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1.
Braz J Cardiovasc Surg ; 34(4): 396-405, 2019 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-31454193

RESUMO

OBJECTIVE: To evaluate whether there is any difference on the results of patients treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) in the setting of ischemic heart failure (HF). METHODS: Databases (MEDLINE, Embase, Cochrane Controlled Trials Register [CENTRAL/CCTR], ClinicalTrials.gov, Scientific Electronic Library Online [SciELO], Literatura Latino-americana e do Caribe em Ciências da Saúde [LILACS], and Google Scholar) were searched for studies published until February 2019. Main outcomes of interest were mortality, myocardial infarction, repeat revascularization, and stroke. RESULTS: The search yielded 5,775 studies for inclusion. Of these, 20 articles were analyzed, and their data were extracted. The total number of patients included was 54,173, and those underwent CABG (N=29,075) or PCI (N=25098). The hazard ratios (HRs) for mortality (HR 0.763; 95% confidence interval [CI] 0.678-0.859; P<0.001), myocardial infarction (HR 0.481; 95% CI 0.365-0.633; P<0.001), and repeat revascularization (HR 0.321; 95% CI 0.241-0.428; P<0.001) were lower in the CABG group than in the PCI group. The HR for stroke showed no statistically significant difference between the groups (random effect model: HR 0.879; 95% CI 0.625-1.237; P=0.459). CONCLUSION: This meta-analysis found that CABG surgery remains the best option for patients with ischemic HF, without increase in the risk of stroke.


Assuntos
Ponte de Artéria Coronária/mortalidade , Insuficiência Cardíaca/cirurgia , Isquemia Miocárdica/cirurgia , Intervenção Coronária Percutânea/mortalidade , Acidente Vascular Cerebral/etiologia , Idoso , Brasil/epidemiologia , Ponte de Artéria Coronária/efeitos adversos , Métodos Epidemiológicos , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Metanálise como Assunto , Estudos Multicêntricos como Assunto , Isquemia Miocárdica/mortalidade , Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como Assunto , Acidente Vascular Cerebral/mortalidade , Resultado do Tratamento
2.
Medicine (Baltimore) ; 98(34): e16880, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31441862

RESUMO

INTRODUCTION: Saphenous vein graft (SVG) is the most common conduit used for coronary artery bypass grafting (CABG) surgery. Unfortunately, SVG are associated with poor long-term patency rates; a significant predictor of re-operation rates and survival. As such, medical therapy to prevent SVG narrowing or occlusion is of paramount importance. Aspirin (ASA) monotherapy is the standard of care after CABG, to improve long-term major adverse cardiovascular events (MACE) and graft patency. Benefits of dual antiplatelet therapy (DAPT) have not been well established in all CABG patients. We present a protocol for a network meta-analysis (NMA) comparing the effects of various antiplatelet therapy regimens on SVG patency, mortality, and bleeding among adult patients following CABG. METHODS: We will search CENTRAL, MEDLINE, EMBASE, CINAHL ACPJC, and grey literature sources (AHA, ACC, ESC, and CCC conference proceedings, ISRCTN Register, and WHO ICTRP) for randomized controlled trials (RCTs) which fit our criteria. RCTs that evaluate different antiplatelet regimens at least 3-months after CABG and have any of SVG patency, mortality, MACE, and major bleeding as outcomes will be selected. We will perform title and abstract screening, full-text screening, and data extraction independently and in duplicate. Two independent reviewers will also assess risk of bias (ROB) for each study, as well as evaluate quality of evidence using the GRADE framework. We will use R to perform the NMA and use low-dose ASA as reference within our network. We will report results as odds ratios with confidence intervals for direct comparisons, and credible intervals for indirect or mixed comparisons. We will use the surface under the cumulative ranking curve (SUCRA) to estimate the ranking of interventions. DISCUSSION: Given the limited direct comparison of various antiplatelet regimens, a network approach is ideal to clarify the optimum antiplatelet therapy after CABG. We hope that our NMA will be the largest quantitative synthesis evaluating antiplatelet regimens among patients requiring CABG. It should inform clinicians and guideline developers in selecting the most effective and safest antiplatelet regimen.Systematic Review registration: International Prospective Register for Systematic Reviews (PROSPERO)-CRD42019127695.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Inibidores da Agregação de Plaquetas/uso terapêutico , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/cirurgia , Humanos , Meta-Análise em Rede , Veia Safena/transplante , Revisão Sistemática como Assunto , Resultado do Tratamento
4.
J Cardiothorac Surg ; 14(1): 109, 2019 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-31202278

