Sustainability of clinical pathway guided care in cardiac surgery ICU patients; 9-years experience in over 7500 patients.

OBJECTIVE: To determine trends over time regarding inclusion of post-operative cardiac surgery intensive care unit (ICU) patients in a clinical pathway (CP), and the association with clinical outcome. DESIGN: Retrospective cohort study. SETTING: ICU of an academic hospital. PARTICIPANTS: All cardiac surgery patients operated between 2007 and 2015. MEASURES AND RESULTS: A total of 7553 patients were operated. Three patient groups were identified: patients treated according to CP (n = 6567), patients excluded from the CP within the first 48 h (n = 633) and patients never included in CP (n = 353). Patients treated according to CP increased significantly over time from 74% to 95% and the median Log EuroSCORE (predicted mortality score) in this group increased significantly over time (P = 0.016). In-hospital length of stay (LOS) decreased in all groups, but significantly in CP group (P < 0.001). Overall, the in-hospital, and 1-year mortality decreased from 1.5 to 1.1% and 3.7 to 2.9%, respectively (both P < 0.05). Patients with a Log EuroSCORE >10 were more likely excluded from CP (P < 0.001), but, if included in CP, these patients had a significantly shorter Intensive Care stay and in-hospital stay compared to excluded patients with a Log EuroSCORE >10 (both P < 0.001). CONCLUSIONS: The use of a CP for all post-operative cardiac surgery patients in the ICU is sustainable. While more complex patients were treated according to the CP, clinical outcome improved in the CP group.

Feasibility and Outcomes of Transcatheter Aortic Valve Implantation Using the Left Axillary Artery as Primary Access Site.

BACKGROUND: The femoral artery is generally used as primary access for transcatheter aortic valve implantation. However, peripheral artery disease often precludes femoral access. The purpose of this study was to describe clinical outcome of transcatheter aortic valve implantation using the left axillary artery (LAA) as primary access site. METHODS: From December 2008 until June 2016, data on all consecutive patients treated with a Medtronic device through the LAA at our hospital were registered, and outcome was prospectively collected according to the updated Valve Academic Research Consortium-2 criteria. Mortality check was performed nationally. RESULTS: In total, 362 patients were included (median age 80 years [range, 76 to 84]; logistic European System for Cardiac Operative Risk Evaluation 17% ± 12%). Successful axillary access was achieved in 99%. Medtronic CoreValve (86%) and Evolut R (14% [Medtronic, Minneapolis, MN]) were implanted. Major vascular complications occurred in 5% of patients, 1% was LAA related. Life-threatening bleeding and major bleeding were observed in 2% and 10%, respectively. Additional complications were new left bundle branch blood (30%), new permanent pacemaker (11%), and stroke (1%). There were 6 procedural deaths (2%) and 19 deaths (5%) within 30 days. One-year mortality rate was 19%. CONCLUSIONS: This is the first study reporting outcome after transcatheter aortic valve implantation using the LAA as default access. We conclude that it is highly feasible and safe with low rates of major vascular complications, bleeding, and stroke.

Effect of dipyridamole on myocardial reperfusion injury: A double-blind randomized controlled trial in patients undergoing elective coronary artery bypass surgery.

Dipyridamole reduces reperfusion-injury in preclinical trials and may be beneficial in patients undergoing coronary angioplasty, but its effect on patients undergoing coronary artery bypass grafting (CABG) is unknown. We hypothesized that dipyridamole limits myocardial reperfusion-injury in patients undergoing CABG. The trial design was a double-blind trial randomizing between pretreatment with dipyridamole or placebo. In all, 94 patients undergoing elective on-pump CABG were recruited between February 2010 and June 2012. The primary endpoint was plasma high-sensitive (hs-) troponin-I at 6, 12, and 24 hours after reperfusion. Secondary endpoints were the occurrence of bleeding, arrhythmias, need for inotropic support, and intensive care unit length of stay. Finally, 79 patients (33 dipyridamole) were included in the per-protocol analysis. Dipyridamole did not significantly affect postoperative hs-troponin-I (change in plasma hs-troponin I -3% [95% confidence interval -23% to 36%]; P > 0.1). Secondary endpoints did not differ between groups. Dipyridamole prior to CABG does not significantly reduce postoperative hs-troponin release.

Sex differences in patient and procedural characteristics and early outcomes following cardiac surgery.

