Search

The article discusses study of 5,277 patients with severe aortic stenosis (AS) who had aortic valve replacement (AVR) at medical centers in Northern New England between 1992 and 2008 and investigated if patients' preoperative ejection fraction (EF) has an effect on their short- and long-term survival. Standard statistical methods were used to compare the characteristics of patients with isolated AVR. It suggests that patients with reduced preoperative EFs be referred for surgical evaluation.

Background: We previously reported that transfusion of 1 to 2 units of red blood cells (RBCs) confers a 16% increased hazard of late death after cardiac surgical treatment. We explored whether a similar effect existed among octogenarians. Methods: We enrolled 17,026 consecutive adult patients undergoing cardiac operations from 2001 to 2008 in northern New England. Patients receiving more than 2 units of RBCs or undergoing emergency operations were excluded. Early (to 6 months) and late (to 3 years, among those surviving longer than 6 months) survival was confirmed using the Social Security Death Index. We estimated the relationship between RBCs and survival, and any interaction by age (<80 years versus ≥ 80 years) or procedure. We calculated the adjusted hazard ratio (HR), and plotted adjusted survival curves. Results: Patients receiving RBCs had more comorbidities irrespective of age. Patients 80 years of age or older underwent transfusion more often than patients younger than 80 years (51% versus 30%; p < 0.001). There was no evidence of an interaction by age or procedure (p > 0.05). Among patients younger than 80 years, RBCs significantly increased a patient''s risk of early death [HR, 2.03; 95% confidence interval [CI], 1.47, 2.80] but not late death 1.21 (95%CI, 0.88, 1.67). RBCs did not increase the risk of early [HR, 1.47; 95% CI, 0.84, 2.56] or late (HR, 0.92 95% CI, 0.50, 1.69) death in patients 80 years or older. Conclusions: Octogenarians receive RBCs more often than do younger patients. Although transfusion of 1 to 2 units of RBCs increases the risk of early death in patients younger than 80 years, this effect was not present among octogenarians. There was no significant effect of RBCs in late death in either age group. [Copyright &y& Elsevier]

Background: Predicting risk for aortic and mitral valve surgery is important both for informed consent of patients and objective review of surgical outcomes. Development of reliable prediction rules requires large data sets with appropriate risk factors that are available before surgery.Methods: Data from eight Northern New England Medical Centers in the period January 1991 through December 2001 were analyzed on 8,943 heart valve surgery patients aged 30 years and older. There were 5,793 cases of aortic valve replacement and 3,150 cases of mitral valve surgery (repair or replacement). Logistic regression was used to examine the relationship between risk factors and in-hospital mortality.Results: In the multivariable analysis, 11 variables in the aortic model (older age, lower body surface area, prior cardiac operation, elevated creatinine, prior stroke, New York Heart Association [NYHA] class IV, congestive heart failure [CHF], atrial fibrillation, acuity, year of surgery, and concomitant coronary artery bypass grafting) and 10 variables in the mitral model (female sex, older age, diabetes, coronary artery disease, prior cerebrovascular accident, elevated creatinine, NYHA class IV, CHF, acuity, and valve replacement) remained independent predictors of the outcome. The mathematical models were highly significant predictors of the outcome, in-hospital mortality, and the results are in general agreement with those of others. The area under the receiver operating characteristic curve for the aortic model was 0.75 (95% confidence interval [CI], 0.72 to 0.77), and for the mitral model, 0.79 (95% CI, 0.76 to 0.81). The goodness-of-fit statistic for the aortic model was χ2 [8 df] = 11.88, p = 0.157, and for the mitral model it was χ2 [8 df] = 5.45, p = 0.708.Conclusions: We present results and methods for use in day-to-day practice to calculate patient-specific in-hospital mortality after aortic and mitral valve surgery, by the logistic equation for each model or a simple scoring system with a look-up table for mortality rate. [Copyright &y& Elsevier]

Objectives: The goal of this study was to assess the concordance between the American College of Cardiology (ACC) and the American Heart Association (AHA) 2004 Guideline Update for Coronary Artery Bypass Graft Surgery and actual clinical practice. Background: There is substantial geographic variability in the population-based rates of coronary artery bypass graft (CABG) procedures, and in recent years, there have been several public concerns about unnecessary cardiac care. The actual rate of inappropriate cardiac procedures is unknown. Methods: We evaluated 4,684 consecutive isolated coronary artery bypass graft procedures performed in 2004 and 2005 in northern New England. Our regional registry data were used to categorize patients into clinical subgroups. Detailed clinical criteria were then used to categorize procedures within these subgroups as class I (useful and effective), class IIa (evidence favors usefulness), class IIb (evidence less well established), and class III (not useful or effective). Results: Among these 4,684 procedures, we were able to classify 99.6% (n = 4,665). The majority of procedures were class I (87.7%). Class II procedures totaled 10.9%. The remaining 1.4% of procedures were class III. Conclusions: In this regional study, we found that 98.6% of CABG procedures that could be classified were considered to be appropriate. In these data, actual clinical practice closely follows the recommendations of the 2004 ACC/AHA guidelines for CABG surgery. [Copyright &y& Elsevier]

Background: Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF., Methods and Results: We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80-766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury., Conclusions: Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.

