The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.

OBJECTIVE: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery. DESIGN: A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data. SETTING: Three interrelated, university-affiliated, community hospitals. PARTICIPANTS: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006. INTERVENTIONS: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A "greedy 5 to 1" propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation. CONCLUSIONS: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.

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.

Initial experience with the enclose proximal aortic anastomosis device during off-pump coronary artery bypass: an alternative to aortic side clamping.

BACKGROUND: The utilization of off-pump coronary artery bypass surgery (OPCAB) has resulted in the development of new technology to facilitate the creation of aorto-coronary graft anastomoses. Proximal aortic devices (PADs) enable the construction of a proximal aortic anastomosis without the use of a side-biting aortic clamp, thus reducing the risk of neurologic injury from particulate embolization. METHODS: One hundred ninety-seven patients underwent OPCAB at our institution between January 2003 and December 2004. Sixty (30.5%) patients had proximal aorto-coronary graft anastomoses constructed with the Novare Enclose PAD. The remaining 137 (69.5%) patients had graft construction with a standard aortic side-clamp technique. We compared the outcomes of these 2 cohorts to evaluate the safety and efficacy of the Novare Enclose PAD. RESULTS: One hundred seven proximal anastomoses were constructed in the PAD group, and 199 proximal were constructed in the side-clamp group. Three patients (1.5%), all in the side-clamp group, sustained permanent neurologic deficits after OPCAB. There were 2 cases of device malfunctions. There were no anastomotic thromboses, no reoperations for anastomotic hemorrhage, and no patients required anastomotic revision. Of the 197 patients in the series, there were 4 deaths, 2 in each group, resulting in an overall mortality rate of 2%. CONCLUSION: The Novare Enclose PAD is a safe device that facilitates suture construction of proximal aorto-coronary graft anastomosis. In a select group of patients, the use of this device may reduce the risk of neurologic injury when compared to the application of an aortic side-biting clamp for coronary bypass surgery.

Port-access-assisted aortic valve replacement: a comparison of minimally invasive and conventional techniques.

BACKGROUND: A hybrid Port-Access (PA) approach to aortic valve surgery (MPAVR) was designed as a less invasive aortic valve operation. The approach combines components of Port-Access technology with conventional cardiac surgical techniques via a limited sternal incision. This technique is compared to conventional aortic vale replacement (CAVR) for safety and efficacy. METHODS: One hundred eighty patients had aortic valve surgery between January 1, 2000, and June 30, 2004. Fifty-eight patients (32%) had primary isolated aortic valve replacement, 22 of those 58 patients (38%) underwent MPAVR procedures consisting of a limited inverted-T sternotomy, direct aortic cannulation, a percutaneous PA endocoronary sinus cardioplegia catheter, an endovent pulmonary artery catheter, and a percutaneous femoral endovenous return catheter. Thirty-six patients (62%) had aortic valve replacement by sternotomy and standard cardiopulmonary bypass techniques. The MPAVR and CAVR groups were compared for demographics and intraoperative and postoperative outcomes. RESULTS: Age, obesity, diabetes, New York Heart Association classification, ejection fraction, and other patient characteristics were not significantly different between the groups. MPAVR patients had lower Society of Thoracic Surgery risk scores (3.1 versus 3.9; P = .277). MPAVR patients were more likely to receive a stentless valve (36% versus 11%; P = .042) and required longer operative times (237 min versus 189 min; P <.001). Postoperative complications were minimal and equivalent. A single mortality in the CAVR group resulted in an overall mortality of 1.7%. CONCLUSION: This hybrid, less invasive PA-assisted approach to aortic valve surgery is safe and effective. A total sternotomy can be avoided in selected aortic valve patients. Results equivalent to CAVR can be expected with this minimal access operation.

Outcomes after usage of a quality initiative program for off-pump coronary artery bypass surgery: a comparison with on-pump surgery.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) may be associated with improved outcomes when compared with on-pump coronary artery bypass. This study evaluates the use of a system for access and stabilization (SAS) with a coronary stabilizer as well as a clinical effectiveness quality initiative (CEQI) process regarding outcomes. This included the development of an expanded heart care team as well as standardization and refinement of perioperative care at The Lankenau Hospital (TLH). Our aim was to evaluate morbidity and mortality of on-pump coronary artery bypass grafting (CABG) compared with OPCAB surgery using SAS in addition to a CEQI initiative. METHODS: A retrospective consecutive cohort study using the Society of Thoracic Surgery (STS) National Database was conducted. Three cohorts were analyzed: pre-SAS (December 1, 1999-August 31, 2000); use of SAS only (September 1, 2000-April 30, 2001), and the use of SAS + CEQI process (May 1, 2001-September 30, 2002). Morbidity and mortality for all on-pump CABG procedures performed over the time period of December 1, 1999-September 30, 2002 were compared with the SAS and SAS + CEQI groups only. RESULTS: One-thousand two-hundred sixty-seven procedures were performed; 405 on-pump CABGs, 90 OPCABs pre-SAS, and 772 OPCABs with SAS, of which 552 were in the SAS + CEQI group. Statistically mortality was significantly lower in the SAS + CEQI vs the on-pump group (0.7% vs 3.0%, p < 0.01). The percentage of patients with prolonged ventilation was significantly lower statistically in the SAS + CEQI vs the on-pump group (4.2% vs 9.7%, p < 0.01). Statistically the length of stay was significantly lower in both SAS groups compared with the on-pump group (p < 0.01). CONCLUSIONS: OPCAB surgery using SAS in conjunction with a CEQI initiative improves outcomes for patients compared with on-pump CABG surgery.

Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry decreases the incidence of stroke for cardiac surgical patients.

BACKGROUND: A recent study demonstrated that almost 75% of strokes after coronary artery revascularization surgery occur in patients classified preoperatively as low to medium risk. Thus, despite the use of risk classification, most strokes can occur when not expected. We hypothesized that optimization of cerebral oxygen delivery variables by using noninvasive cerebral oximetry could reduce the incidence of stroke. METHODS: Cerebral oximetry was used by all surgeons to monitor cerebral oxygen saturation in all cardiac surgery patients from January 1, 2002, until June 30, 2003 (n = 1034; 18 months, treatment group). Cerebral oxygen delivery was optimized during surgery by modifying oxygen delivery and consumption variables to maintain oximetry values at or near the patient's preinduction baseline. Stroke was defined according to guidelines of the Society of Thoracic Surgeons. The incidence of stroke in the treatment group was compared with that for patients who underwent cardiac surgery between July 1, 2000, and December 31, 2001, (n = 1245; 18 months, control group) before cerebral oximetry was incorporated. RESULTS: Age and sex distribution were similar in the 2 groups. The study group had significantly more patients in New York Heart Association (NYHA) classes III and IV than the control group, and patients in the study group were sicker overall. Despite this difference, the study group overall had fewer permanent strokes (10 [0.97%] versus 25 [2.5%]; P < .044). This difference remained significant when the results were controlled for NYHA class and on-pump or off-pump surgery. When the patients were examined by NYHA class, the proportion of patients requiring prolonged ventilation was significantly smaller in the study group (6.8% versus 10.6%; P < .0014), as was the length of hospital stay (P < .046). CONCLUSIONS: The treatment group, which underwent all cardiac surgeries with optimized cerebral oxygen delivery using cerebral oximetry monitoring, demonstrated a significantly lower incidence of permanent stroke. Because our study is retrospective, a prospective randomized trial is warranted.