Conservative fluid resuscitation protocol does not reduce the incidence of reoperation for bleeding after emergency CABG.

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG. TRIAL REGISTRATION: www. CLINICALTRIALS: gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT04533698.

CCTA-Guided Invasive Coronary Angiography in Patients With CABG: A Multicenter, Randomized Study.

BACKGROUND: Coronary computed tomography angiography (CCTA) in patients with post-coronary artery bypass graft (CABG) has a high diagnostic accuracy for visualization of grafts. Invasive coronary angiography (ICA) in patients with CABG is associated with increased procedural time, contrast agent administration, radiation exposure, and complications, compared with non-CABG patients. The aim of this multicenter, randomized controlled trial was to compare the strategy of CCTA-guided ICA versus classic ICA in patients with prior CABG. METHODS: Patients with prior CABG were randomly assigned (1:1 ratio) to have a CCTA before ICA (CCTA-ICA, group A) or not (ICA-only, group B). The primary end point of the study was the total volume (milliliters) of the contrast agent administered. RESULTS: A total of 251 patients were randomized, and 225 were included in analysis; 110 in group A and 115 in group B. The total contrast volume was higher in group A (184.5 [143-255] versus 154 [102-240] mL; P=0.001). The contrast volume administered during the invasive procedure was lower in group A (101.5 [60-151] versus 154 [102-240]; P<0.001). Total fluoroscopy time was decreased in group A (480 [259-873] versus 594 [360-1080] seconds; P=0.027), but total effective dose was increased (24.1 [17.7-32] versus 10.8 [5.6-18] mSv; P<0.001). The rate of contrast-induced nephropathy, periprocedural complications, and major adverse cardiac events during 3 to 5 and 30 days did not differ significantly between the 2 groups. CONCLUSIONS: A CCTA-directed ICA strategy for patients with CABG is associated with expedition of the invasive procedure, and less fluoroscopy time, at the cost of higher total contrast volume and effective radiation dose, compared with the classic ICA approach. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04631809.

Development of a machine learning model to estimate length of stay in coronary artery bypass grafting.

OBJECTIVE: To develop and validate a predictive model utilizing machine-learning techniques for estimating the length of hospital stay among patients who underwent coronary artery bypass grafting. METHODS: Three machine learning models (random forest, extreme gradient boosting and neural networks) and three traditional regression models (Poisson regression, linear regression, negative binomial regression) were trained in a dataset of 9,584 patients who underwent coronary artery bypass grafting between January 2017 and December 2021. The data were collected from hospital discharges from 133 centers in Brazil. Algorithms were ranked by calculating the root mean squared logarithmic error (RMSLE). The top performing algorithm was validated in a never-before-seen database of 2,627 patients. We also developed a model with the top ten variables to improve usability. RESULTS: The random forest technique produced the model with the lowest error. The RMLSE was 0.412 (95%CI 0.405-0.419) on the training dataset and 0.454 (95%CI 0.441-0.468) on the validation dataset. Non-elective surgery, admission to a public hospital, heart failure, and age had the greatest impact on length of hospital stay. CONCLUSIONS: The predictive model can be used to generate length of hospital stay indices that could be used as markers of efficiency and identify patients with the potential for prolonged hospitalization, helping the institution in managing beds, scheduling surgeries, and allocating resources.

Hospital and Physician Variability in Revascularization Decisions and Outcomes for Patients With 3-Vessel and Left Main Coronary Artery Disease: A Population-Based Cohort Study.

BACKGROUND: Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. METHODS AND RESULTS: From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. CONCLUSIONS: Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Spontaneous avulsion of left internal mammary artery graft a complication of coronary artery bypass surgery: case report and review of the literature.