Introduction: The long-term clinical usefulness of conventional coronary artery bypass graft surgery (CCAB) versus off-pump surgery (OPCAB) remains controversial. Long-term survival and elevation in cardiac troponin T (cTnT) concentration following CCAB and OPCAB have not been assessed. We tested the hypothesis that long-term survival rates for CCAB and OPCAB patients were similar when stratified by cTnT concentration., Methods and Results: In this prospective cohort, we followed 1511 nonemergency patients with 2- or 3-vessel disease (778 CCAB and 733 OPCAB cases) from a hospital in northern New England to determine if 6-year survival rates for CCAB and OPCAB patients were similar. The patients underwent surgery between 2000 and 2004 by surgeons who used both procedures. Postoperative cTnT elevation was defined as > or =1 ng/mL, the upper quartile of cTnT values. Data were linked to the Social Security Administration Death Master File. Kaplan-Meier analysis and Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI), with adjustments for baseline patient and disease characteristics. Patients were followed for a median of 4.1 years (mean, 4.0 years). Patients were similar with regard to baseline disease characteristics, comorbidities, cardiac history, function, and anatomy. OPCAB was associated with increased rates of postoperative bleeding and with a worse 6-year survival rate compared with CCAB, regardless of cTnT concentration (cTnT <1 ng/mL, P < .013; cTnT > or =1 ng/mL, P = .017). Compared with CCAB patients, the adjusted HR (95% CI) was 1.59 (1.09-2.32) for OPCAB patients with cTnT concentrations <1 ng/mL and 1.93 (1.12-3.31) for OPCAB patients with cTnT concentrations > or =1 ng/mL., Conclusion: Survival is better for CCAB patients than for OPCAB patients, regardless of cTnT concentration. This effect is sustained after multivariable adjustment for baseline mortality risk factors.

Background: The effects of diabetes on short-term results of coronary artery bypass graft (CABG) surgery are known, but less is known about the long-term effects of diabetes and diabetic-related sequelae for patients undergoing this surgery. We studied the 10-year survival of nondiabetic and diabetic patients undergoing CABG surgery., Methods and Results: A prospective regional cohort study was conducted of 36,641 consecutive isolated CABG patients in northern New England from 1992 through 2001. Patient records were linked to the National Death Index to assess mortality. There were 154,140 person-years of follow-up and 5779 deaths. Kaplan-Meier techniques were used. Survival was stratified into three categories: no diabetes, diabetes without peripheral vascular disease and renal failure, and diabetes with peripheral vascular disease and/or renal failure. The overall annual incidence rate of death was 3.7 deaths per 100 person-years. Annual incidence rates for nondiabetic subjects and diabetic subjects were similar: 3.1 deaths per 100 person-years and 4.4 deaths per 100 person-years, respectively. The annual incidence rate for diabetic subjects with renal failure, peripheral vascular disease, or both was 9.4 deaths per 100 person-years. The log-rank test showed that the survival curves were significantly different (P<0.001)., Conclusions: Patients that have diabetes without the sequelae of renal failure and/or peripheral vascular disease have long-term survival similar to but slightly less than patients without diabetes who undergo CABG surgery. Survival of CABG surgery patients with diabetes is greatly affected by associated comorbidities of peripheral vascular disease and renal failure. This knowledge may help guide the patient as well as the cardiologist and cardiac surgeon in making appropriate decisions in these critically ill patients.

Mediastinitis is a dreaded complication of CABG surgery. Short-term outcomes have been described, but there have been only a few long-term studies. We examined the survival of patients undergoing isolated CABG surgery between 1992 and 2001. Mediastinitis was identified during the index admission. Proportional hazards regression was used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI 95%). Among 36,078 consecutive patients, there were 5749 deaths during 148,319 person years of follow-up. There were 418 cases of mediastinitis (1.16%). The incidence of death was 11.15 per 100 person/years with mediastinitis and 3.81 deaths/100 person years without. (P < 0.001). We also examined the mortality rates of patients who survived at least 6 months after their CABG surgery. Patients with mediastinitis had an incidence rate of 5.70 deaths per 100 person/years while those without had a rate of 2.66 deaths per 100 person/years (P < 0.001). After adjustment for baseline differences in patient and disease characteristics, the hazard ratio was 2.12 (CI95% = 1.86,2.58; P < 0.001). The adjusted hazard ratios for patients who survived 6 months postsurgery was 1.70 (CI95% = 1.36,2.13; P < 0.001). Mediastinitis is associated with a marked increase in both acute and long-term mortality rates.

Background: A prospective study of patients undergoing coronary artery bypass graft surgery (CABG) was conducted to identify patient and disease factors related to the development of a perioperative stroke. A preoperative risk prediction model was developed and validated based on regionally collected data., Methods: We performed a regional observational study of 33,062 consecutive patients undergoing isolated CABG surgery in northern New England between 1992 and 2001. The regional stroke rate was 1.61% (532 strokes). We developed a preoperative stroke risk prediction model using logistic regression analysis, and validated the model using bootstrap resampling techniques. We assessed the model's fit, discrimination, and stability., Results: The final regression model included the following variables: age, gender, presence of diabetes, presence of vascular disease, renal failure or creatinine greater than or equal to 2 mg/dL, ejection fraction less than 40%, and urgent or emergency. The model significantly predicted (chi(2) [14 d.f.] = 258.72, p < 0.0001) the occurrence of stroke. The correlation between the observed and expected strokes was 0.99. The risk prediction model discriminated well, with an area under the relative operating characteristic curve of 0.70 (95% CI, 0.67 to 0.72). In addition, the model had acceptable internal validity and stability as seen by bootstrap techniques., Conclusions: We developed a robust risk prediction model for stroke using seven readily obtainable preoperative variables. The risk prediction model performs well, and enables a clinician to estimate rapidly and accurately a CABG patient's preoperative risk of stroke.