Enhanced Recovery After Surgery Is Associated With Improved Outcomes and Reduced Racial and Ethnic Disparities After Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis With Propensity-Score Matching.

OBJECTIVES: To evaluate whether enhanced recovery after surgery (ERAS) protocol implementation was associated with improved outcomes and decreased racial and ethnic outcome disparities after isolated coronary artery bypass graft (CABG) surgery. DESIGN: A retrospective analysis of an institutional CABG database with propensity-score matching. SETTING: At a single tertiary care teaching hospital. PARTICIPANTS: One thousand seven hundred thirty-five patients undergoing isolated CABG: 656 patients from 2016 to 2017 (pre-ERAS) and 1,079 patients from 2018 to 2020 (post-ERAS). Each patient cohort was divided into a White subgroup and a racial and ethnic minorities (Minorities) subgroup. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Propensity-matched post-ERAS patients (n = 584) compared to pre-ERAS patients (n = 584) demonstrated reductions in total length of stay (LOS) (median [interquartile range]): (7 [5-10] v 8 [6-11.5] days, p = .006), postoperative LOS (5 [4-7] v 5 [4-7] days, p = .001), total ventilation time (6.1 [4.8-9.5] v 6.6 [5.2-10.9] hours, p = .004), postoperative morphine milligram equivalents (mean ± standard deviation: 68.6 ± 57.5 v 100.0 ± 59.4, p < .001), and increased likelihood of early extubation (48.8% v 42.3%, p = .026); the Minorities subgroup demonstrated reductions in likelihood of intensive care unit (ICU) readmission (1.3% v 8.1%, p = .012) and postoperative morphine milligram equivalents (73.6 ± 64.0 v 107.8 ± 71.9, p < .001). Logistic regression models demonstrated that disparities in ICU readmission and postoperative LOS between White and Minorities patients were eliminated post-ERAS. CONCLUSIONS: ERAS for isolated CABG surgery was associated with reduced total and postoperative LOS, reduced total ventilation time, and increased early extubation for all patients, as well as reduced ICU readmission for the Minorities subgroup. ERAS implementation was associated with reduced disparities between White and racial and ethnic minority patients for ICU readmission and postoperative LOS.

Urgent aortic valve replacement in octogenarians: does an 'urgent' status increase morbidity and mortality?

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate the influence of 'urgent' status on short and long-term mortality and morbidity in a consecutive series of octogenarian patients who underwent aortic valve replacement (AVR). METHODS: Between January 2005 and March 2009, data were extracted for 141 consecutive patients aged over 80 years who underwent AVR either urgently (n = 49) or electively (n = 92). Early outcomes (in-hospital mortality, postoperative morbidities) and long-term outcomes were compared during a 39-month follow up period. The outcomes were compared after adjustment for differences in baseline risk factors. RESULTS: Patients of the 'urgent' group were older and had more comorbidities than those in the 'elective' group. There was a non-significant trend towards a higher in-hospital mortality in the 'urgent' group (10.2% versus 4.3%, p = 0.18). The 39-month survival rate was 81% in elective patients, and 71% in urgent patients (p = 0.166). CONCLUSION: AVR can be performed in the elderly population with acceptable early and mid-term results, despite their urgent status. A large clinical trial is warranted to confirm the influence of an urgent status in octogenarian patients treated with surgical AVR.

The impact of pulmonary hypertension on outcomes of patients with low left ventricular ejection fraction: a propensity analysis.

