The Influence of Choice of Surgical Procedure on Long-Term Survival After Cardiac Surgery.

BACKGROUND: There is some interest in long-term survival after various cardiac surgical strategies, including off-pump versus on-pump coronary artery surgery (CAG), mitral valve (MV) repair versus replacement, and aortic valve (AV) bioprosthetic versus mechanical replacement. METHODS: We studied patients older than 49 years of age, recording risk factors and surgical details at the time of surgery. We classified procedures as: MV surgery with or without concurrent grafts or valves; AV surgery with or without concurrent CAG; or isolated CAG. Follow-up was through the state death register and state-wide hospital attendance records. Risk-adjusted survival was estimated using Cox proportional hazards. Observed survival was compared to the expected age- and sex- matched population survival. RESULTS: During a median follow-up of 14.8 years 5,807 of 11,718 patients died. The difference between observed and expected survival varied between 3.4 years for AV surgery and 9.6 years for females undergoing MV surgery. The risk-adjusted mortality hazard rate after off-pump CAG was 0.93 (95% CI 0.8-1.0, p=0.84), MV repair 0.67 (95% CI 0.6-0.8, p<0.0001), MV bioprosthesis 0.82 (95% CI 0.81 (0.6-1.0, p=0.11) and bioprosthetic AV replacement 1.02 (95% CI 0.9-1.2, p=0.82). CONCLUSIONS: Compared to the general population, cardiac surgical patients have a shorter than expected life expectancy. We observed a survival benefit of mitral valve repair over replacement. We did not observe significant survival differences between off-pump and on-pump CAG, nor between bioprosthetic and mechanical replacement.

Moderate exposure to allogeneic blood products is not associated with reduced long-term survival after surgery for coronary artery disease.

BACKGROUND: It has been suggested that blood transfusion has an adverse effect on long-term health, mainly through immune modulation and tumor promotion. To further assess this concern, the authors have performed a prospective observational study with the hypothesis that after taking perioperative risk factors relevant to long-term survival into account, patients undergoing coronary artery surgery who receive a perioperative allogeneic blood transfusion have worse long-term survival than those who do not. METHODS: The health outcomes of 1,841 consecutive subjects who had isolated nonemergency first-time coronary artery surgery and who survived more than 60 days after surgery were determined by record linkage. The association between length of survival, blood products transfused, and risk factors for long-term survival at entry to the study were determined by Cox proportional hazards regression. RESULTS: A total of 1,062 subjects were transfused. Of these, 266 subjects died during a mean follow-up of 8.1 yr. Of subjects who were transfused, 27% had a new malignant condition recorded on the death certificate, compared with 43% who were not transfused. Older age, cerebrovascular disease, use of a mammary graft, chronic pulmonary disease, renal dysfunction, reduced left ventricular function, and preoperative anemia were predictive of reduced long-term survival. There was no association between transfusion of blood products and long-term survival. CONCLUSIONS: Patients who have undergone coronary artery surgery and who have received moderate amounts of blood as part of responsible and conservative management should be reassured that they are unlikely to experience a reduction in long-term survival.

The effect of preoperative aspirin-free interval on red blood cell transfusion requirements in cardiac surgical patients.

OBJECTIVE: To compare red blood cell transfusion in first-time coronary artery surgery patients who stopped taking aspirin < or = 2 days, 3 to 7 days, or >7 days preoperatively. DESIGN: Observational study. SETTING: University-affiliated teaching hospital. PARTICIPANTS: Adult patients (n = 797) undergoing first-time coronary artery surgery on cardiopulmonary bypass who were not receiving other anticoagulant or antiplatelet drugs before surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were divided into 4 groups based on days since last ingestion of aspirin. Blood products transfused in the groups were (aspirin < or =2 days) (n = 140) 2.2 +/- 4 U of red cell concentrate (RCC) (mean +/- SD), 1.4 +/- 3 U of fresh frozen plasma (FFP), and 2.7 +/- 6 U of platelets; (aspirin 3 to 5 days) (n = 255), 1.5 +/- 2 U of RCC, 0.8 +/- 2 U of FFP, and 1.6 +/- 4 U of platelets; (aspirin 6 to 7 days) (n = 215), 1.6 +/- 3 U of RCC, 0.9 +/- 3 U of FFP, and 1.5 +/- 3 U of platelets; and (aspirin >7 days) (n = 187), 1.3 +/- 2 U of RCC; 0.6 +/- 2 U of FFP, and 0.9 +/- 2 U of platelets. CONCLUSION: Patients who stop taking aspirin < or =2 s preoperatively have increased allogenic red blood cell transfusion requirements perioperatively. Patients who stop taking aspirin 3 to 7 days preoperatively have little or no increased requirement for allogenic red blood cell transfusion.