Racial disparity persists after on-pump and off-pump coronary artery bypass grafting.

BACKGROUND: Race has been shown to be an independent risk factor for operative mortality after coronary artery bypass grafting (CABG). This study sought to determine the extent to which race is a risk factor for adverse events, long-term mortality, and whether off-pump surgery (OPCAB) modifies that risk. METHODS AND RESULTS: The Society of Thoracic Surgeons Adult Cardiac Database at Emory Healthcare affiliated hospitals was queried for all primary isolated CABG records from 1997 to 2007. A propensity score was formulated to balance the patient groups with respect to treatment assignment (OPCAB or CABG on cardiopulmonary bypass). Multivariable logistic regression was used to assess the impact of black race and OPCAB on in-hospital outcomes (death, stroke, myocardial infarction, and their composite, major adverse cardiac events). Cox proportional hazards regression model and Kaplan-Meier curves determined whether black race affected long-term all-cause mortality. Interaction terms were constructed to test whether OPCAB surgery influences surgical results differently in black patients than in white patients. There were 12 874 consecutive CABG patients, including 2033 (15.8%) blacks and 10 841 (84.2%) whites. Survival at 3, 5, and 10 years for blacks (87.5%, 81.4%, 63.8%) was significantly lower than for whites (90.7%, 85.2%, 67.1%, P<0.001). Blacks (adjusted odds ratio, 0.77; 95% CI, 0.44 to 1.36) and whites (adjusted odds ratio, 0.72; 95% CI, 0.53 to 0.99) who had OPCAB had lower risk-adjusted odds of major adverse cardiac events than their racial counterparts who had CABG on cardiopulmonary bypass. CONCLUSIONS: Short- and long-term outcomes are significantly worse in black than in white patients undergoing primary isolated CABG. OPCAB does not narrow the disparity in outcomes between blacks and whites.

Impact of renal dysfunction on outcomes of coronary artery bypass surgery: results from the Society of Thoracic Surgeons National Adult Cardiac Database.

BACKGROUND: Although patients with end-stage renal disease are known to be at high risk for mortality after coronary artery bypass graft (CABG) surgery, the impact of lesser degrees of renal impairment has not been well studied. The purpose of this study was to compare outcomes in patients undergoing CABG with a range from normal renal function to dependence on dialysis. METHODS AND RESULTS: We reviewed 483,914 patients receiving isolated CABG from July 2000 to December 2003, using the Society of Thoracic Surgeons National Adult Cardiac Database. Glomerular filtration rate (GFR) was estimated for patients with the use of the Modification of Diet in Renal Disease study formula. Multivariable logistic regression was used to determine the association of GFR with operative mortality and morbidities (stroke, reoperation, deep sternal infection, ventilation >48 hours, postoperative stay >2 weeks) after adjustment for 27 other known clinical risk factors. Preoperative renal dysfunction (RD) was common among CABG patients, with 51% having mild RD (GFR 60 to 90 mL/min per 1.73 m2, excludes dialysis), 24% moderate RD (GFR 30 to 59 mL/min per 1.73 m2, excludes dialysis), 2% severe RD (GFR <30 mL/min per 1.73 m2, excludes dialysis), and 1.5% requiring dialysis. Operative mortality rose inversely with declining renal function, from 1.3% for those with normal renal function to 9.3% for patients with severe RD not on dialysis and 9.0% for those who were dialysis dependent. After adjustment for other covariates, preoperative GFR was one of the most powerful predictors of operative mortality and morbidities. CONCLUSIONS: Preoperative RD is common in the CABG population and carries important prognostic importance. Assessment of preoperative renal function should be incorporated into clinical risk assessment and prediction models.

Pretreatment with phenoxybenzamine attenuates the radial artery's vasoconstrictor response to alpha-adrenergic stimuli.