AIM: The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer postoperative complications and mortality than men with respect to baseline and procedural characteristics. METHODS: Data of 4030 adult patients undergoing cardiac surgery between January 2007 and June 2012 were retrospectively analyzed; 3075 isolated CABGs (CABG-group) and 955 aortic valve replacements (AVR) whether or not in combination with CABG (VALVE-group) The total study population, had a mean age 69.6 ±10.3 years, and there were 1073/4030 women (26.6%). RESULTS: Female patients were older (P=0.001), at higher EuroSCORE risk (P=0.001) and have a higher BMI (P=0.001). In the CABG-group female patients receive fewer distal anastomoses (P=0.001) and arterial grafts were less frequently used (P=0.002). In the combined procedures in women less distal anastomoses were applied (P=0.029). Postoperative female CABG patients have a higher hospital mortality (P=0.031) and early mortality (P=0.019). In the VALVE group there is no difference in hospital or early mortality between both genders. Binary logistic regression did not identify female gender as an independent risk factor for hospital- or early mortality in both patient groups. CONCLUSION: Although female patients undergoing cardiac surgery are older and at higher risk, female gender is not an independent risk factor. The operative procedure and gender related differences in treatment may be important and affect the outcome.

Organized follow-up is essential for the evaluation of cardiac surgery.

AIM: Follow-up in adult cardiac surgery seems problematic. Mostly only hospital data are presented. Evaluation of performed cardiac surgery, is based on these data. However is this appropriate? This study evaluates the results of our follow-up (FU) in terms of completeness, drop out and survival in relation to the operative risk and the difference between hospital mortality, 30-day, 6-month and 1-year mortality. METHODS: Three thousand three hundred twenty-eight patients operated between January 2007 and December 2010 were included. Hospital mortality was 1.68% (56/3328). The date of mortality or the last date of information is endpoint. Our FU is twofold, the Organized FU (OFU) a yearly performed FU by mean of a written survey directly to all patients. A non-organized FU (NOFU) covering all information supplied spontaneously by cardiologists, general practitionars, family or others. RESULTS: Completeness decreases from 99.1% at 30-days over 85.6% at 1-year postoperative. During the first year there is no statistical significant difference between patients in or lost for FU, concerning age and Euroscore risk. Survival analysis shows a difference in one-year survival related to the risk.The statistical difference between hospital mortality and the registered 30-day, 6-month and 1-year mortality is related to the Euroscore risk class but also to the number of unobserved patients survival or mortality. CONCLUSION: This study shows that hospital mortality, 30-day-, 6 months- and 1-year mortality is related to the operative risk and the number of unobserved patients Most efficient seems an OFU at one year postoperative, where not only mortality but also survival is registered.

Is a sedentary lifestyle an independent predictor for hospital and early mortality after elective cardiac surgery?

OBJECTIVE: This study evaluates whether a sedentary lifestyle is an independent predictor for increased mortality after elective cardiac surgery. METHODS: Three thousand one hundred fifty patients undergoing elective cardiac surgery between January 2007 and June 2012 completed preoperatively the Corpus Christi Heart Project questionnaire concerning physical activity (PA). Based on this questionnaire, 1815 patients were classified as active and 1335 patients were classified as sedentary. The endpoints of the study were hospital mortality and early mortality. RESULTS: The study population had a mean age of 69.7 ± 10.1 (19-95) years and a mean logistic EuroSCORE risk of 5.1 ± 5.6 (0.88-73.8). Sedentary patients were significantly older (p = 0.001), obese (p = 0.001), had a higher EuroSCORE risk (p = 0.001), and a higher percentage of complications. Hospital mortality (1.1 % versus 0.4 % (p = 0.014)) and early mortality (1.5 % versus 0.6 % (p = 0.006)) were significantly higher in the sedentary group compared with the active group. However, a sedentary lifestyle was not identified as an independent predictor for hospital mortality (p = 0.61) or early mortality (p = 0.70). CONCLUSION: Sedentary patients were older, obese and had a higher EuroSCORE risk. They had significantly more postoperative complications, higher hospital mortality and early mortality. Despite these results, sedentary behaviour could not be identified as an independent predictor for hospital or early mortality.

Cardiac operative risk evaluation: The EuroSCORE II, does it make a real difference?