RESUMO

BACKGROUND: The purpose of this study was to investigate whether age has an effect on short and long-term outcome in patients who undergo simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy. METHODS: From 2005 to 2017, 186 consecutive elective patients underwent CABG and synchronous endarterectomy at our institution. Patients were retrospectively classified according to age into 2 groups: patients above 70 years (elderly group: n = 97, 76.1 ± 3.9 years) and patients below 70 years (younger group: n = 89, 63.2 ± 4.8 years). RESULTS: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, 4.4% vs. 2.5%; p < 0.001) and Society of Thoracic Surgeons (STS) score (0.7% vs. 1.6%; p < 0.001) were significantly higher in the elderly group. Otherwise, there was no difference between the two groups concerning important preoperative risk factors or the intraoperative data. Postoperatively, the incidence of temporary dialysis was significantly higher in the elderly group (14.4% vs. 3.4%; p = 0.009). The rate of tracheotomy (16.5% vs. 2.2%; p = 0.001), of re-intubation (7.9% vs. 18.6%; p = 0.033) and drainage loss (600 ml vs. 800 ml; p = 0.035) was significantly higher in this elderly group. Neurological complications and 30-day mortality were comparable. Long-term survival was satisfactory for both groups. Nevertheless, 5-year survival rates (63% vs. 85%) were significantly lower in the elderly group (p = 0.003). Logistic regression analysis identified chronic obstructive pulmonary disease (COPD) and arrhythmia as significant risk factors for 30-day-mortality, but not age. CONCLUSIONS: CABG in combination with synchronous endarterectomy can also be performed with satisfactory results in elderly patients.


Assuntos
Ponte de Artéria Coronária/mortalidade , Endarterectomia das Carótidas/mortalidade , Fatores Etários , Idoso , Arritmias Cardíacas/etiologia , Feminino , Alemanha , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
5.
Braz J Cardiovasc Surg ; 34(5): 542-549, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31112030

RESUMO

OBJECTIVE: To evaluate the prognostic value of CHA2DS2-VASc score in individuals undergoing isolated coronary artery bypass grafting (CABG) surgery. METHODS: Records of consecutive 464 patients who underwent elective isolated CABG, between January 2015 and August 2017, were retrospectively reviewed. A major adverse cardiac event (MACE) was the primary outcome of this study. MACE in patients with low (L) (<2, n: 238) and high (H) (≤2, n: 226) CHA2DS2-VASc scores were compared. Univariate logistic regression analysis identified preditors of MACE. RESULTS: Hypertension, diabetes mellitus, and peripheral vascular disease were more frequent in the H group than in the L group. European System for Cardiac Operative Risk Evaluation (EuroSCORE) I and SYNTAX I scores were similar in both groups while SYNTAX II-CABG score was significantly higher in the H group than in the L group. Postoperative myocardial infarction, need for intra-aortic balloon pump, acute renal failure, and mediastinitis were more frequent in the H group than in the L group. The H group had significantly higher in-hospital mortality and MACE rates than the L group (P<0.01). EuroSCORE I, SYNTAX II-CABG, and CHA2DS2-VASc scores were predictors for MACE. SYNTAX II-CABG > 25.1 had 68.4% sensitivity and 52.7% specificity (area under the curve [AUC]: 0.653, P=0.04, 95% confidence interval [CI]: 0.607-0.696) and CHA2DS2-VASc > 2 had 52.6% sensitivity and 84.1% specificity (AUC: 0.752, P<0.01, 95% CI: 0.710-0.790) to predict MACE. Pairwise comparison of receiver-operating characteristic curves revealed similar accuracy for both scoring systems. CONCLUSION: CHA2DS2-VASc score may predict MACE in patients undergoing isolated CABG.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Medição de Risco/métodos , Idoso , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/complicações , Doença da Artéria Coronariana/mortalidade , Complicações do Diabetes , Feminino , Cardiopatias/mortalidade , Mortalidade Hospitalar , Humanos , Hipertensão/complicações , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Valores de Referência , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Estatísticas não Paramétricas , Resultado do Tratamento
6.
Medicine (Baltimore) ; 98(20): e15453, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31096441

RESUMO

Preoperative renal dysfunction is associated with mortality in patients who undergo coronary artery bypass graft and valve surgery. However, the role of preoperative renal dysfunction in type A aortic dissection (TAAD) remains unclear. This study aimed to evaluate the impact of preoperative renal dysfunction on the outcome of surgical intervention in patients with TAAD.We retrospectively studied the outcomes of 159 patients with TAAD who were treated at a tertiary referral hospital between 2005 and 2010. The demographics and surgical details of patients were analyzed according to their renal function. Risk factors for outcomes were analyzed using multivariable logistic regression. Thirty-two of the patients (20.1%) had preoperative serum creatinine of 1.5 mg/dL or more. The multivariable logistic regression model revealed independent risk factors of in-hospital mortality to be renal dysfunction (odds ratio [OR], 3.79; 95% confidence interval [CI], 1.64-8.77), preoperative shock (OR, 8.75; 95% CI, 2.83-27.02), and bypass time (OR, 1.008; 95% CI, 1.003-1.013). In addition, patients with renal dysfunction exhibited a lower 90-day survival rate than did patients without the condition (P of log-rank test = .005).Preoperative renal dysfunction may have a critical role in the surgical outcomes of patients with TAAD. Additional large-scale investigations are warranted.


