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Background: Bleeding following lung surgery can lead to reoperation and blood transfusions, potentially impairing outcomes. This study aimed to assess how bleeding complications affect long-term survival and postoperative complications in a nationwide contemporary group of patients undergoing lung resections. Methods: Adult patients who underwent lung resections, for both malignant and nonmalignant diagnoses, between 2013-2021, were included from the Swedish national registry for thoracic surgery. Patients with bleeding complications, defined as requiring reexploration and/or transfusions, were compared to patients without bleeding complications regarding long-term survival and postoperative complications. We used propensity scores and optimal full matching to account for differences in baseline characteristics between the groups. Results: The cohort comprised 15,617 adult patients, of which 646 patients (4.1%) had bleeding complications. The unadjusted 90-day mortality was 9.4% vs. 1.0% in the bleeding group vs. no bleeding group, respectively. After matching, the odds ratio (OR) for 90-day mortality in the bleeding group compared with the no bleeding group was 3.66 [95% confidence interval (CI): 2.17-6.17]. Long term overall survival was lower among patients in the bleeding group, adjusted hazard ratio (95% CI) for all-cause mortality was 1.47 (1.29-1.69). Postoperative complications were more common in the bleeding group (OR: 3.00, 95% CI: 2.38-3.79), including infections (OR: 2.80, 95% CI: 1.86-4.20). Bleeding complications were more frequent during the first third of the study time period as compared to the last third (P<0.001). Conclusions: Patients with bleeding complications had reduced long-term survival and higher incidence of postoperative complications. A declining trend in bleeding rates over time was noted.
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BACKGROUND: Observational studies have shown reduced perioperative bleeding in patients undergoing minimally invasive, compared with full sternotomy, aortic valve replacement. Data from randomized trials are conflicting. METHODS: This was a Swedish single center study where adult patients with aortic stenosis, 100 patients were randomly assigned in a 1:1 ratio to undergo either minimally invasive (ministernotomy) or full sternotomy aortic valve replacement. The primary outcome was severe or massive bleeding defined by the Universal Definition of Perioperative Bleeding in adult cardiac surgery (UDPB). Secondary outcomes included blood product transfusions, chest tube output, re-exploration for bleeding, and several other clinically relevant events. RESULTS: Out of 100 patients, three patients randomized to ministernotomy were intraoperatively converted to full sternotomy (none was bleeding-related). Three patients (6%) in the full sternotomy group and 3 patients (6%) in the ministernotomy group suffered severe or massive postoperative bleeding according to the UDPB definition (p = 1.00). Mean chest tube output during the first 12 postoperative hours was 350 (standard deviation (SD) 220) ml in the full sternotomy group and 270 (SD 190) ml in the ministernotomy group (p = 0.08). 28% of patients in the full sternotomy group and 36% of patients in the ministernotomy group received at least one packed red blood cells transfusion (p = 0.39). Two patients in each group (4%) underwent re-exploration for bleeding. CONCLUSIONS: Minimally invasive aortic valve replacement did not result in less bleeding-related outcomes compared to full sternotomy. CLINICAL TRIAL REGISTRATION: http://www. CLINICALTRIALS: gov . Unique identifier: NCT02272621.
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Estenosis de la Válvula Aórtica , Válvula Aórtica , Implantación de Prótesis de Válvulas Cardíacas , Procedimientos Quirúrgicos Mínimamente Invasivos , Hemorragia Posoperatoria , Esternotomía , Humanos , Masculino , Femenino , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Anciano , Esternotomía/métodos , Esternotomía/efectos adversos , Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Anciano de 80 o más Años , Suecia , Persona de Mediana Edad , Resultado del Tratamiento , Pérdida de Sangre Quirúrgica/prevención & controlRESUMEN
OBJECTIVES: Coronary events and disease recurrence following coronary artery bypass (CABG) surgery could derive from either failure in the internal thoracic artery (ITA) graft, failure in other conduits or progressive disease in the coronaries. We aim to estimate the contribution of ITA graft failure to the recurrence of symptoms after CABG surgery. METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry, we identified patients who had coronary artery bypass grafting from 1997 to 2020 with a single-vessel ITA graft bypass. Deaths, postoperative incidence of coronary angiography and the presence of a failed graft at the time of the angiography were recorded. RESULTS: The study population consisted of 1939 patients with a mean follow-up time (SD) of 17.2 (5.6) years. The cumulative incidence (95% CI) at 20 years for a first clinically-driven postoperative angiography was 38.6% (36.2-41.1). A failed ITA graft was reported in 16.4% of the angiographies. CONCLUSIONS: A substantial part of recurrent symptoms of coronary artery disease do not seem to be related to ITA failure. Disease progression in the native coronary vessels may instead be the main driver of symptom recurrence.