BACKGROUND: Although the radial artery bypass conduit has excellent intermediate-term patency, it has a proclivity to vasospasm. We tested the hypothesis that brief pretreatment of a radial artery graft with the irreversible adrenergic antagonist phenoxybenzamine attenuates the vasoconstrictor response to the vasopressors phenylephrine and norepinephrine compared with the currently used papaverine/lidocaine. METHODS: Segments of human radial artery grafts were obtained after a 30-minute intraoperative pretreatment with a solution containing 20 mL of heparinized blood, 0.4 mL of papaverine (30 mg/mL), and 1.6 mL of lidocaine (1%). The segments were transported to the laboratory and placed into a bath containing Krebs-Henseleit solution and 10, 100, or 1000 micromol/L phenoxybenzamine or vehicle. The segments were tested in organ chambers for contractile responses to increasing concentrations of phenylephrine and norepinephrine (0.5-15 micromol/L). RESULTS: Contractile responses to 15 micromol/L phenylephrine in control radial artery segments averaged 44.2% +/- 9.1% of the maximal contractile response to 30 mmol/L KCl. Papaverine/lidocaine modestly attenuated contraction to 15 micromol/L phenylephrine (32.1% +/- 5.9%; P =.22), but 1000 micromol/L phenoxybenzamine completely abolished radial artery contraction (-7.2% +/- 4.4%; P <.001). The effect of 10 and 100 micromol/L phenoxybenzamine on attenuating vasocontraction was intermediate between 1000 micromol/L phenoxybenzamine and papaverine/lidocaine. Responses to 15 micromol/L norepinephrine in control radial artery segments averaged 54.7% +/- 7.5% of maximal contraction to 30 mmol/L KCl. Papaverine/lidocaine modestly attenuated the contraction response of radial artery segments (35.6% +/- 5.1%; P =.04). In contrast, 1000 micromol/L phenoxybenzamine showed the greatest attenuation of norepinephrine-induced contraction (-10.5% +/- 2.0%; P <.001). CONCLUSIONS: A brief pretreatment of the human radial artery bypass conduit with 1000 micromol/L phenoxybenzamine completely attenuates the vasoconstrictor responses to the widely used vasopressors norepinephrine and phenylephrine. Papaverine/lidocaine alone did not block vasoconstriction to these alpha-adrenergic agonists.

Impact of renal disease in cardiovascular surgery: emphasis on the African-American patient.

Cardiovascular disease remains a significant source of morbidity and mortality for patients with kidney disease. Coincident with the development of chronic renal failure, patients typically manifest a systemic vasculopathy often involving the cardiovascular system. The renal failure patient is also plagued by multiple comorbid conditions that may adversely affect cardiovascular outcomes. Consistent with the national trend of increasing numbers of patients requiring renal replacement therapy (RRT), patients requiring invasive cardiovascular procedures are also on the incline. The morbidity and mortality related to these procedures has remained high despite significant advances in delivery and maintenance of care. Is the African-American patient with renal failure unique in terms of cardiovascular morbidity and mortality? Numerous studies have documented racial differences in access to invasive cardiovascular procedures, even after controlling for multiple physiologic risk factors and socioeconomic and sociocultural factors. Studies have also shown higher morbidity and lower survival for African-American patients after cardiac procedures. In this high-risk population these same issues perhaps would persist. The following paper will examine the current status of cardiovascular disease in the renal failure patient with emphasis on the African-American patient population.

Perfusion-assisted direct coronary artery bypass provides early reperfusion of ischemic myocardium and facilitates complete revascularization.

BACKGROUND: Perfusion-assisted direct coronary artery bypass (PADCAB) was developed to initiate early reperfusion of grafted coronary artery segments during off-pump operations to resolve episodes of myocardial ischemia and avoid its sequelae. This case series outlines intraoperative findings and clinical outcomes of our first year clinical experience with PADCAB. METHODS: From November 1999 to November 2000, 169 PADCAB and 358 off-pump coronary artery bypass procedures were performed at the Emory University Hospitals. The decision to use PADCAB was predicated on surgeon preference. Perfusion pressure and flow, amount of intracoronary nitroglycerin, and total perfusion time and volume were recorded at the time of operation. RESULTS: One off-pump coronary artery bypass patient required emergent conversion to cardiopulmonary bypass. Two PADCAB patients had ischemic ventricular arrhythmias during target vessel occlusion that resolved once active perfusion had begun. Perfusion pressure in PADCAB grafts was on average 44% higher than mean arterial pressure (p < 0.001). Nitroglycerin, infused locally by PADCAB, was used in 67 patients to resolve ischemic episodes and increase initial coronary flows. The mean number of diseased coronary territories and grafts placed was 2.8 +/- 0.5 and 3.4 +/- 0.7, respectively, in the PADCAB group, and 2.3 +/- 0.8 and 2.7 +/- 1.0, respectively, in the off-pump coronary artery bypass group (p < 0.001 for both comparisons). More PADCAB patients received lateral wall grafts than off-pump coronary artery bypass patients (83.4% vs 59.4%; p < 0.001). Hospital death and postoperative myocardial infarction were not different between groups. CONCLUSIONS: PADCAB can provide suprasystemic perfusion pressures and a means to add vasoactive drugs to target coronary vessels. PADCAB provides early reperfusion of ischemic myocardium and facilitates complete revascularization of severe multivessel coronary artery disease.