Assuntos
Aneurisma Dissecante/cirurgia , Nefropatias/diagnóstico , Nefropatias/fisiopatologia , Rim/fisiopatologia , Adulto , Idoso , Aneurisma Dissecante/mortalidade , Aneurisma Dissecante/fisiopatologia , Ponte de Artéria Coronária/mortalidade , Creatinina/sangue , Feminino , Mortalidade Hospitalar , Humanos , Nefropatias/mortalidade , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pré-Operatório , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida , Resultado do Tratamento
7.
Med Care ; 57(5): 377-384, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30870389

RESUMO

BACKGROUND: Risk adjustment is critical in the comparison of quality of care and health care outcomes for providers. Electronic health records (EHRs) have the potential to eliminate the need for costly and time-consuming manual data abstraction of patient outcomes and risk factors necessary for risk adjustment. METHODS: Leading EHR vendors and hospital focus groups were asked to review risk factors in the New York State (NYS) coronary artery bypass graft (CABG) surgery statistical models for mortality and readmission and assess feasibility of EHR data capture. Risk models based only on registry data elements that can be captured by EHRs (one for easily obtained data and one for data obtained with more difficulty) were developed and compared with the NYS models for different years. RESULTS: Only 6 data elements could be extracted from the EHR, and outlier hospitals differed substantially for readmission but not for mortality. At the patient level, measures of fit and predictive ability indicated that the EHR models are inferior to the NYS CABG surgery risk model [eg, c-statistics of 0.76 vs. 0.71 (P<0.001) and 0.76 vs. 0.74 (P=0.009) for mortality in 2010], although the correlation of the predicted probabilities between the NYS and EHR models was high, ranging from 0.96 to 0.98. CONCLUSIONS: A simplified risk model using EHR data elements could not capture most of the risk factors in the NYS CABG surgery risk models, many outlier hospitals were different for readmissions, and patient-level measures of fit were inferior.


Assuntos
Ponte de Artéria Coronária/mortalidade , Registros Eletrônicos de Saúde , Risco Ajustado/métodos , Estudos de Viabilidade , Grupos Focais , Humanos , Modelos Estatísticos , New York , Sistema de Registros
8.
Braz J Cardiovasc Surg ; 34(2): 149-155, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30916124

RESUMO

INTRODUCTION: Renal function is an independent risk factor for mortality among on-pump coronary bypass grafting (ONCABG) patients. This association is well known in the international literature, but there is a lack of knowledge of how admission creatinine (AC) levels modulate each cardiovascular risk factor. OBJECTIVE: The aim of this paper was to assess the effect of different AC levels on mortality among ONCABG patients. METHODS: 1,599 patients who underwent ONCABG between December 1999 and February 2006 at Hospital de Base in São José do Rio Preto/SP-Brazil were included. They were divided into quartiles according to their AC levels (QI: 0.2 ≤AC < 1.0 mg/dL; QII: 1.0 ≤ AC < 1.2 mg/dL; QIII: 1.2 ≤ AC < 1.4 mg/dL; and QIV: 1.4 ≤ AC ≤ 2.6 mg/dL). Seven risk factors were then evaluated in each stratum. RESULTS: Mortality was higher in the QIV group than QI or QII groups. Factors such as age (≥ 65 years) and cardiopulmonary bypass (CPB) time (≥ 115 minutes) in QIV, as well preoperative hospital stay (≥ 5 days) in QIII, were associated with higher mortality rates. Creatinine variation greater than or equal to 0.4 mg/dL increased mortality rates in all groups. The use of intra-aortic balloon pump and dialysis increased mortality rates in all groups except for QII. Type I neurological dysfunction increased the mortality rate in the QII and III groups. CONCLUSION: Creatinine levels play an important role in ONCABG mortality. The combination of selected risk factors and higher AC values leads to a worse prognosis. On the other hand, lower AC values were associated with a protective effect, even among elderly patients and those with a high CPB time.


Assuntos
Ponte de Artéria Coronária/mortalidade , Creatinina/sangue , Período Pré-Operatório , Idoso , Brasil , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Prognóstico , Valores de Referência , Insuficiência Renal/sangue , Insuficiência Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
9.
Braz J Cardiovasc Surg ; 34(2): 156-164, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30916125

RESUMO

OBJETIVE: Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) improved symptoms and increased survival and quality of life in patients with coronary artery disease. However, it should be the main cause of a complex organic systemic inflammatory response that greatly contributes to several postoperative adverse effects. METHODS: We aimed to evaluate heat-shock protein 70 (HSP 70) expression as a morbimortality predictor in patients with preserved ventricular function undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and to determine their association with the lactate as a marker of tissue hypoperfusion and the EuroSCORE risk score. This is a prospective, observational study including 46 patients and occurring between May and July 2016. Patients without ventricular dysfunction undergoing myocardial revascularization with extracorporeal circulation were included. They were divided into (1) complicated and (2) uncomplicated postoperative evolution groups. EuroSCORE, lactate levels, and HSP 70 expression and their correlations were determined. RESULTS: Statistical analysis showed that the group with complicated evolution had higher EuroSCORE values than the other group. HSP 70 protein levels were significantly increased in the group with uncomplicated evolution and showed similar results. According to our results, HSP family proteins may be independent predictors of uncomplicated evolution in patients without ventricular dysfunction undergoing CABG with CPB. CONCLUSION: HSP 70 should be a good discriminator and protection marker for complications in cardiac surgery.