BACKGROUND AND AIM OF THE STUDY: Pulmonary hypertension (PH) is commonly described as a risk factor in cardiac surgery; however, the effect of a low left ventricular ejection fraction (LVEF) on PH has not been assessed. Hence, the study aim was to determine whether PH increases operative mortality and survival outcome in patients with a low LVEF. METHODS: Between January 2001 and September 2009, a total of 845 consecutive patients with LVEF < 40% was enrolled into the study. Among these patients, 444 had a pulmonary pressure < 40 mmHg (NPH group), while in 401 patients the pulmonary pressure was > or = 40 mmHg. RESULTS: Preoperatively, the PH patients were older (p < 0.001), had a lower LVEF (p = 0.001), and had a higher logistic EuroSCORE (p < 0.001) and serum creatinine level (p < 0.026) when compared to NPH patients. The PH patients showed a greater tendency to develop postoperative complications (p < 0.001). After adjusting by propensity score, the in-hospital mortality was significantly higher among PH patients (p < 0.001), while multivariate logistic regressions revealed PH as an independent predictor for in-hospital mortality (p = 0.036). The 12-, 36-, and 60-month follow up mortality rates were significantly higher in the PH group. By using a Cox logistic regression model, PH was shown to be an independent predictor for follow up mortality (p = 0.035). CONCLUSION: Pulmonary hypertension increased the morbidity and mortality in patients with a low LVEF who were undergoing cardiac surgery. Future studies may identify subgroups that may benefit from a preoperative optimization of PH and/or intra- and postoperative therapies directed at minimizing the effects of the condition.

Long-term efficacy and safety of sirolimus-eluting vs bare-metal stents.

BACKGROUND: Although previous studies have documented persistent clinical benefit of sirolimus-eluting stents (SES)in reducing the need for target vessel revascularization without an increase in myocardial infarction (MI) or mortality, the long-term safety and efficacy of CYPHER stent use in routine clinical practice, including off-label stent implantation, remains uncertain. METHODS: We compared long-term clinical outcomes in 2,550 patients treated with one or more SES with 1,022 patients treated with one or more bare metal or heparin-coated stents (BMS). The study groups included 1,058 SES patients (41.5%) and 488 BMS patients (47.7%) with off-label indications. A propensity-score method was utilized to adjust for differences in baseline characteristics. Patients were followed for up to five years for the occurrence of all-cause mortality, MI and repeat target vessel revascularization. RESULTS: Compared to BMS patients, SES patients demonstrated significantly improved event-free survival with respect to all-cause mortality (RR, 1.39; 95% CI, 1.07 to 1.80, P = 0.014) and repeat target vessel revascularization (RR, 2.72; 95% CI, 1.99 to 3.73, P < 0.001), with no significant difference in the incidence of cumulative MI. A landmark analysis, examining composite adverse events occurring six months after stent implantation in the two study groups, demonstrated no increased late hazard associated with SES use (relative risk, 1.08; 95% CI, 0.80 to 1.46). CONCLUSIONS: Use of SES in routine clinical practice, including off-label indications, is associated with improved long-term mortality, reduced need for repeat target vessel revascularization and no increase in MI compared to BMS.

Results of primary percutaneous transluminal coronary angioplasty plus abciximab with or without stenting for acute myocardial infarction complicated by cardiogenic shock.

This study examines the effects of abciximab as adjunctive therapy in primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI) complicated by cardiogenic shock. Abciximab improves the outcome of primary PTCA for AMI, but its efficacy in cardiogenic shock remains unknown. Case report forms were completed in-hospital and follow-up was obtained by telephone, outpatient visit, and review of hospital readmission records. A total of 113 patients with cardiogenic shock from AMI were included. All underwent emergency PTCA during which abciximab was administered to 54 patients (48%). The 2 groups of patients who received and did not receive abciximab were similar at baseline. Coronary stents were implanted slightly more often in the abciximab group (59% vs 42%; p = 0.1). A significantly improved final TIMI flow, less no-reflow, and a decrease in vessel residual diameter stenosis occurred in the abciximab group. At 30-day follow-up, the composite event rate of death, myocardial reinfarction, and target vessel revascularization was better in the abciximab group (31% vs 63%; p = 0.002). The combination of abciximab and stents was synergistic and resulted in improvement of all components of the composite end point beyond that seen with each therapy alone. Thus, abciximab therapy improves the 30-day outcome of primary PTCA in cardiogenic shock, especially when combined with coronary stenting.