The impact of specific preoperative organ dysfunction in patients undergoing aortic valve replacement.

BACKGROUND: Optimizing treatment strategies to risk profile patients undergoing aortic valve replacement remains a priority. The role that specific and combinations of preoperative organ dysfunction (OD) plays in informing these decisions remains uncertain. This study sought to determine the relative effect that OD in particular systems has on short- and long-term outcomes. METHODS: A total of 1,759 aortic valve replacement cases with and without coronary artery bypass grafting performed from January 2002 to June 2010 at Emory University are the basis for this retrospective analysis. Patients were classified by the presence or absence of preoperative OD: (1) cardiac: congestive heart failure (ejection fraction <0.35), (2) pulmonary: forced expiratory volume in 1 second less than 50% predicted, (3) neurologic (prior stroke), and (4) renal: chronic renal failure. The impact of individual and combined OD on outcomes was evaluated. Kaplan-Meier survival estimates and Cox regression models were used to assess the relationship between OD and long-term survival. RESULTS: A total of 513 patients (29.2%) had at least one OD, including 95 patients (5.4%) with more than one OD. Organ dysfunction in each organ system was associated with poorer survival. Renal (hazard ratio, 3.90) and pulmonary (hazard ratio, 2.40) OD patients had poorer long-term survival, including 30-day mortality. Seven-year survival for OD patients is as follows: prior stroke, 48.6%; severe chronic obstructive pulmonary disease, 30.8%; congestive heart failure, 55.9%; and chronic renal failure, 11.7%. The sequential addition of OD systems was a powerful predictor of poorer long-term survival. CONCLUSIONS: The presence of chronic renal failure most profoundly decreases survival, followed by severe chronic obstructive pulmonary disease and prior stroke. Furthermore, multiple OD systems significantly decrease short- and long-term survival.

Impact of preoperative chronic lung disease on survival after surgical aortic valve replacement.

BACKGROUND: An increasing number of patients requiring surgical aortic valve replacement (SAVR) present with chronic pulmonary obstructive disease (COPD). The purpose of this study was to compare patients who had a range of COPD from normal to severe and were undergoing SAVR. METHODS: Retrospective review of 2,379 patients undergoing SAVR ± coronary artery bypass grafting (CABG) from January 2002 to April 2012 at a US academic institution was performed. COPD was defined according to the Society of Thoracic Surgeons (STS) adult cardiac database: normal (forced expiratory volume [FEV] > 75% predicted), mild (FEV in 1 second [FEV1] 60%-75%), moderate (FEV1 50%-59%), and severe (FEV1 < 50%). Multivariable logistic and Cox regression methods were used to determine independent association between COPD and short- and long-term outcomes. Selection bias adjustment was achieved using the STS predicted risk of mortality (PROM). Adjusted odds ratios (AORs) and adjusted hazard ratios (AHR) were calculated using the normal lung function group as the reference. Kaplan-Meier curves were created to estimate long-term survival. RESULTS: One thousand five hundred seventeen of 2,379 patients (63.8%) had isolated SAVR, whereas 862 of 2,379 (36.2%) patients underwent SAVR + CABG. Preoperative COPD was common among patients (21.9%) undergoing SAVR ± CABG and included 332 (14.0%) patients with mild COPD, 89 (3.7%) patients with moderate COPD, and 101 (4.2%) patients with severe COPD. Unadjusted in-hospital mortality rose significantly with COPD class, from 3.9% for those with no COPD to 9.6% to patients with severe COPD. After adjustment, in-hospital mortality was not statistically different in normal patients and in those with COPD. In contrast, when compared with normal patients, adjusted long-term survival was worse across levels of COPD: mild (AHR, 1.70; p < 0.001), moderate (AHR, 2.25; p < 0.001), and severe (AHR, 2.28; p < 0.001). CONCLUSIONS: Preoperative COPD is common in the SAVR population and is associated with diminished long-term but not short-term survival.

Sternotomy versus nonsternotomy LIMA-LAD grafting for single-vessel disease.