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Enfermedad de la Arteria Coronaria , Arterias Mamarias , Humanos , Arterias Mamarias/trasplante , Anastomosis Interna Mamario-Coronaria/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/etiología , Angiografía Coronaria , Grado de Desobstrucción VascularRESUMEN
OBJECTIVES: Coronary artery bypass grafting for advanced coronary artery disease is a well-established procedure with excellent long-term results. The issue of saphenous vein graft (SVG) performance and its relation to clinical symptoms and thereby the potential for improvement by using superior grafts are still not fully understood. We aim to estimate the contribution of late SVG failure to the long-term outcome. METHODS: A study population operated between 1997 and 2020, with an internal thoracic artery with a single distal anastomosis and 1, 2 or 3 distal SVG anastomoses, was isolated from the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies registry. Data regarding postoperative clinically driven coronary angiography and status of bypass grafts were collected. RESULTS: The study population consisted of 44 951 patients. Clinically driven angiography occurred in 10.1% (9.5-10.8), 7.9% (7.6-8.3) and 7.1% (6.7-7.5), respectively, of patients within 3 years and 23.6% (22.6-24.5), 20.0% (19.5-20.6) and 17.5% (16.9-18.2), respectively, of patients within 10 years after surgery. Excluding the first 3 postoperative years, no failed SVGs were found in >75%, 60% and 45%, respectively, of cases when an angiography was performed in the first 10 years after surgery. CONCLUSIONS: The results suggest that the risk of symptomatic graft failure due to vein graft disease during the first 10 years after surgery is in the range of 1-2% for every grafted coronary vessel and provide an estimate for the upper limit of the improvements in results that could be achieved by replacing SVGs with superior grafts.
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OBJECTIVES: Re-exploration for bleeding after cardiac surgery increases the risk of other severe postoperative complications and early mortality. Patients re-explored for bleeding after coronary artery bypass grafting are potentially subject to threats to graft patency. Our goal was to assess the effects of re-exploration for bleeding regarding the incidence of coronary angiographies, the need for coronary reintervention and mortality during long-term follow-up. METHODS: Within the SWEDEHEART registry, all isolated coronary artery bypass operations with a single internal mammary artery and saphenous vein graft in patients aged 40-80 between the years 2005 and 2015 were identified. Incidences of coronary angiography and the subsequent need for coronary reintervention were recorded, and multivariable adjusted hazard ratios (HRs) were calculated. RESULTS: The study cohort consisted of 27 957 patients, and the mean follow-up time was 6.5 ± 3.1 years. The incidence of re-exploration for bleeding was 3.8% (n = 1071). The cumulative incidence [95% confidence interval (CI)] of a clinically occurring coronary angiography within 1 year after surgery was 7.8% (6.3-9.7) in re-explored and 4.8% (4.6-5.1) in non-re-explored patients, and the adjusted HR was 1.64 (1.31-2.06), (P < 0.001). The cumulative incidence of the need for coronary reintervention within 1 year (95% CI) was 4.9% (3.7-6.4) in re-explored and 2.6% (2.4-2.8) in non-re-explored patients, and the adjusted HR was 1.91 (1.43-2.56). No difference in incidence or hazard ratio was observed beyond the first year. Mortality rate was increased within but not beyond 90 days after surgery. CONCLUSIONS: Re-exploration for bleeding is associated with an increased risk for the need of repeat coronary reintervention during the first year after coronary artery bypass surgery.
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Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Hemorragia Posoperatoria/epidemiología , Sistema de Registros , Reoperación/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Hemorragia Posoperatoria/diagnóstico , Hemorragia Posoperatoria/cirugía , Suecia/epidemiología , Resultado del TratamientoRESUMEN
Aortic stenosis (AS) and coronary artery disease (CAD) influence the coagulation system, potentially affecting hemostasis during cardiac surgery. Our aim was to evaluate 2 preoperative global hemostasis assays, plasma thrombin potential and thromboelastometry, in patients with severe aortic valve stenosis compared to patients with CAD. A secondary aim was to test whether the assays were associated with postoperative bleeding. Calibrated automated thrombogram (CAT) in platelet-poor plasma and rotational thromboelastometry (ROTEM) in whole blood were analyzed in patients scheduled for elective surgery due to severe AS (n = 103) and stable CAD (n = 68). Patients with AS displayed higher plasma thrombin potential, both thrombin peak with median 252 nmol/L (interquartile range 187-319) and endogenous thrombin potential (ETP) with median 1552 nmol/L/min (interquartile range 1340-1838), when compared to patients with CAD where thrombin peak was median 174 nmol/L (interquartile range 147-229) and ETP median 1247 nmol/L/min (interquartile range 1034-1448; both P < .001). Differences persisted after adjustment for age, gender, comorbidity, and antithrombotic treatment. Differences observed in thromboelastometry between the groups did not persist after adjustment for baseline characteristics. Bleeding amount showed no relationship with plasma thrombin potential but weakly to thromboelastometry ( R2 = .064, P = .001). Patients with AS exhibited preoperatively increased plasma thrombin potential compared to patients with CAD. Plasma thrombin potential was not predictive for postoperative bleeding in patients scheduled for elective surgery.