Assuntos
Ponte Cardiopulmonar/mortalidade , Ponte de Artéria Coronária/mortalidade , Proteínas de Choque Térmico HSP70/análise , Ácido Láctico/sangue , Período Pré-Operatório , Medição de Risco/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/análise , Western Blotting , Ponte Cardiopulmonar/métodos , Ponte de Artéria Coronária/métodos , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Miocárdio/patologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Valores de Referência , Fatores de Risco , Sensibilidade e Especificidade , Estatísticas não Paramétricas
10.
J Cardiovasc Surg (Torino) ; 60(3): 396-405, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30916532

RESUMO

BACKGROUND: Left ventricular (LV) dysfunction alone is insufficient as an independent predictor of postoperative complications and mortality in coronary artery bypass graft (CABG) surgery. Our objective was to identify additional independent risk factors in patients with low left ventricle ejection fraction (EF) who underwent CABG. METHODS: We retrospectively analyzed CABG results of 346 consecutive patients with low EF (≤30%) in a single institution between 2009 and 2015. The primary study endpoint was 30-day all-cause mortality. The secondary endpoints were the development of major adverse cardiac events (MACE) and renal complications after operation. A subgroup of patients underwent additional analyses of the interaction between extents of viable myocardium and postoperative endpoints. RESULTS: The analysis showed that preoperative hemodynamic instability (AOR=4.57; 95% CI: 1.53-13.7, P=0.007) and serum creatinine >166 µmol/L (AOR=3.46; 95% CI: 1.12-10.7, P=0.031) were independent predictors of 30-day death. Both urgent and emergency operations were predictors for MACE (P=0.038; P=0.005) and renal complications (P=0.004; P=0.007). Pre-existing diabetes mellitus increased the likelihood of renal complications (P=0.020). In the sub-analysis of patients with viable myocardium, the mortality was significantly lower with predicted mortality (P=0.014). CONCLUSIONS: Patients with significant LV dysfunction undergoing isolated CABG have fair short-term survival even with EF less than 30%. Hemodynamic instability prior to operation and preoperative kidney dysfunction are strong predictors of mortality in patients with low EF. Favorable coronary targets, meticulous operative techniques, and optimal surgical timing before hemodynamic deterioration occurs are essential to minimize the risk of revascularization complications and early postoperative mortality.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/cirurgia , Volume Sistólico , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Idoso , Biomarcadores/sangue , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Rim/fisiopatologia , Nefropatias/diagnóstico , Nefropatias/mortalidade , Nefropatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/mortalidade
11.
Thorac Cardiovasc Surg ; 67(7): 546-553, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30836396

RESUMO

BACKGROUND: The current study analyzed and compared early-term outcomes of off-pump versus on-pump beating heart coronary artery bypass surgery. METHODS: From January 2011 to January 2018, a total of 736 patients underwent isolated first-time elective beating-heart coronary artery bypass surgery without the use of aortic cross-clamping and cardioplegic arrest at our institution, and they were included in this study. Data of patients were collected and retrospectively analyzed. Patients were divided into two groups according to the use of cardiopulmonary bypass during the operation, as off-pump group (n = 399) and on-pump beating-heart group (n = 337). Both groups were compared with each other in terms of preoperative, intraoperative, and postoperative data. RESULTS: Groups were statistically similar with regard to baseline clinical characteristics and demographics. When compared with off-pump group, on-pump beating-heart group had a greater number of distal bypass, longer length of hospital stay, and lower postoperative hematocrit level, and received more blood product transfusion. No statistically significant differences were detected between the groups with respect to mortality and postoperative complications except for atrial fibrillation. Atrial fibrillation was significantly frequent in on-pump beating-heart group. CONCLUSION: Our study suggested that off-pump and on-pump beating-heart coronary artery bypass procedures had similar early mortality and major complication rates except for atrial fibrillation. However, it seemed that off-pump procedure was superior to on-pump beating-heart procedure with regard to length of hospital stay, blood product transfusion, and atrial fibrillation development. Further prospective randomized studies with larger patient series are needed to support our research and attain more accurate data.


Assuntos
Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
12.
J Card Surg ; 34(4): 196-201, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30851212

RESUMO

BACKGROUND: The incidence of severe coronary artery disease (CAD) in patients with end-stage renal disease (ESRD) on dialysis is high. Coronary artery bypass grafting (CABG) is the preferred treatment in those with severe CAD. Bilateral internal thoracic artery (BITA) vs single internal thoracic artery (SITA) grafting has been shown to improve late survival in other high-risk populations. In ESRD, comparative studies are limited by sample size to detect outcome differences. We sought to determine the late survival and early outcomes of BITA compared with SITA in patients with ESRD. METHODS: MEDLINE and EMBASE were searched from inception to 2017 for studies directly comparing BITA to SITA in patients with ESRD undergoing CABG. The primary outcome was late survival; secondary outcomes were in-hospital/30-day mortality, stroke, and deep sternal wound infection (DSWI). Kaplan-Meier curve reconstruction for late mortality was performed. RESULTS: Five studies (three adjusted [n = 197] and two unadjusted observational studies [n = 231]) were included in the analysis. Reported ITA skeletonization ranged from 83% to 100% (median: 100%). There was no difference in in-hospital mortality (risk risk [RR], 0.84; 95% confidence interval [95%CI], 0.36,1.98; P = 0.70), perioperative stroke (RR, 1.97; 95%CI, 0.58,6.66; P = 0.28), and DSWI (RR, 1.56; 95%CI, 0.60,4.07; P = 0.36) between BITA and SITA. All studies reported adjusted late mortality, which was similar between BITA and SITA (incident rate ratio, 0.81; 95%CI, 0.59,1.11) at mean 3.7-year follow-up. CONCLUSIONS: BITA grafting is safe in patients with ESRD although there was no survival benefit at 3.7 years. Additional studies with longer follow-up are required to determine the potential late benefits of BITA grafting in patients with ESRD.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Falência Renal Crônica/complicações , Artéria Torácica Interna/transplante , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/etiologia , Bases de Dados Bibliográficas , Diálise , Humanos , Falência Renal Crônica/terapia , Taxa de Sobrevida , Resultado do Tratamento
13.
Cochrane Database Syst Rev ; 3: CD006715, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30821845