BACKGROUND: Single-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by left internal mammary artery (LIMA) grafting either through a sternotomy or a nonsternotomy approach. Nonsternotomy approaches are used in the hope of achieving a less invasive operation. It is unknown whether nonsternotomy approaches impact in-hospital or midterm outcomes. METHODS: The institutional Society of Thoracic Surgeons (STS) database at a single US academic center was reviewed for 597 consecutive patients treated surgically for single-vessel LAD disease from January 1, 2002 to June 30, 2011. In-hospital adverse events and length of stay (LOS) were compared between patients who had LIMA-LAD grafting performed through a sternotomy (sternotomy patients) versus patients who had this procedure performed through a nonsternotomy approach (nonsternotomy patients), adjusted for propensity score (likelihood of receiving sternotomy, calculated on 33 variables). Midterm survival between groups was compared using Kaplan-Meier and Cox regression analysis by referencing the National Social Security Death Index. RESULTS: There were 597 consecutive patients who underwent single-vessel grafting by LIMA-LAD coronary artery grafting. Of these patients, 234 underwent sternotomy, whereas 363 patients had nonsternotomy procedures: 239 patients had endoscopic LIMA harvest and left anterolateral thoracotomy, 106 patients had robot LIMA harvest and left anterolateral thoracotomy, and 18 patients had minimally invasive direct coronary artery bypass. There were no strokes in the nonsternotomy group and 3 (1.3%) in the sternotomy group (p = 0.031). Thirty-day mortality, incidence of myocardial infarction, hospital LOS, and midterm survival were similar between groups. Operative time was significantly longer in the nonsternotomy group (1.8 hours, 95% confidence interval [CI], 1.5-2.1). CONCLUSIONS: In this propensity-adjusted comparison, sternal-sparing incisions were associated with similar 30-day adverse events and midterm survival compared with sternotomy for single-vessel LIMA-LAD artery grafting.

Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery.

BACKGROUND: Off-pump coronary artery bypass graft (OPCAB) may be associated with improved hospital outcomes compared with on-pump coronary artery bypass graft. However, intraoperative conversion to on-pump coronary artery bypass graft has been associated with adverse outcomes. The purpose of this study was to identify preoperative risk factors for intraoperative conversion in nonemergent patients undergoing isolated OPCAB. METHODS: From 2002 to 2010, 8,077 consecutive OPCAB cases were performed at a single US academic center. Of these, 200 (2.5%) required intraoperative conversion. Standard variables from The Society of Thoracic Surgeons database were analyzed. A multivariable logistic model with adjusted odds ratios (OR) and 95% confidence intervals was used to identify independent risk factors for conversion. Adjusted in-hospital and long-term survival between converted and nonconverted patients were determined using multiple logistic regression and Cox proportional hazards regression, respectively. RESULTS: Converted patients had a higher Society of Thoracic Surgeons predicted risk of mortality (2.8% versus 2.1%; p<0.001). Surgeon identity was the most significant multivariable predictor of conversion. After adjustment for surgeon identity, the following independent risk factors were associated with intraoperative conversion: previous coronary artery bypass graft (OR, 3.43; p=0.018), congestive heart failure (OR, 1.51), myocardial infarction (OR, 1.86), number of grafts (OR, 1.45), left main disease (OR 1.41), and urgent status (OR, 1.77; all p<0.05). Conversion to on-pump coronary artery bypass graft was associated with increased in-hospital (OR, 4.8; p<0.001) and long-term mortality (hazard ratio, 1.65; p<0.001). CONCLUSIONS: Conversion to cardiopulmonary bypass during OPCAB is associated with increased in-hospital and long-term mortality and may be related to surgeon experience. Recognition of the preoperative risk factors associated with an increased risk of conversion may allow for better patient selection and reduce the incidence of intraoperative conversion during OPCAB.

A randomized trial of a skin sealant to reduce the risk of incision contamination in cardiac surgery.

