other institutions to confirm that the EuroSCORE and the simple Bayes model are suitable for institutional risk-adjusted comparisons.

Multi-vessel off-pump coronary artery bypass grafting can be taught to trainee surgeons.

BACKGROUND: Although, Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively. METHODS: Registry data, notes and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training programme for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it has had an established recent experience in performing non-selective OPCAB for all coming-in patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses. RESULTS: The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed satisfactory seventeen (100%) distal anastomoses. CONCLUSION: With appropriate training, it is possible for trainees to learn OPCAB and perform multi-vessel revascularization in relatively high-risk patients with good results.

Endoscopic versus open radial artery harvesting for coronary artery bypass grafting.

AIM: The radial artery has become the artery of choice after the internal thoracic artery for coronary artery bypass grafting (CABG). This study compares wound healing and arm complications after endoscopic versus open radial artery harvesting for CABG. METHODS: From January 2002 to July 2004, 509 patients underwent CABG in which a radial artery conduit was used. Thirty-nine had endoscopic and 470 had conventional open radial artery harvesting. A propensity score was used to obtain 1:3 matching of all endoscopic to 117 open-harvesting patients. Postoperative wound healing using the Hollander scale, local neurologic deficits, wound infection, and pain scores were compared. RESULTS: Wound healing: 34 of 39 endoscopic wounds exhibited a perfect Hollander score versus 339 of 470 open-harvest wounds (P=0.01). Wound appearance in particular was better than for open harvesting (P=0.004), with no abnormal step-off borders, irregular contours, or abnormal scar width observed. Neurologic deficits. Three incomplete neurologic deficits were observed after open harvesting (two being distal sensitivity localized in the interspace between the first and second metacarpals); one complete neurologic deficit occurred after endoscopic harvesting, but improved remarkably prior to hospital discharge. Wound infection. Occurrence of wound infection was similar in the two groups (P=0.7), although infection was more severe with open harvesting. Pain: pain score was lower (P=0.006) with endoscopic harvesting. CONCLUSION: Compared with conventional open harvesting, endoscopic radial artery harvesting was associated with better wound appearance and less pain. Occurrence of neurologic deficits and wound infection was infrequent in both groups.

Implementation of a process-orientated multidisciplinary approach (POMA), a system of cost-effective healthcare delivery within a cardiac surgical unit.

BACKGROUND: The process-orientated multidisciplinary approach (POMA) is a means of delivering consultant-led healthcare from the first outpatient clinic visit through to discharge, bringing together clinical and operational management that can result in effective resource utilisation and improved patient care. METHODS: Prospectively collected data from patients undergoing primary isolated coronary artery bypass graft (CABG) were collected before and after the application of POMA (246 and 260 patients, respectively). The impact of POMA was analysed on the number of cancellations (NOC), postoperative clinical incidents (POCI), postoperative length of stay (PLOS) and cost in the practice of one consultant surgeon. Data were obtained from our clinical database (PATS-Dendrite), which is used risk stratify patients and prospectively to collect clinical/operative data and outcomes. RESULTS: Patients were matched for all variables except for the European Cardiac Surgical Risk Score (EuroSCORE) which was 1.93 for pre-POMA patients and 2.73 for post-POMA patients (p<0.05). Cancellations significantly decreased from 4.5% (n = 11, pre-POMA) to 0.4% (n = 1, post-POMA) (p<0.05). POCI significantly decreased from 44.3% (n = 109, pre-POMA) to 36.2% (n = 94, post-POMA) (p<0.05). PLOS significantly decreased from 6.3 (pre-POMA) to 6.1 days (post-POMA) (p = 0.002). Regression analysis showed that implementation of POMA was the only significant factor in the reduction of POCI and PLOS (p<0.05). POMA resulted in an overall saving of 285,868 pound (400,215 euro; US $508,845) calculated using the 2005 National Health Service (NHS) tariffs. CONCLUSIONS: The implementation of POMA was the only significant known (or measured) factor that improved the operational efficiency and clinical outcome of a single surgeon's practice. The authors believe the principles deserve to be studied further to see if the results can be replicated.

Predictors of poor mid-term health related quality of life after primary isolated coronary artery bypass grafting surgery.

OBJECTIVE: To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG). METHODS: 463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome. RESULTS: 437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables-gastrointestinal problems, congestive heart failure, and type D personality trait-predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables-peripheral vascular disease, infective complications, and type D personality trait-predicted poor physical scores independently. CONCLUSION: Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL.

Integrated approach to off-pump coronary artery bypass surgery.

BACKGROUND: The Off-Pump Coronary Artery Bypass (OPCAB) technique is becoming more popular in many cardiac units throughout the world. This relatively new technique has prompted surgeons and anaesthetists to review and modify the routine approach to Coronary Artery Bypass Surgery (CABG). In this study we reviewed and analysed the outcome of an integrated anaesthetic and surgical peri-operative approach that allowed routine use of OPCAB and avoided the use of cardiopulmonary bypass (CPB). METHODS: We reviewed and analysed the data on the first consecutive 285 patients who were operated on using the OPCAB technique. These represent our initial experience with applying the OPCAB technique non-selectively for all patients over a period of 16 months. RESULTS: All patients had at least 2-vessel disease. 807 grafts were performed (mean 2.8 per patient) of which 647 (80%) were arterial (mean 2.3 per patient). 179 (63%) patients underwent total arterial revascularization. Eight patients required cardiopulmonary bypass; all other operations were completed off-pump. Complications--mortality 3 (1%); renal failure 24 (8%); stroke 3 (1%) and atrial fibrillation 60 (21%). CONCLUSION: This retrospective analysis shows that provided a combined and integrated anaesthetic and surgical approach is used, beating heart technique for CABG can be safely offered to all patients with a good outcome.

Quality of life and coping following minimally invasive direct coronary artery bypass (MIDCAB) surgery.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has been shown to be a promising technique for surgical treatment of single or double vessel disease. However, little is known about quality of life, mood state or coping in this group of patients. The records of 55 consecutive patients who underwent MIDCAB surgery at Harefield Hospital between April 1999 and May 2001 were reviewed. In order to assess quality of life, mood state and coping, patients were contacted by telephone to conduct a semi-structured interview and were subsequently sent four questionnaires. The measures used were the Hospital Anxiety and Depression Scale, the Short Form Health Survey, the WHOQoL-BREF and the COPE. Forty-eight patients were contacted by telephone, forty-four of whom returned the completed questionnaires. Overall ratings of quality of life were excellent for the majority of patients, and rates of anxiety and depression were lower than previously found following coronary artery bypass surgery. It is concluded that following MIDCAB surgery quality of life and mood state outcomes are encouraging. However, a prospective, longitudinal study is now required to further elucidate the relationship between quality of life, mood state and coping and to identify predictive factors for physical and psychological outcome following this new surgical technique.

Validation of four different risk stratification systems in patients undergoing off-pump coronary artery bypass surgery: a UK multicentre analysis of 2223 patients.

BACKGROUND: Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass. OBJECTIVE: To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK. METHODS: Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer-Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area. RESULTS: 30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81. CONCLUSIONS: The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.