RESUMO

BACKGROUND: General anaesthesia combined with epidural analgesia may have a beneficial effect on clinical outcomes. However, use of epidural analgesia for cardiac surgery is controversial due to a theoretical increased risk of epidural haematoma associated with systemic heparinization. This review was published in 2013, and it was updated in 2019. OBJECTIVES: To determine the impact of perioperative epidural analgesia in adults undergoing cardiac surgery, with or without cardiopulmonary bypass, on perioperative mortality and cardiac, pulmonary, or neurological morbidity. SEARCH METHODS: We searched CENTRAL, MEDLINE, and Embase in November 2018, and two trial registers up to February 2019, together with references and relevant conference abstracts. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) including adults undergoing any type of cardiac surgery under general anaesthesia and comparing epidural analgesia versus another modality of postoperative pain treatment. The primary outcome was mortality. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures as expected by Cochrane. MAIN RESULTS: We included 69 trials with 4860 participants: 2404 given epidural analgesia and 2456 receiving comparators (systemic analgesia, peripheral nerve block, intrapleural analgesia, or wound infiltration). The mean (or median) age of participants varied between 43.5 years and 74.6 years. Surgeries performed were coronary artery bypass grafting or valvular procedures and surgeries for congenital heart disease. We judged that no trials were at low risk of bias for all domains, and that all trials were at unclear/high risk of bias for blinding of participants and personnel taking care of study participants.Epidural analgesia versus systemic analgesiaTrials show there may be no difference in mortality at 0 to 30 days (risk difference (RD) 0.00, 95% confidence interval (CI) -0.01 to 0.01; 38 trials with 3418 participants; low-quality evidence), and there may be a reduction in myocardial infarction at 0 to 30 days (RD -0.01, 95% CI -0.02 to 0.00; 26 trials with 2713 participants; low-quality evidence). Epidural analgesia may reduce the risk of 0 to 30 days respiratory depression (RD -0.03, 95% CI -0.05 to -0.01; 21 trials with 1736 participants; low-quality evidence). There is probably little or no difference in risk of pneumonia at 0 to 30 days (RD -0.03, 95% CI -0.07 to 0.01; 10 trials with 1107 participants; moderate-quality evidence), and epidural analgesia probably reduces the risk of atrial fibrillation or atrial flutter at 0 to 2 weeks (RD -0.06, 95% CI -0.10 to -0.01; 18 trials with 2431 participants; moderate-quality evidence). There may be no difference in cerebrovascular accidents at 0 to 30 days (RD -0.00, 95% CI -0.01 to 0.01; 18 trials with 2232 participants; very low-quality evidence), and none of the included trials reported any epidural haematoma events at 0 to 30 days (53 trials with 3982 participants; low-quality evidence). Epidural analgesia probably reduces the duration of tracheal intubation by the equivalent of 2.4 hours (standardized mean difference (SMD) -0.78, 95% CI -1.01 to -0.55; 40 trials with 3353 participants; moderate-quality evidence). Epidural analgesia reduces pain at rest and on movement up to 72 hours after surgery. At six to eight hours, researchers noted a reduction in pain, equivalent to a reduction of 1 point on a 0 to 10 pain scale (SMD -1.35, 95% CI -1.98 to -0.72; 10 trials with 502 participants; moderate-quality evidence). Epidural analgesia may increase risk of hypotension (RD 0.21, 95% CI 0.09 to 0.33; 17 trials with 870 participants; low-quality evidence) but may make little or no difference in the need for infusion of inotropics or vasopressors (RD 0.00, 95% CI -0.06 to 0.07; 23 trials with 1821 participants; low-quality evidence).Epidural analgesia versus other comparatorsFewer studies compared epidural analgesia versus peripheral nerve blocks (four studies), intrapleural analgesia (one study), and wound infiltration (one study). Investigators provided no data for pulmonary complications, atrial fibrillation or flutter, or for any of the comparisons. When reported, other outcomes for these comparisons (mortality, myocardial infarction, neurological complications, duration of tracheal intubation, pain, and haemodynamic support) were uncertain due to the small numbers of trials and participants. AUTHORS' CONCLUSIONS: Compared with systemic analgesia, epidural analgesia may reduce the risk of myocardial infarction, respiratory depression, and atrial fibrillation/atrial flutter, as well as the duration of tracheal intubation and pain, in adults undergoing cardiac surgery. There may be little or no difference in mortality, pneumonia, and epidural haematoma, and effects on cerebrovascular accident are uncertain. Evidence is insufficient to show the effects of epidural analgesia compared with peripheral nerve blocks, intrapleural analgesia, or wound infiltration.