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Estenosis de la Válvula Aórtica , Enfermedad de la Arteria Coronaria , Cuidados Preoperatorios , Tromboelastografía , Trombina/metabolismo , Anciano , Estenosis de la Válvula Aórtica/sangre , Estenosis de la Válvula Aórtica/cirugía , Enfermedad de la Arteria Coronaria/sangre , Enfermedad de la Arteria Coronaria/cirugía , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: Saphenous vein grafts (SVGs) most often used in coronary artery bypass grafting (CABG) are subject to graft disease and have poor long-term patency, however the clinical implication of this is not completely known. We aim to assess the influence of graft failure on the postoperative recurrence of coronary artery disease (CAD) symptoms in relation to the contribution from progression of atherosclerosis in the native coronary vessels. DESIGN: Within the SWEDEHEART registry we identified 46,663 CABG cases between 2001 and 2015 with patient age 40-80 years where single internal mammary artery (IMA) anastomosis (IMA), single IMA with one (1SVG) or multiple SVG anastomoses (2+ SVG) had been performed. Clinical characteristics as well as mortality and postoperative incidence of coronary angiography were recorded and multivariable adjusted hazard ratios were calculated. Indications for the angiographies and occurrence of graft failure were also registered. RESULTS: The adjusted hazard ratio for death was similar for the three groups. The adjusted hazard ratio for being submitted to angiography as compared to 2+ SVG was (95% CI) 1.24 (1.06-1.46) for IMA and 1.21 (1.15-1.28) for 1SVG. Failed grafts were found at the first postoperative angiography with preceding CAD symptoms in 21.4% of patients in the IMA group, 41.6% in the 1SVG group and 61.1% in the 2+ SVG group. CONCLUSIONS: A substantial amount of angiographies occur in patients without any graft failure and a large part of postoperative recurrence of CAD symptoms and are likely attributed to IMA failure or progression of atherosclerosis in the native coronary arteries.
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Puente de Arteria Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/cirugía , Anastomosis Interna Mamario-Coronaria/efectos adversos , Vena Safena/trasplante , Adulto , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Progresión de la Enfermedad , Femenino , Humanos , Anastomosis Interna Mamario-Coronaria/mortalidad , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Modelos de Riesgos Proporcionales , Recurrencia , Sistema de Registros , Retratamiento , Factores de Riesgo , Suecia , Factores de Tiempo , Insuficiencia del TratamientoRESUMEN
OBJECTIVES: Coronary artery bypass grafting using saphenous vein grafts (SVGs) in addition to the left internal mammary artery (IMA) graft is vitiated by poor long-term patency of the vein grafts. Hypothetically, the increased use of arterial grafts could confer even better outcomes. Our goal was to evaluate results after coronary artery bypass grafting in Sweden, where arterial grafts were used as a second conduit. METHODS: Within the Swedish Web System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry, we identified patients who had coronary artery bypass grafting from 2001 to 2015 using the IMA and the SVG, the radial artery (RA) or the additional IMA [bilateral IMA (BIMA)] as a second conduit. Deaths, postoperative incidence of coronary angiography and need for reintervention were recorded, and multivariable adjusted hazard ratios were calculated for different types of grafts. RESULTS: The study population comprised 46 343 cases of IMA + SVG, 1036 cases of IMA + RA and 862 cases of BIMA. The mean follow-up time (SD) was 9.3 (4.2) years for IMA + SVG, 10.7 (4.1) years for IMA + RA grafts and 5.5 (5.0) years for the BIMA graft. The adjusted hazard ratio for death was (95% confidence interval) 1.01 (0.89-1.14) for IMA + RA and 0.87 (0.72-1.06) for BIMA grafts compared with IMA + SVG. The adjusted hazard ratio for the first angiographic examination was (95% confidence interval) 0.96 (0.84-1.10) for IMA + RA and 1.13 (0.95-1.35) for BIMA grafts. The adjusted hazard ratio for the need for reintervention was (95% confidence interval) 0.91 (0.75-1.09) for IMA + RA and 1.26 (1.00-1.58) for BIMA grafts. CONCLUSIONS: Patients who had arterial grafts as second conduits did not demonstrate a better outcome in any of the studied end-points. Radial artery grafts seem to be preferable to BIMA grafts as an alternative to an SVG.