BACKGROUND: Coronary artery bypass grafting (CABG) surgery is a common procedure for managing multi-vessel coronary artery disease to revascularize the myocardium. Among the various conduits used, the left internal mammary artery (LIMA) is preferred due to its better long-term patency rate. However, CABG procedures involving LIMA may result in rare but serious complications, such as avulsion of the LIMA post-CABG, which leads to disruption of blood flow to the myocardium and the development of fatal cardiac tamponade. CASE PRESENTATION: We hereby present a unique case of spontaneous avulsion of a LIMA graft to the left anterior descending artery (LAD) away from the site of anastomosis, twenty-four hours following CABG surgery in a 67-year-old male patient. Emergency re-exploration and repair of the LIMA with interposition vein graft were performed and resulted in successful stabilization of the patient's critical condition. However, this was followed by a complicated recovery period involving atrial fibrillation, acute kidney injury, and wound infection. CONCLUSION: Avulsion of LIMA graft following CABG is rare, yet a fatal complication that requires high clinical suspicion and prompt management. Avulsion has been reported a few times in literature following both minimal invasive and conventional CABG. Understanding the etiology, clinical presentation, and management of this complication is crucial to avoid catastrophic outcomes.

In patients with NSTE-ACS and previous CABG, routine invasive vs. conservative management does not improve outcomes.

SOURCE CITATION: Kelham M, Vyas R, Ramaseshan R, et al. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J. 2024;45:2380-2391. 38805681.

Sex differences in outcomes of patients undergoing on-pump coronary artery bypass grafting surgery.

There are controversies regarding the impact of sex on mortality and postoperative complications in patients undergoing on-pump coronary artery bypass grafting (CABG), although some studies demonstrate comparable outcomes. This study sought to evaluate sex differences regarding risk factors associated with hospital mortality and postoperative clinical outcomes among patients undergoing isolated on-pump CABG. We conducted a retrospective observational cohort study of patients who underwent isolated on-pump CABG from January 1996 to January 2020. Patients were divided into two groups (male and female) and compared regarding preoperative characteristics, surgical technical variables, and in-hospital outcomes. All-cause mortality between groups was compared using logistic regression. Risk factors for mortality, along with their respective odds ratios (OR), were separately assessed using a logistic regression model with p-values for interaction. We analyzed 4,882 patients, of whom 31.6% were female. Women exhibited a higher prevalence of age >75 years (12.2% vs 8.3%, p<0.001), obesity (22.6% vs 11.5%, p<0.001), diabetes (41.6% vs 32.2%, p<0.001), hypertension (85.2% vs 73.5%, p<0.001), and NYHA functional classes 3 and 4 (16.2% vs 11.2%, p<0.001) compared to men. Use of the mammary artery for revascularization was less frequent among women (73.8% vs 79.9%, p<0.001), who also received fewer saphenous vein grafts (2.17 vs 2.27, p = 0.002). A history of previous or recent myocardial infarction (MI) had an impact on women's mortality, unlike in men (OR 1.61 vs 0.94, p = 0.014; OR 1.86 vs 0.99, p = 0.015, respectively). After adjusting for several risk factors, mortality was found to be comparable between men and women, with an OR of 1.20 (95% CI 0.94-1.53, p = 0.129). In conclusion, female patients undergoing isolated on-pump CABG presented with a higher number of comorbidities. Previous and recent MI were associated with higher mortality only in women. In this cohort analysis, female gender was not identified as an independent risk factor for outcome after CABG.

The relationship between tricuspid annular plane systolic excursion on transesophageal echocardiography and the incidence of postoperative acute kidney injury in patients undergoing coronary artery bypass grafting surgery: a multicenter prospective cohort study.