Assuntos
Analgesia Epidural/efeitos adversos , Anestesia Geral/efeitos adversos , Procedimentos Cirúrgicos Cardíacos , Infarto do Miocárdio/etiologia , Acidente Vascular Cerebral/etiologia , Adulto , Analgesia Epidural/métodos , Analgesia Epidural/mortalidade , Anestesia Geral/métodos , Anestesia Geral/mortalidade , Arritmias Cardíacas/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Transtornos Respiratórios/etiologia
14.
J Am Coll Cardiol ; 73(4): 415-423, 2019 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-30704573

RESUMO

BACKGROUND: Post-operative acute coronary ischemia is an uncommon complication of coronary artery bypass grafting (CABG). However, data on the incidence and outcomes of early coronary ischemia and in-hospital percutaneous coronary interventions (PCIs) after CABG are scarce. OBJECTIVES: The aim of this study was to assess the incidence, predictors, and outcomes of early (in-hospital) PCI following CABG. METHODS: This study utilized the National Inpatient Sample to select patients who underwent CABG between January 1, 2003, and December 31, 2014. Patients who had acute coronary ischemia requiring in-hospital PCI after CABG were compared with patients who did not need PCI. The primary endpoint was in-hospital mortality. Secondary endpoints were major complications, length-of-stay, and cost. Predictors of the need for post-CABG PCI were assessed in multivariate regression analyses. RESULTS: Among the 554,987 studied patients, 24,503 (4.4%) had suspected acute coronary ischemia and underwent angiography post-operatively, of whom 14,323 had PCI. The majority (71.4%) of PCIs were performed within 24 h following CABG. Unadjusted in-hospital mortality was higher in patients who underwent PCI (5.1% vs. 2.7%; p < 0.001). The excess mortality persisted after multiple risk adjustments and sensitivity analyses. Patients who underwent post-CABG PCI had higher rates of strokes (2.1% vs. 1.6%; p < 0.001), acute kidney injury (16% vs. 12.3%; p < 0.001), and infectious complications. Post-CABG PCI was also associated with longer hospitalizations and a ∼50% increase in cost. Nonelective admissions and off-pump CABG were the strongest predictors of needing an in-hospital PCI following CABG. CONCLUSIONS: In-hospital post-CABG PCI is uncommon but is associated with significantly increased morbidity, mortality, and cost. Further studies are needed to assess modifiable risk factors for early coronary compromise following CABG.


Assuntos
Ponte de Artéria Coronária/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricos , Complicações Pós-Operatórias/cirurgia , Idoso , Ponte de Artéria Coronária/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia
15.
Medicine (Baltimore) ; 98(6): e14388, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30732179

RESUMO

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a frequent comorbid disease in patients undergoing coronary artery bypass grafting (CABG) surgery, with an incidence ranging from 4% to 20.5%. Conventionally, COPD was recognized as a surgical contraindication to CABG. Because of the recent improvements in surgical techniques, anesthesia, and postoperative management, CABG has been performed more commonly in patients with COPD. However, studies have shown the various effects of COPD on postoperative morbidity and mortality after CABG, and this remains to be well defined. OBJECTIVES: To compare the postoperative outcomes after CABG between patients with and those without COPD. METHODS: A systematic search was conducted in the Cochrane Library, PubMed, EmBase, and Ovid databases (until May 10, 2018). Studies comparing perioperative results and mortality outcomes after CABG between patients with and those without COPD were evaluated independently by 2 reviewers to identify the potentially eligible studies. Review Manager and STATA software were used for statistical analyses. RESULTS: No significant difference in the mortality rates were found between patients with and those without COPD. COPD was associated with a higher respiratory failure rate (odds ratio [OR] = 4.01; 95% CI: 1.19-13.51, P = .03; P <.001 for heterogeneity), higher pneumonia rate (OR = 2.92; 95% CI: 2.37-3.60, P <.00001; P = .73 for heterogeneity), higher stroke rate (OR = 2.91; 95% CI: 1.37-6.18, P = .005; P = .60 for heterogeneity), higher renal failure rate (OR = 1.60; 95% CI: 1.30-1.97, P <.00001; P = .19 for heterogeneity), and higher wound infection rate (OR = 2.16; 95% CI: 1.21-3.88, P = .01; P = .53 for heterogeneity) after CABG. CONCLUSIONS: Patients with COPD were at higher risks for developing postoperative morbidities, particularly pneumonia, respiratory failure, stroke, renal failure, and wound infection. Although COPD was not associated with a higher risk of mortality, caution should be taken when a patient with COPD is indicated for CABG, considering the higher odds of postoperative complications involving the respiratory system and others.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/cirurgia , Complicações Pós-Operatórias/epidemiologia , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Humanos , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Doença Pulmonar Obstrutiva Crônica/mortalidade
16.
Gen Thorac Cardiovasc Surg ; 67(8): 661-668, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30734216