BACKGROUND: Immobilizing skin microbes is a rational approach to reducing contamination of surgical sites by endogenous microorganisms. METHODS: This randomized, controlled, parallel-group, multicenter, open-label clinical trial (ClinicalTrials.gov NCT00467857) enrolled 300 adults scheduled for elective coronary artery bypass graft surgery. Patients received iodine-based skin preparations followed by a cyanoacrylate-based skin sealant or skin preparations alone. Microbiological samples collected from sternal and graft incision sites immediately before any skin preparation, at the wound border after skin incision, and at the incision after fascial closure were evaluated quantitatively. RESULTS: In evaluable patients, mean microbial counts in collected samples increased at the sternal site after fascial closure compared with after skin incision by 0.37 log10 colony-forming units (CFU)/mL in the skin sealant group (n=120) and by 0.57 log10 CFU/mL in the control group (n=132) (p=0.047, Wilcoxon rank sum test). At the graft site, mean microbial counts increased by 0.09 (n=119) and 0.27 (n=127) log10 CFU/mL, respectively (p=0.037). There was a 35.3% relative risk reduction in surgical site infection (SSI) occurring in the skin sealant group (9 of 146 patients, 6.2%) versus the control group (14 of 147 patients, 9.5%). In obese patients (body mass index [BMI]>30.0 to ≤37.0 kg/m2), the relative risk reduction for SSI associated with skin sealant was 83.3%. CONCLUSIONS: Pretreatment with skin sealant protects against contamination of the surgical incision by migration of skin microbes. Further data are needed to confirm the impact of this technology on SSI rates in clinical practice.

Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.

BACKGROUND: The objective of this study was to assess short-term and long-term outcomes after valve replacement with biologic or mechanical prostheses in patients with preoperative end-stage renal disease on chronic dialysis. METHODS: A retrospective review of patients with end-stage renal disease undergoing valve replacement from January 1996 through March 2008 at Emory Healthcare Hospitals was performed. Outcomes were compared using χ(2) tests and 2-sample t tests. Adjusted long-term survival up to 10 years was assessed with Kaplan-Meier plots and compared between biologic and mechanical replacements using the Cox proportional hazards model. RESULTS: A total of 202 patients underwent 211 valve replacement operations. Patient age was 20 to 83 years (mean age, 54.8 ± 14.0); 115 of 211 (54.5%) were male. Operations included the following: 100 of 211 (47.4%) isolated aortic; 49 of 211 (23.2%) isolated mitral; 4 of 211 (1.9%) isolated tricuspid; and 58 of 211 (27.5%) combined replacements. Thirteen (6.2%) patients underwent reoperative valve replacements. Most patients received bioprosthetic valves (143 of 211, 67.8%), while 68 of 211 (32.2%) received mechanical valves. Concomitant coronary artery bypass was performed in 53 of 211 (25.1%) patients. Thirty-day mortality was in 42 of 211 patients (19.9%) and was not different between bioprosthetic and mechanical replacements. Overall 10-year survival was 18.1% for all patients and was not influenced by valve type implanted. CONCLUSIONS: For patients with end-stage renal disease treated with dialysis, valve replacement carries acceptable operative mortality. Long-term survival is similar among patients receiving bioprosthetic versus mechanical valve replacement. Careful risk assessment and choice of valve prosthesis should be performed prior to surgical intervention in this high-risk patient population.

Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement.

BACKGROUND: The impact of the degrees of renal dysfunction (RD) after aortic valve replacement (AVR) has not been well described. The purpose of this study was to compare patients undergoing AVR with a range of renal function from normal to dialysis-dependence. METHODS: A retrospective review of 2,408 patients undergoing AVR with or without coronary artery bypass graft surgery (CABG) from January 1996 to March 2009 was performed. Glomerular filtration rate (GFR) was estimated for patients using the Modification of Diet in Renal Disease formula. Multivariable logistic and Cox regression methods were used to determine the independent association of GFR with outcomes. Adjusted odds ratios were calculated for in-hospital outcomes, and Kaplan-Meier curves were created to estimate long-term survival. RESULTS: In all, 1,512 patients (62.8%) had isolated AVR, and 896 (37.2%) underwent AVR plus CABG. Preoperative RD was common among all patients: 1,148 of 2,408 (47.7%) with mild RD (GFR 60 to 90 mL·min(-1)·1.73 m(-2)), 644 of 2,408 (26.7%) moderate RD (GFR 30 to 59 mL·min(-1)·1.73 m(-2)), 59 of 2,408 (2.5%) severe RD (GFR 15 to 30 mL·min(-1)·1.73 m(-2)), and 114 (4.7%) with kidney failure (GFR<15) or requiring dialysis. In-hospital mortality generally rose with RD, from 2.9% for patients with no RD to 15.8% for patients with severe RD, and 17.3% for patients requiring dialysis. Patients with severe RD or preoperative dialysis were associated with significantly poorer outcomes. Adjusted long-term survival is progressively worse across levels of RD, as was postoperative length of stay (p<0.001). CONCLUSIONS: Preoperative RD is common among the AVR population and is associated with diminished long-term survival. The association between RD and worse outcomes after AVR surgery has significant clinical implications.