BACKGROUND: The EuroSCORE, worldwide used as a model for prediction of mortality after cardiac surgery, has recently been renewed. Since October 2011, the EuroSCORE II calculator is available at the EuroSCORE website and recommended for clinical use. The intention of this paper is to compare the use of the initial EuroSCORE and EuroSCORE II as a risk evaluation tool. METHODS: 100 consecutive patients who underwent combined mitral valve and coronary bypass surgery (MVR + CABG) and 100 consecutive patients undergoing combined aortic valve surgery and coronary bypass surgery (AVR + CABG) at the Radboud University Nijmegen Medical Center before 10 October 2011 were included. For both groups the initial EuroSCORE and the EuroSCORE II model were used for risk calculation and based on the calculated risks, cumulative sum charts (CUSUM) were constructed to evaluate the impact on performance monitoring. RESULTS: For the MVR + CABG group the calculated risk using the initial logistic EuroSCORE was 9.95 ± 8.47 (1.51-45.37) versus 5.08 ± 4.03 (0.67-19.76) for the EuroSCORE II. For the AVR + CABG group 9.50 ± 8.6 (1.51-69.5) versus 4.77 ± 6.6 (0.96-64.24), respectively. For both groups the calculated risk by the EuroSCORE II was statistically lower compared with the initial EuroSCORE (p < 0.001). This lower expected risk has influence on performance monitoring, using risk-adjusted CUSUM analysis. CONCLUSION: The EuroSCORE II, based on a recently updated database, reduces the overestimation of the calculated risk by the initial EuroSCORE. This difference is statistically significant and the EuroSCORE II may also reflect better current surgical performance.

Quality of life one year post myocardial revascularization and aortic valve replacement in patients aged 70 year or older.

AIM: The aim of this study was to investigate changes of health-related quality of life (HRQOL) at one year post myocardial revascularization (CABG) and post aortic valve replacement (AVR) in patients aged 70 years or older. METHODS: Of 102 CABG patients and 69 AVR patients preoperative and follow-up data on QOL, were completed. For assessing HRQoL, the EuroQol instrument (EQ) was used. The EQ-5D index score was calculated, based on separate scores of 5 health domains, to express the global health status of the patient. The EQ visual analogue scale (VAS) was used to describe patients' subjective HRQoL. RESULTS AND CONCLUSION: At one year postoperative, the EQ-5D index of the CABG group shows a significant increase (P=0.038), while that of the AVR group does not (P=0.26). The EQ-VAS registration, however, shows a significant increase for both the CABG group (P=0.003) and the AVR group (P=0.021). Considering the 5 domains of the registered HRQOL, in the AVR group only the calculated mean of the item "pain and discomfort" shows a significantly better score postoperatively (P=0.006). In the CABG group, mobility (P=0.016), pain and discomfort (P=0.15) and anxiety (P=0.036) get significantly better scores postoperatively. In conclusion, in elderly patients HRQOL strongly increases after CABG and AVR. However the improvement of functional and social quality of life is less far-going in patients undergoing AVR than in CABG patients.

Evaluation of quality in adult cardiac surgery: let us speak the same language.

Over the last years, measurements of quality of care have become more and more a public product, used by providers, purchasers and consumers, and patients. This information serves as an important guide for improvement, as well as a decision support tool for everybody taking part in medical treatment. This evolution can be compared with advertising and as in commercials it is important to use the right information. In this report we focus on the quality of adult cardiac surgery. Honest information is of course essential, but in this article attention is asked for the variables used to evaluate the quality of cardiac surgery. (Neth Heart J 2010;18:365-9.).

Stroke after coronary artery bypass grafting. Is there place for a stroke-risk stratification model?

AIM: Preoperative carotid screening is common in the prevention of perioperative stroke. The authors describe our experience with selective screening of patients with a recent (<1 year) neurological event. Because many variables are related with the development of perioperative stroke we additionally evaluate the value of a stroke-risk stratification model. METHODS: Of 1 442 isolated myocardial revascularizations performed between January 2002 and December 2005, 118 patients had a history of preoperative stroke. Twenty-four patients had a recent stroke. In 5/24 patients duplex revealed significant stenosis of the internal carotid artery, which was treated prophylactically. RESULTS: Eleven patients (0.83%) developed a perioperative stroke. Three patients recovered completely during hospital stay, three died related to their stroke. Of the other 94 patients with a history of stroke, 5 had a stroke, none of them had a significant stenosis of the carotid artery. Of the 1,224 patients without a history of stroke, 6 developed a perioperative stroke. Three of them had a significant carotid artery stenosis, however in two patients stroke deficit was on the ipsilateral side and the third patient had a transient ischemic attack. All eleven patients had a calculated stroke risk of 3 or higher corresponding with a expected risk of at least 0.9%. CONCLUSIONS: With the used protocol, in the described patient population, perioperative stroke incidence is low. on the other hand, the complexity of the mechanism of perioperative stroke is confirmed and the use of a stroke-risk stratification model seems us justified for a better identification of patients at risk.

