Background It is not clear whether radial artery (RA), right internal thoracic artery (RITA), or saphenous vein (SV) is the preferred second bypass graft during coronary artery bypass graft surgery ...using the left internal thoracic artery (LITA) in patients aged less or greater than 70 years. Methods Late survival data were collected for 13,324 consecutive, isolated, primary coronary artery bypass graft surgery patients from three hospitals. Cox regression analysis was performed on all patients grouped by age. Results Adjusted Cox regression showed overall better RA versus SV survival (hazard ratio HR 0.82, p < 0.001) and no difference in RITA versus SV survival (HR 0.95, p = 0.35). However, the survival benefit of RA versus SV was seen only in patients aged less than 70 years (HR 0.77, p < 0.001); and RITA patients aged less than 70 years also had a survival benefit compared with SV (HR 0.86, p = 0.03). There was no difference in survival for RA versus RITA across all ages. Conclusions For patients aged less than 70 years, the optimal grafting strategy is using either RA or RITA as the second preferred graft. In patients aged 70 years or more, RA and RITA grafting should be used selectively. Multiple arterial grafting using either RA or RITA should be more widely utilized during coronary artery bypass graft surgery for patients less than 70 years of age.
Background Both anemia and transfusions (Tx) are associated with mortality after cardiac operations. However, the relative contributions of anemia and Tx and their interaction on late mortality have ...not been determined. Methods 922 patients who underwent isolated coronary artery bypass grafting (CABG) were retrospectively studied. Anemia (A+) was defined as hemoglobin <12 g/dL for men and <11 g/dL for women. Patients who received (Tx+) and did not receive (Tx-) transfusions were compared; patient characteristics were controlled for by the use of Cox analysis and then by matching Tx+ to Tx- patients based on identical hemoglobin levels at admission and by propensity matching. Results 5.3% of Tx- patients died, compared with 11% of Tx+ patients ( p = 0.001). The interaction of anemia and Tx was associated with a greater hazard of dying. In particular, A+Tx+ (anemic, received transfusion) patients had a threefold hazard of death (2.918, 95% confidence interval = 1.512–5.633, p = 0.001) compared with A−Tx− (nonanemic, no transfusion) patients. A+Tx+ patients had twice the hazard of dying as did A+Tx− (anemic, no transfusion) (hazard ratio = 2.087, 95% confidence interval = 1.004–4.336, p = 0.049). In populations matched by preoperative hemoglobin levels or by propensity scores, similar results were seen: a significant interaction between anemia and transfusion of red blood cells. A+Tx+ patients fared significantly worse than did the other three groups. Although there was no difference in mortality between A− patients who did or did not receive transfusions, A+T+ patients had triple the risk as A+T- patients, whereas A+Tx− patients had a similar risk of late mortality as A−Tx− patients. Conclusions The anemia–transfusion interaction was associated with an increased hazard of late mortality.
Background Red blood cell transfusion after coronary artery bypass graft surgery has been associated with increased late all-cause death. Yet, whether this association is, first, independent of the ...packed red blood cells and perioperative morbidity association, and second, of a cardiac versus noncardiac etiology remains unknown. Methods We analyzed patients undergoing coronary artery bypass graft surgery at two Ohio hospitals (n = 6,947) from 1994 to 2007. Salvage operations and patients with preoperative renal failure were excluded. Long-term outcomes and leading cause of death (cardiac, noncardiac, all cause) were derived from the US Social Security Death Index and later from Ohio Department of Health Death Index. Fifteen-year mortality cumulative incidence functions were compared for transfusion groups (yes, n = 2,540; no, n = 4,806) overall, and then stratified based on perioperative complications status (yes, n = 2,638; no, n = 4,708). Comprehensive, 32 covariates, risk-adjusted transfusion effects were estimated by competing risk regression. Results were confirmed by propensity score adjusted analysis. Results Perioperative transfusions and complications occurred in 33.9% and 35.2% of patients, respectively. In all, 3,108 deaths (48.1%) have been documented (median time to death, 7.43 years). Both transfusion rates (25.6% versus 49.1%, p < 0.001) and deaths (58.2% versus 38.5%, p < 0.001) were more frequent among complications patients. Red blood cells transfusion increased intermediate to late mortality risk overall (15-year adjusted hazard ratio AHR 1.21, 95% confidence interval CI: 1.11 to 1.31), and for complications (AHR 1.24, 95% CI: 1.11 to 1.39) and no complications (AHR 1.16, 95% CI: 1.03 to 1.31). The increased mortality was true for cardiac and noncardiac etiologies (AHR 1.19, 95% CI: 1.03 to 1.36, and AHR 1.14, 95% CI: 1.01 to 1.29, respectively). Red blood cell transfusion increased mostly cardiac deaths (AHR 1.38, 95% CI: 1.14 to 1.66) among the complications group, and noncardiac mortality (AHR 1.24, 95% CI: 1.05 to 1.47) for the no complications group. A parallel propensity matched sensitivity analysis confirmed these findings. Conclusions Perioperative red blood cells transfusion is associated with significant adverse late death effects among both complicated patients and noncomplicated patients, principally seen between 0 and 5 years postoperatively, and is driven by both increased cardiovascular and noncardiovascular mortality. Further studies are needed to elucidate the mechanisms behind these findings, including their potential dose dependence.