RESUMO

OBJECTIVE: Quality metrics and reimbursement models focus on 30-day readmission rates after coronary artery bypass grafting (CABG). Certain preoperative variables are associated with higher rates of readmission. The purpose of this study was to determine whether STS Predicted Risk of Mortality (PROM) scores predict 30-day readmission following CABG. METHODS: A retrospective review of all patients undergoing isolated CABG between 2002 and 2017 at a US academic institution was performed. Logistic regression analysis was used to determine the association between PROM and 30-day readmission, and the area under the receiver-operator curve (ROC) was calculated to estimate predictive accuracy. RESULTS: During the study period, 21,719 patients underwent CABG and 2,023 (9.2%) were readmitted within 30 days. Readmitted patients were sicker with higher rates of comorbid conditions and higher STS PROM scores (1.03% vs 1.42%, GMR 1.33, CI 1.27-1.38, p < 0.0001). Median time to readmission was 8 days (IQR 4-15) with length of stay 5 days (4-6). By PROM quintile, higher PROM scores were associated with increased odds of readmission. PROM-adjusted 30-day mortality was higher in the readmitted group (1.04% vs 0.21%, OR 4.53, CI 2.67-7.69, p < 0.001), and mid-term survival was worse as well. PROM alone was a modest predictor of readmission (area under ROC 0.59, CI 0.57-0.60) compared to insurance status (0.55, 0.53-0.56), ejection fraction (0.52, 0.50-0.54), and history of heart failure (0.51, 0.50-0.52). CONCLUSION: STS PROM scores are associated with increased risk of readmission following CABG.


Assuntos
Ponte de Artéria Coronária/mortalidade , Mortalidade Hospitalar/tendências , Readmissão do Paciente/estatística & dados numéricos , Idoso , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Indicadores de Qualidade em Assistência à Saúde/tendências , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
17.
J Card Surg ; 34(3): 110-117, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30735576

RESUMO

BACKGROUND: Dialysis-dependent patients have a higher risk of short-term morbidity and mortality following cardiac surgery. However, longitudinal survival and readmissions in this patient population after isolated coronary artery bypass grafting (CABG) are lacking in the literature. METHODS: All patients undergoing isolated CABG from 2011 to 2017 were included. Perioperative data were retrospectively extracted from a prospectively maintained cardiac surgical database with a primary focus on longitudinal mortality and readmissions. RESULTS: The total study population consisted of 6874 nondialysis-dependent patients and 174 patients with dialysis dependence. Patients in the dialysis-dependent group presented a higher risk of morbidity and mortality as reflected in the Society of Thoracic Surgeons-Predicted Risk of Morbidity and Mortality (STS-PROM) (8.4% ± 9.7% vs 2.3% ± 3.9%; P < 0.001). Operative (30-day) mortality was significantly higher in the dialysis group (8.6% vs 2.3%; P < 0.001). Unadjusted outcomes yielded 30-day (92% vs 98%; P < 0.001), 1-year (80% vs 94%; P < 0.001), and 5-year (38% vs 84%; P < 0.001) survival that was significantly worse for the dialysis group. Freedom from readmission at 30 days (93% vs 87%; P = 0.005), 1 year (78% vs 56%; P < 0.001), and 5 years (62% vs 39%; P < 0.001) was significantly better for the nondialysis cohort. Dialysis dependence was an independent predictor of mortality at 30 days (hazard ratio [HR], 3.86; 95% confidence interval [CI], 2.96, 5.03; P < 0.001), 1 year (HR, 3.20; 95% CI, 2.14, 2.79; P < 0.001), and 5 years (HR, 4.02; 95% CI, 3.07, 5.26; P < 0.001) despite risk adjustment. CONCLUSION: Dialysis-dependent patients have significantly elevated operative risk, which translates to worse short- and long-term survival following isolated CABG. The need for dialysis alone is an independent predictor of both mortality and readmission in the midterm.


Assuntos
Ponte de Artéria Coronária/mortalidade , Diálise , Idoso , Estudos de Coortes , Diálise/efeitos adversos , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Insuficiência Renal/mortalidade , Risco , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
18.
Braz J Cardiovasc Surg ; 34(1): 62-69, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30810676

RESUMO

OBJECTIVE: This study aims to compare the early and medium outcomes of on-pump beating-heart (OPBH) coronary artery bypass grafting (CABG) and off-pump CABG (OPCABG) in patients with left ventricular ejection fraction (LVEF) between 30% and 40%. METHODS: This is a retrospective study of ischemic heart disease patients with LVEF between 30% and 40% who underwent surgical revascularization from January 2013 to December 2017. Patients were divided into OPBH group (n=44) and OPCABG group (n=68), according to the surgical method. Clinical material with early and medium outcomes were investigated and compared between these groups. RESULTS: The two groups had similar baseline. Two OPBH patients and 3 OPCABG patients died in the hospital, which had no statistical significance (P>0.05). OPBH patients received a greater number of grafts (3.74±0.84) and presented more improved LVEF (45.92±7.11%) than OPCABG patients (3.36±0.80) and (42.81±9.29%), respectively, which had statistical significance (P<0.05). An increased amount of drainage during the first 12 hours was found in the OPBH group (P<0.05). Reoperation for bleeding, duration of mechanic ventilation, and other early outcomes had no statistical significance between the two groups. During the medium-time follow-up, OPBH patients showed significantly lower major adverse cardiovascular events (MACE)-free survival time (P=0.049) than OPCABG patients. CONCLUSION: The OPBH technique was a safe and an acceptable alternative for surgical revascularization in patients with moderate left ventricular dysfunction which provided better mid-term MACE-free survival compared with OPCABG.