Will cardiac surgery improve my quality of life?: Visual analogue score as a first step in preoperative counseling.

BACKGROUND.: The intention of this study is to analyse the correlation between a visual analogue scale (VAS) and the most common preoperative comorbidity and cardiac variables in patients undergoing elective cardiac surgery. This VAS is simple, easy to register and can be used as a global measurement of quality of life (QOL). METHODS.: Preoperative assessment of QOL in 1351 patients, 979 men and 372 women, with a mean age of 64.5+/-10.5 (18-88), undergoing elective cardiac surgery between January 2003 and December 2005. QOL was measured by the EuroQol questionnaire. RESULTS.: The mean VAS was 58.7+/-20.9, range 3 to 100. Univariate analysis showed a difference for sex (p=0.000), and NYHA (p=0.009) between patients with an isolated CABG and those with a combined revascularisation (p=0.05). Stepwise logistic regression analysis identified female gender (p=0.00), NYHA (p=0.00) and valve disease (p=0.03) as independent variables for a low QOL. The correlation between NYHA and QOL was low (r=-0.09, p=0.003). CONCLUSION.: The clinical consequence is that using this simple VAS we can identify patients with a good QOL. If these patients present for high-risk surgery, with a better quality of life as primary indication, more extended counselling regarding their QOL is recommended. (Neth Heart J 2007;15:51-4.).

Physical activity post myocardial revascularization. ''Will surgery improve my mobility?

AIM: The aim of this study is to evaluate the influence of coronary artery bypass graft (CABG) on physical activity (PA) one year postoperative and the influence of the preoperative level of PA on the postoperative PA level. METHODS: In 428 patients, mean age 64.1+/-9.2 (30-84), undergoing an isolated CABG in 2003, pre and one year postoperatively PA was recorded. Preoperatively, 4 patients (0.9%) were in NYHA I, 33 (7.7%) in NYHA II, 334 (78%) in NYHA III and 57 patients (13.4%) in NYHA class IV. PA was recorded following the Honolulu Heart project. For analysis purposes PA levels were classified as sedentary, 41 patients (9.5%) or minimally active, 161 patients (37.6%) were included in a single sedentary group; 202 patients (47.1%). Patients classified as moderately active, 127 patients (29.6%), active, 72 patients (16.8%) and very active, 27 patients (6.3%) were included in a single active group, 226 patients (52.9%). RESULTS: One year postoperatively, 394 patients (92.%) indicated they were angina-free. One hundred seventy-seven patients (41.3%) recorded a better PA-level. One hundred seventy-one patients (40%) recorded the same and 80 patients (18.7%) had a lower PA level. Significantly more patients, 63.9% of the sedentary group versus 21.2% of the active group recorded a higher PA level (P=0.00). Multivariate analysis identified a preoperative active level and vascular disease as risk factors for decreased postoperative PA (P=0.00, odds ratio: 8.1) and a sedentary level as a risk factor for no increase (P=0.00, odds ratio 6.8) CONCLUSIONS: Sedentary patients are likely to show an improvement, however, a sedentary lifestyle is a predictor of no increase in PA. Patients with an active level are unlikely to benefit from surgery.

Myocardial revascularisation in women: evaluation of hospital mortality and morbidity.

BACKGROUND: Although women are reported to be at higher risk for mortality and morbidity after coronary artery bypass graft (CABG), there is no consensus in literature. METHOD: Pre-, peri- and postoperative hospital data of 8578 patients undergoing an isolated myocardial revascularisation from January 1987 to December 2004 were analysed. Of these patients, 2083 (24.3%) were female. RESULTS: Female patients were significantly older (p=0.001), and risk factors as diabetes (p=0.001), hypertension (p=0.001), hyperlipidaemia (p=0.001) were significantly more prevalent than in men. The incidence of preoperative myocardial infarction (p=0.001) and triple-vessel disease (p=0.001) was lower, but the incidence of unstable angina (NYHA IV) (p=0.001) was significantly higher than in men. Significantly fewer women (p=0.04) received an arterial graft. Postoperatively, there was no significant difference in the registered morbidity, with the exception of a lower incidence of female patients with non-sinus rhythm (p=0.001) and a higher incidence of pulmonary problems (p=0.006). Hospital mortality was not significantly different between the genders: 3.5 vs. 3.4% (p=0.9). A preoperative myocardial infarction was identified as the only independent predictor for hospital mortality. CONCLUSION: The preoperative profiles of women and men undergoing CABG are dissimilar. However, the incidences of hospital mortality, and morbidity were not statistically different. Female gender was not identified as predictor for death or adverse outcome.