The effect of diabetes mellitus on in-hospital and long-term outcomes after heart valve operations.

BACKGROUND: Diabetes mellitus (DM) is associated with adverse in-hospital and long-term outcomes in patients undergoing coronary artery bypass grafting. This study evaluated outcomes in patients with DM undergoing isolated heart valve operations. METHODS: From January 1, 1996, to March 31, 2008, 2964 consecutive patients underwent primary, isolated heart valve operations at Emory University Hospitals. Patients undergoing concomitant coronary bypass grafting were excluded. Of the heart valve patients, 424 (14.3%) had a diagnosis of DM, and 126 (29.7%) received insulin therapy. Long-term survival status was determined using the Social Security Death Index. Odds ratios and proportional hazards regression analysis (hazard ratio) were used to identify risk factors for in-hospital and long-term mortality, respectively. RESULTS: Thirty-four DM patients (8.0%) died in-hospital compared with 99 (3.9%) without DM (p < 0.001). In-hospital mortality was higher in DM patients who received insulin (12.7%) than in those without insulin therapy (6.0%, p = 0.021). DM patients had significantly reduced 10-year survival of 41.5% vs 70.5% for those without DM (p < 0.001). After risk adjustment, DM remained a strong risk factor for reduced 10-year survival (hazard ratio, 1.30; 95% confidence interval, 1.05 to 1.61; p = 0.018); other risk factors include advanced age, stroke, female gender, peripheral vascular disease, advanced heart failure, and renal failure. CONCLUSIONS: DM is associated with significantly worse outcomes after valve operations. Given the reduced long-term survival observed in these patients, this information should be used when making operative decisions regarding surgical techniques and types of prosthesis in these complex patients.

Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction.

BACKGROUND: The purpose of this study was to assess the impact of left ventricular dysfunction and other risk factors on short- and mid-term outcomes after aortic valve replacement for aortic stenosis. METHODS: From January 1, 2002, to December 31, 2007, 773 consecutive patients underwent primary aortic valve replacement for aortic stenosis at a single institution; concomitant coronary artery bypass graft surgery (CABG) was performed in 45.4% (351 of 773). Multivariable regression analysis was used to identify predictors of in-hospital mortality, with ejection fraction (EF) as the primary variable of interest. After discharge, survival status was determined using the Social Security Death Index. A Cox proportional hazards regression model was used to identify predictors of mid-term mortality. RESULTS: On univariable analysis, EF (odds ratio [OR] 0.979, 95% confidence interval [CI]: 0.960 to 0.999, p = 0.044) but not concomitant CABG emerged as a predictor of in-hospital mortality. However, on multivariable analysis, neither EF nor concomitant CABG was associated with increased in-hospital mortality. Multivariable predictors of in-hospital mortality included age, emergent status, and prolonged bypass time. On univariable analysis, mid-term mortality was associated with EF and concomitant CABG (OR 0.979, 95% CI: 0.966 to 0.991, p = 0.001, and OR 1.61, 95% CI: 1.11 to 2.36, p = 0.013, respectively). However, after multivariable adjustment, only EF was associated with mid-term mortality (adjusted OR 0.985, 95% CI: 0.970 to 1.00, p = 0.049). Other multivariable predictors of mid-term mortality included age, dialysis-dependent renal failure, previous stroke, and peripheral vascular disease. CONCLUSIONS: Left ventricular dysfunction, in addition to other patient comorbidities, may negatively impact survival after aortic valve replacement. Careful consideration of the cumulative effect of these multiple risk factors is necessary to optimize patient outcomes.

Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery.