BACKGROUND: To date, the relationship between the Transesophageal Echocardiography (TEE) monitoring indicator tricuspid annular plane systolic excursion (TAPSE) and the incidence of postoperative acute kidney injury (AKI) in Coronary Artery Bypass Grafting(CABG) patients remains unknown. The main objective of this study was to explore the relationship between the TAPSE and the incidence of AKI in CABG patients. METHODS: This was a multicenter prospective cohort study was conducted between September 2021 and July 2022. Among 266 patients aged at least 18 years who underwent elective CABG, 140 were included. RESULTS: We measured TAPSE via M-mode TEE via the mid-esophageal (ME) right ventricle(RV) inflow-outflow view (60°). All echocardiographic measurements were performed three separate times at each time point: T0 (before the start of CABG), T2 (approximately 5 ∼ 10 min after neutralization of protamine) and T3 (before leaving the operating room), and then averaged. Serum creatinine was measured 1 day before and within 7 days after CABG. There was no statistically significant association between the TEE-monitoring indicator TAPSE and the incidence of postoperative AKI in patients who underwent CABG. CONCLUSIONS: The TAPSE was not significantly correlated with postoperative AKI incidence and could not predict the early occurrence of postoperative AKI in CABG patients. TEE needs more evaluation for clinical efficacy of predicting the early occurrence of postoperative AKI in isolated CABG.

A systematic review and meta-analysis of differences between men and women in short-term outcomes following coronary artery bypass graft surgery.

We provide an update regarding the differences between men and women in short-term postoperative mortality after coronary artery bypass grafting (CABG) and highlight the differences in postoperative risk of stroke, myocardial infarction, and new onset atrial fibrillation. We included 23 studies, with a total of 3,971,267 patients (70.7% men, 29.3% women), and provided results for groups of unbalanced studies and propensity matched studies. For short-term mortality, the pooled odds ratio (OR) from unbalanced studies was 1.71 (with 95% CI 1.69-1.74, I2 = 0%, p = 0.7), and from propensity matched studies was 1.32 (95% CI 1.14-1.52, I2 = 76%, p < 0.01). For postoperative stroke, the pooled effects were OR = 1.50 (95% CI 1.35-1.66, I2 = 83%, p < 0.01) and OR = 1.31 (95% CI 1.02-1.67, I2 = 81%, p < 0.01). For myocardial infarction, the pooled effects were OR = 1.09 (95% CI = 0.78-1.53, I2 = 70%, p < 0.01) and OR = 1.03 (95% CI = 0.86-1.24, I2 = 43%, p = 0.18). For postoperative atrial fibrillation, the pooled effect from unbalanced studies was OR = 0.89 (95% CI = 0.82-0.96, I2 = 34%, p = 0.18). The short-term mortality risk after CABG is higher in women, compared to men. Women are at higher risk of postoperative stroke. There is no significant difference in the likelihood of postoperative myocardial infarction in women compared to men. Men are at higher risk of postoperative atrial fibrillation after CABG.

Healthcare-related carbon footprinting-lower impact of a coronary stenting compared to a coronary surgery pathway.

Healthcare is a major generator of greenhouse gases, so consideration of this contribution to climate change needs to be quantified in ways that can inform models of care. Given the availability of activity-based financial data, environmentally-extended input-output (EEIO) analysis can be employed to calculate systemic carbon footprints for healthcare activities, allowing comparison of different patient care pathways. We thus quantified and compared the carbon footprint of two common care pathways for patients with stable coronary artery disease, with similar clinical outcomes: coronary stenting and coronary artery bypass surgery (CABG). Healthcare cost data for these two pathways were disaggregated and the carbon footprint associated with this expenditure was calculated by connecting the flow of money within the economy to the greenhouse gases emitted to support the full range of associated activities. The systemic carbon footprint associated with an average stable patient CABG pathway, at a large tertiary referral hospital in Sydney, Australia in 2021-22, was 11.5 tonnes CO2-e, 4.9 times greater than the 2.4 tonnes CO2-e footprint of an average comparable stenting pathway. These data suggest that a stenting pathway for stable coronary disease should be preferred on environmental grounds and introduces EEIO analysis as a practical tool to assist in health-care related carbon footprinting.

Comparison of the Effect of Pump Flow Type (Pulsatile or Non-Pulsatile) on Postoperative Neurocognitive Functions in Coronary Artery Surgery.