Background We currently have an incomplete understanding of which postoperative complications after coronary artery bypass grafting (CABG) are associated with long-term death. The purpose of this ...study was to find the associations between complications and attributable death. Methods Prospectively collected data on patient characteristics, risk factors, and complications of patients undergoing isolated CABG with 20-year follow-up were analyzed with a Cox regression model to calculate the overall hazard of dying associated with each postoperative complication. An individual’s age and hazard of dying from each complication were then used to calculate years of life lost to each complication. Results The postoperative mortality rate was 0.79% (69 of 8,773) at 30 days, 2.85% (250 of 8,773) at 180 days, and 6.38% (560 of 8,773) at 2 years. At a median follow-up of 9.8 years, 1,891 patients (21.6%) had died. Postoperative complications occurred in 3,438 patients (39.2%). Cardiac arrest (hazard ratio, 2.153), reoperation (hazard ratio, 1.679), and new dialysis (hazard ratio, 1.64) were the complications with the greatest hazard of death. After adjusting for complication incidence and patient age, cardiac arrest (703 years), reoperation (544 years), atrial fibrillation (470 years), and prolonged mechanical ventilation (371 years) were associated with the greatest number of years of life lost. Conclusions Acute cardiac arrest, reoperation for other cardiac reasons, new dialysis, atrial fibrillation, and prolonged mechanical ventilation are associated with the largest increase in attributable deaths. Prevention and treatment of these complications may improve mortality rates after cardiac operations.
Sudden cardiac death (SCD) is a leading cause of mortality in patients with cardiomyopathy. Although angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) decrease ...cardiac mortality in these cohorts, their role in preventing SCD has not been well established. We sought to determine whether the use of ACEi or ARB in patients with cardiomyopathy is associated with a lower incidence of appropriate implantable cardiac defibrillator (ICD) shocks in the Genetic Risk Assessment of Defibrillator Events study that included subjects with an ejection fraction of ≤30% and ICDs. Treatment with ACEi/ARB versus no-ACEi/ARB was physician dependent. There were 1,509 patients (mean age SD 63 12 years, 80% men, mean SD EF 21% 6%) with 1,213 (80%) on ACEi/ARB and 296 (20%) not on ACEi/ARB. We identified 574 propensity-matched patients (287 in each group). After a mean (SD) of 2.5 (1.9) years, there were 334 (22%) appropriate shocks in the entire cohort. The use of ACEi/ARB was associated with lower incidence of shocks at 1, 3, and 5 years in the matched cohort (7.7%, 16.7%, and 18.5% vs 13.2%, 27.5%, and 32.0%; RR = 0.61 0.43 to 0.86; p = 0.005). Among patients with glomerular filtration rate (GFR) >60 and 30 to 60 ml/min/1.73 m2 , those on no-ACEi/ARB were at 45% and 77% increased risk of ICD shock compared with those on ACEi/ARB, respectively. ACEi/ARB were associated with significant lower incidence of appropriate ICD shock in patients with cardiomyopathy and GFR ≥30 ml/min/1.73 m2 and with neutral effect in those with GFR <30 ml/min/1.73 m2.
Containing more than 6 million cumulative operative records and accounting for 90% to 95% of adult cardiac surgery performed in the United States, The Society of Thoracic Surgeons Adult Cardiac ...Surgery Database is an invaluable resource for performance assessment, quality improvement, and clinical research. This article reviews the seven major research efforts published in 2016 that utilized the Adult Cardiac Surgery Database. Two studies evaluated national trends in clinical practice, three assessed the effect of several risk factors on postoperative morbidity and mortality, and two developed new models to evaluate quality of care. The findings of these studies have enhanced clinical practice and delineated areas for future quality improvement research.