BACKGROUND: The predictive role of hemoglobin A1c (HbA1c) on long-term outcomes after coronary artery bypass surgery has not been evaluated. METHODS: Preoperative HbA1c levels were obtained in 3,201 patients undergoing primary, elective coronary artery bypass surgery at Emory Healthcare Hospitals from January 2002 to December 2006 and entered prospectively into a computerized database. Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Log-rank (unadjusted) and Cox proportional hazards regression models (adjusted) were employed to determine whether HbA1c and diabetes mellitus were independent risk factors for reduced long-term survival, adjusted for 29 covariates. Hazard ratios for each unit increase in continuous HbA1c were calculated. RESULTS: Patients with HbA1c of 7% or greater had lower unadjusted 5-year survival compared with patients with HbA1c less than 7% (p = 0.001). Similarly, patients with diabetes mellitus had lower unadjusted 5-year survival compared with patients without diabetes (p < 0.001). After multivariable adjustment, higher HbA1c (measured as a continuous variable) was associated with reduced long-term survival for each unit increase in HbA1c (hazard ratio 1.15, p < 0.001), but preoperative diagnosis of diabetes was not associated with reduced long-term survival after coronary artery bypass surgery (p = 0.41). Other multivariable predictors of reduced long-term survival included age, cerebrovascular disease, elevated serum creatinine, renal insufficiency, congestive heart failure, previous myocardial infarction, chronic lung disease, and peripheral vascular disease. CONCLUSIONS: Poor preoperative glycemic control, as measured by an elevated HbA1c, is associated with reduced long-term survival after coronary artery bypass surgery. Optimizing glucose control in these patients may improve long-term survival.

Influence of on-pump versus off-pump techniques and completeness of revascularization on long-term survival after coronary artery bypass.

BACKGROUND: Off-pump coronary artery bypass graft surgery (OPCABG) may be associated with reduced morbidity and in-hospital mortality. In this study, we report the influence of surgery type, number of grafts, and the Index of Completeness of Revascularization (ICOR), namely, the number of grafts/number diseased vessel systems, on long-term survival. METHODS: From 1997 to 2006, 12,812 consecutive patients underwent isolated CABG at a single academic center. Ten-year survival data were obtained by cross-referencing patients with the national Social Security Death Index. A propensity score analysis of 46 preoperative characteristics balanced risk factors between surgical groups. A proportional hazards regression analysis modeled the hazard of death as a function of surgery type (on versus off), distal group (1 to 3 versus 4 to 7 vessels), ICOR, and propensity score. RESULTS: Proportional hazards regression analysis showed no significant influence of surgery type or number of grafts on long-term survival within the four groups: OPCABG 1 to 3 grafts (n = 3,946; ICOR 1.11), OPCABG 4 to 7 grafts (n = 1,721; ICOR 1.56), on-pump CABG 1 to 3 grafts (n = 3,380; ICOR 1.21), and on-pump CABG 4 to 7 grafts (n = 3,765; ICOR 1.64). Irrespective of technique of revascularization, there was a survival advantage for patients with higher ICOR. CONCLUSIONS: Long-term survival was similar for patients receiving 1 to 3 or 4 to 7 grafts by either on-pump or off-pump techniques. However, higher ICOR was associated with improved long- term survival within all groups.

Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective.

BACKGROUND: With the recent advent of percutaneous valve therapy, an increased need for the evaluation of outcomes after open aortic valve replacement (AVR) in elderly patients is warranted. This study compares the short- and long-term survival outcomes of octogenarians after AVR with younger age groups in the modern surgical era. METHODS: A retrospective review was performed on patients who underwent isolated, primary AVR from 1996 to 2006 at the Emory Healthcare Hospitals. Five-hundred fifteen patients were divided into three age groups: 60 to 69 (n = 206), 70 to 79 (n = 221), and 80 to 89 years of age (n = 88). Outcomes were compared among the age groups using logistic regression and analysis of variance techniques. Long-term survival between age groups was compared using the Cox proportional hazards model. Kaplan-Meier plots were used to determine survival rates. RESULTS: The groups were similar with respect to in-hospital mortality (p = 0.66) and hospital length of stay (p = 0.08). Preoperative predictors of in-hospital mortality included stroke (odds ratio [OR] 5.36), chronic lung disease (OR 4.51), and renal failure (OR 1.39). As expected, age significantly impacted long-term survival (hazard ratio [HR] 1.06). Other predictors of long-term survival included stroke (HR 2.15), current smoker (HR 2.03), diabetes (HR 1.53), and renal failure (HR 1.4). The Kaplan-Meier estimate of median survival for octogenarians was 7.4 years. CONCLUSIONS: In the modern era, octogenarians have acceptable short- and long-term results after open AVR. Comparisons of less invasive techniques for AVR should rely on outcomes based in the modern era and decisions regarding surgical intervention in patients requiring AVR should not be based on age alone.

Propensity-score analysis of early outcomes after bilateral versus single internal thoracic artery grafting.