INTRODUCTION: The effect of pump flow type on perfusion in coronary surgery using cardiopulmonary bypass (CPB) is discussed. We aimed to evaluate the effect of pump flow type on cognitive functions with neurocognitive function tests. METHODS: One hundred patients who underwent isolated coronary artery bypass surgery between November 2020 and July 2021 were divided into two equa groups. Groups were formed according to pump flow type pulsatile (Group 1) and non-pulsatile (Group 2). Clock drawing test (CDT) and standardized mini mental test (SMMT) were performed on the patients in both groups in the preoperative period, on the 1st preoperative day, and on the day before discharge. Neurocognitive effects were compared with all follow-up parameters. RESULTS: There was no difference between the groups in terms of demographic data and in terms of neurocognitive tests performed before the operation. SMMT on postoperative day 1 (Group I: 27.64 ± 1.05; Group II: 24.44 ± 1.64; P=0.001) and CDT (Group I: 5.4 ± 0.54; Group II: 4 .66 ± 0.52; P=0.001), and SMMT on the day before discharge (Group I: 27.92 ± 1.16; Group II: 24.66 ± 1.22; P=0.001) and CDT (Group I: 5 It was calculated as .66 ± 0.48; Group II: 5.44 ± 0.5; P=0.001). The duration of intensive care and hospitalization were higher in the non-pulsatile group. CONCLUSION: We think that the type of pump flow used in coronary artery bypass surgery using CPB is effective in terms of neurocognitive functions and that pulsatile flow makes positive contributions to this issue.

Assessment of EuroSCORE II and STS Score Performance and the Impact of Surgical Urgency in Isolated Coronary Artery Bypass Graft Surgery at a Referral Center in São Paulo, Brazil.

INTRODUCTION: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil. OBJECTIVE: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center. METHODS: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS). RESULTS: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients. CONCLUSION: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

Simultaneous bilateral bullectomy and coronary artery bypass grafting through median sternotomy approach.

Lung bullae can severely compromise lung function. Smoking is an important cause of chronic obstructive pulmonary disease, as well as coronary artery disease and peripheral arterial disease. Significant diseases in the cardiovascular and thoracic systems may require multiple interventions apart from medical management. We discuss a patient in which simultaneous bilateral bullectomy and coronary artery bypass grafting were performed through the median sternotomy approach.

Risk Model for Laryngeal Complications Prediction in Chinese PatientGBVs After Coronary Artery Bypass Grafting.

INTRODUCTION: The aim of this study was to identify perioperative risk factors of laryngeal symptoms and to develop an implementable risk prediction model for Chinese hospitalized patients undergoing coronary artery bypass grafting (CABG). METHODS: A total of 1476 Chinese CABG patients admitted to Wuhan Asian Heart Hospital from January 2020 to June 2022 were included and then divided into a modeling cohort and a verification cohort. Univariate analysis was used to identify laryngeal symptoms risk factors, and multivariate logistic regression was applied to construct a prediction model for laryngeal symptoms after CABG. Discrimination and calibration of this model were validated based on the area under the receiver operating characteristic (ROC) curve and the Hosmer-Lemeshow (H-L) test, respectively. RESULTS: The incidence of laryngeal symptoms in patients who underwent CABG was 6.48%. Four independent risk factors were included in the model, and the established aryngeal complications risk calculation formula was Logit (P) = -4.525 + 0.824 × female + 2.09 × body mass index < 18.5 Kg/m2 + 0.793 × transesophageal echocardiogram + 1.218 × intensive care unit intubation time. For laryngeal symptoms, the area under the ROC curve was 0.769 in the derivation cohort (95% confidence interval [CI]: 0.698-0.840) and 0.811 in the validation cohort (95% CI: 0.742-0.879). According to the H-L test, the P-values in the modeling group and the verification group were 0.659 and 0.838, respectively. CONCLUSION: The prediction model developed in this study can be used to identify high-risk patients for laryngealsymptoms undergoing CABG, and help clinicians implement the follow-up treatment.