Assuntos
Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Ponte de Artéria Coronária/métodos , Disfunção Ventricular Esquerda/cirurgia , Idoso , Ponte de Artéria Coronária/mortalidade , Ponte de Artéria Coronária sem Circulação Extracorpórea/mortalidade , Ecocardiografia/métodos , Feminino , Hemodinâmica , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/cirurgia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade
19.
Braz J Cardiovasc Surg ; 34(1): 70-75, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30810677

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a frequent event after cardiac surgery with increased mortality and morbidity. We explored frequency, risk factors, and associated morbidity and mortality of AKI after isolated coronary artery bypass grafting (CABG) surgery at a single institution. METHODS: All consecutive adults undergoing CABG surgery from March 2013 to October 2016 were assessed for development and severity of AKI based on Acute Kidney Injury Network (AKIN) criteria. The patients were also investigated regarding their need for renal replacement therapy (RRT), predictive risk factors, and associated outcomes, including duration of mechanical ventilation, mortality, intensive care unit (ICU) and hospital length of stay. RESULTS: Of 1737 patients in the study, 275 (15.8%) developed AKI. Twenty-five (12.8%) cases required RRT. Patients with AKI had longer ventilation time, ICU and hospital length of stay (P<0.001). Mortality rates were 28 (10.2%) and 22 (1.5%) in patients with and without AKI, respectively (P<0.001). There was a strong association between advanced age (aOR=1.016, 95% CI=1.002-1.030, P=0.028), diabetes (aOR=1.36, 95% CI=1.022-1.809, P=0.035), on-pump surgery (aOR=2.63, 95% CI=1.543-4.483, P<0.001), transfusion of more than 1 unit of red blood cells (aOR=2.154, 95% CI=1.237-3.753, P=0.007), and prolonged mechanical ventilation and development of AKI (aOR=2.697, 95% CI=1.02407.071, P<0.001). AKI was seen less frequently in those with opium abuse (aOR=0.613, 95% CI=0.409-0.921, P=0.018). CONCLUSION: We demonstrated that advanced age, diabetes, on-pump surgery, red blood cell transfusion, and prolonged mechanical ventilation were independent positive risk factors for the development of AKI after isolated CABG while opium abuse was a protective factor.


Assuntos
Lesão Renal Aguda/etiologia , Ponte de Artéria Coronária/efeitos adversos , Lesão Renal Aguda/mortalidade , Idoso , Ponte de Artéria Coronária/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Gravidez , Estudos Prospectivos , Valores de Referência , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Medição de Risco/métodos , Fatores de Risco , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
20.
Ann Thorac Surg ; 108(1): 67-73, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30690021

RESUMO

BACKGROUND: Most robotic coronary bypass operations are single-vessel procedures. Very few centers perform totally endoscopic coronary artery bypass (TECAB), and even fewer perform multivessel grafting endoscopically. We hypothesized that a robotic beating-heart approach using distal anastomotic connectors facilitates multivessel TECAB with similar safety and efficacy to single-vessel TECAB. METHODS: We reviewed patients undergoing robotic TECAB at our institution between July 2013 and March 2018. There were 344 consecutive patients divided into two groups: multivessel (MV, group 1), and single-vessel (SV, group 2). We interrogated our prospectively collected database for preoperative, intraoperative, and postoperative outcomes to compare the groups. RESULTS: There were 197 patients in group 1 and 147 patients in group 2. Mean Society of Thoracic Surgeons scores were 1.69% ± 2.4% and 1.96% ± 3.5%, respectively (p = 0.389). Patients in group 1 were older, 67 ± 9.4 versus 63 ± 11.2 years (p < 0.001) and had more triple-vessel disease, 135 (69%) versus 31 (21%; p < 0.001). In group 1, 174 patients (88%) had bilateral internal mammary artery grafts and 13% had triple-vessel TECAB. Mean hospital stay was 3.07 ± 1.2 days in group 1 and 2.81 ± 1.4 days in group 2 (p = 0.072), and overall mortality was 1.45% (2.0% and 0.7%, respectively; p = 0.268). Graft patency (mean, 7 months) was 95.6% (151 of 158 grafts) in group 1 and 94.9% (37 of 39 grafts) in group 2 (p = 0.896). CONCLUSIONS: Multivessel grafting is feasible during robotic beating-heart connector TECAB with good outcomes. We found no significant difference in mortality, hospital stay, midterm major adverse cardiac events, and interim graft patency compared with single-vessel TECAB. Further studies are warranted.


Assuntos
Ponte de Artéria Coronária/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Angiografia Coronária , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/mortalidade , Grau de Desobstrução Vascular
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