OBJECTIVE: : The use of bilateral internal thoracic arteries (BITAs) during coronary artery bypass grafting (CABG) improves long-term and event-free survival compared with single internal thoracic artery (SITA) grafting. It is controversial whether BITA grafting alters in-hospital adverse events after CABG. METHODS: : Isolated CABG cases using BITA or SITA at a single US academic center between January 1, 1997 and June 30, 2006 were retrospectively reviewed. A propensity score was used as a covariate to balance the treatment groups (BITA and SITA) with respect to 44 preoperative risk factors. A multivariable logistic regression model tested whether treatment type was significantly associated with in-hospital death, deep sternal wound infection (DSWI), or hospital length of stay (LOS). RESULTS: : There were 599 BITA and 10,212 SITA cases performed. Overall for all BITA versus SITA cases, adjusted mortality (0.8% vs. 1.7%, P = 0.85) was not different between the groups. However, adjusted incidence of DSWI (2.0% vs. 1.2%, P = 0.036) and LOS (6.7 vs. 6.1, P = 0.025) were significantly higher in BITA patients. Subsets analyses of obese patients and diabetic patients revealed no statistical differences for any of the outcomes between BITA and SITA. CONCLUSIONS: : The long-term benefits of BITA grafting do not come at the cost of increased adjusted risk of in-hospital death. BITA grafting was associated with an increased risk of DSWI and a longer adjusted LOS. Neither obesity, nor diabetes significantly increased the risk of poor outcomes after BITA.

Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival.

BACKGROUND: This study compared in-hospital major adverse cardiac events (MACE) and long-term survival after off-pump (OPCAB) vs on-pump (CPB) coronary artery bypass grafting (CABG). METHODS: Reviewed were 12,812 consecutive isolated CABG patients from 1997 to 2006. A propensity score (PS), including 40 preoperative risk factors, balanced characteristics between OPCAB and CPB groups. Multiple logistic regression models tested whether gender or surgery type, or their interaction, were associated with in-hospital mortality and MACE. A proportional hazards regression model and Kaplan-Meier curves related long-term survival with gender, surgery type, and their interaction, adjusted for PS and age. RESULTS: OPCAB was associated with a significant reduction in operative mortality (adjusted odds ratio [AOR], 0.68; p = 0.045), stroke (AOR, 0.48; p < 0.001), and MACE (AOR, 0.66; p = 0.018). Female gender was associated with higher rates of death (AOR, 1.93), stroke (AOR, 1.82), myocardial infarction (AOR, 2.19), and MACE (AOR, 1.97; each p < 0.001). Women disproportionately benefited from OPCAB in operative mortality (p = 0.04). Odds of death for women on CPB were higher than for women treated with OPCAB (AOR, 2.07, p = 0.005). Odds of death for men on CPB were not significantly higher than for men treated with OPCAB (AOR, 1.16, p = 0.51). Male gender was associated with longer-term survival (p = .011), but surgery type (OPCAB vs CPB) was not (p = 0.23). CONCLUSIONS: OPCAB provides significant early mortality and morbidity advantages, especially for women. During the 10-year follow-up, OPCAB and CPB result in similar survival, regardless of gender.

Outcomes after off-pump reoperative coronary artery bypass grafting.

OBJECTIVE: : Application of off-pump techniques to reoperative coronary artery bypass (redo CABG) has been limited by technical difficulty and potential for embolism of atheromatous debris from diseased grafts, resulting in myocardial infarction and rapid hemodynamic deterioration. We compared outcomes after off-pump (OPCAB) and on-pump (ONCAB) in redo CABG. METHODS: : A retrospective chart review was performed for patients who underwent redo CABG at a single academic institution between January 1997 and December 2004. Outcomes were compared between groups based on intention to treat. Propensity scores were calculated for each patient using 23 preoperative risk factors. Logistic regression was applied for each end point as a function of group and propensity score. RESULTS: : A total of 771 consecutive patients had redo CABG (639 ONCAB and 132 OPCAB); 22 patients (16.7%) were converted from OPCAB to ONCAB for hemodynamic in stability, severe adhesions, or graft injury; 7 patients (1.1%) were converted from ONCAB to OPCAB for severe aortic calcification. Propensity-matched comparison of outcomes after OPCAB versus ONCAB for redo CABG showed that OPCAB was associated with a reduction in postoperative complications, transfusion, atrial fibrillation, and length of stay. OPCAB patients received fewer grafts with similar use of left internal mammary artery conduit; conversion from OPCAB to ONCAB did not reduce the benefit of OPCAB. CONCLUSIONS: : OPCAB can be safely and effectively applied to reoperative CABG in selected cases.