Background We aimed to determine whether the reported late survival benefit of radial artery (RA) versus saphenous vein (SV) grafting in the general coronary artery bypass graft surgery (CABG) ...population is maintained in elderly patients aged 70 years or older. Methods We reviewed our 1996 to 2007 experience in 2,120 elderly patients (RA, n = 607; SV, n = 1,513) who underwent primary, nonsalvage CABG with multiple completed grafts including at least one internal thoracic artery (ITA) graft. Patients were excluded in case of single-vessel disease, bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery. Kaplan-Meier 12-year survival estimates were compared for 1-to-1 matched ITA/RA and ITA/SV cohorts based on a nonparsimonious RA use propensity model (48 variables). Results The ITA/RA and ITA/SV cohorts (both, aged 75 ± 4yrs and 3.5 ± 0.8 grafts) were well matched and had identical operative mortality (2.3%; 11 of 480 each). Late survival was superior ITA/RA versus ITA/SV ( p < 0.001), estimated at 85.1% versus 70.6% and 70.9% versus 50.5% for 5 and 10 years, respectively. Late survival risk ratios (95% confidence interval) for RA versus SV grafting was 0.47 (0.36 to 0.61), and the relative SV to RA death hazard was greater than 1 between 1 and 144 months. Conclusions The late survival results suggest that elderly (≥70 years) primary multivessel CABG patients benefit substantially when RA is used as the second conduit in combination with ITA. Indeed, compared with previously published comparisons including all age groups, the derived risk ratio indicates that the benefit for the elderly may exceed that for younger patients in the initial decade after CABG. Use of RA should not be avoided in the elderly.
The Society of Thoracic Surgeons Adult Cardiac Database (ACSD) is an international voluntary effort that is the foundation of our specialty’s efforts in clinical performance assessment and quality ...improvement. Containing nearly 6,000,000 patient records, the ACSD is a robust resource for clinical research. Seven major original publications and four review articles were generated from the ACSD in 2015. The risk-adjusted outcome analyses and quality measures reported in these studies have made substantial contributions to inform daily clinical practice. This report summarizes the ACSD-based research efforts published in 2015.
Background Packed red blood cell (RBC) transfusions are associated with increased mortality after coronary artery bypass grafting (CABG) but not after cardiac valve operations. Transfusions are ...associated with increased strokes and deep venous thromboses after cardiac operations as well as increased peripheral vascular graft thrombosis. The purpose of this study was to determine if RBC transfusions were associated with a greater hazard of an occluded graft developing after CABG. Methods Patients who underwent symptom-driven coronary artery angiography after CABG were analyzed using Cox models and propensity scoring to compare outcomes based on the RBC transfusion status during their index CABG hospitalization. Results We analyzed 940 patients. We found that patients who received transfusions were more likely to have occluded grafts on angiography (hazard ratio HR, 1.24; 95% confidence interval CI, 1.03–1.50; p = 0.02). After adjusting for other factors, we found that RBC transfusion was associated with about a 20% increased hazard of graft occlusion (HR, 1.21; 95% CI,1.07–1.37; p = 0.003). Conclusions Perioperative RBC transfusion is associated with graft occlusion after CABG at both the patient and graft levels. These results add to the growing body of evidence that homologous RBC transfusion is not risk free but is associated with a variety of adverse effects including midterm graft failure.
Background This study aimed to compare the survival benefit derived from using radial artery (RA) as a second arterial conduit in combination with internal thoracic artery (ITA), as opposed to ITA ...plus saphenous vein (SV) in men and women. Methods We reviewed the 1996 to 2007 primary, nonsalvage coronary artery bypass graft surgery (CABG) experience at Mercy Saint Vincent Medical Center (n = 6,384; 69% men, 31% women). Study subjects had two or more completed grafts including one ITA graft. Patients with bilateral ITA, ITA-only grafts, or concomitant valve/aortic surgery were excluded. Separate sex nonparsimonious propensity models for RA grafting based on 47 preoperative and intraoperative factors were used to identify matched ITA/RA and ITA/SV cohorts. Kaplan-Meier and Cox regression analyses were then applied to assess sex-specific 12-year survival risk ratios of RA versus SV grafting. Results Patient variables for the RA and SV cohorts were well-matched in both men (n = 1,416 each; median age 62 years) and women (n = 567 each; median age 66 years). Thirty-day mortality was similar for ITA/RA versus ITA/SV in men (1.3% versus 1.2%; p = 1.0) and women (1.4% versus 1.9%; p = 0.664). Late mortality (1 to 144 months) was significantly better for ITA/RA in men (risk ratio 0.65, 95% confidence interval: 0.54 to 0.79; p < 0.001) and women (risk ratio 0.75, 95% confidence interval: 0.57 to 0.99; p = 0.045). Conclusions Late survival results suggest that male and female CABG patients benefit appreciably from use of RA as a second arterial conduit in combination with ITA. Yet, the late survival advantage derived from RA use was relatively less for women. This sex variance in benefit likely reflects differences in risk profiles of male and female CABG patients.
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