RESUMEN
INTRODUCTION: Numbers of patients undergoing mitral valve repair (MVr) surgery for severe mitral regurgitation have grown and will continue to rise. MVr is routinely performed via median sternotomy; however, there is a move towards less invasive surgical approaches.There is debate within the clinical and National Health Service (NHS) commissioning community about widespread adoption of minimally invasive MVr surgery in the absence of robust research evidence; implementation requires investment in staff and infrastructure.The UK Mini Mitral trial will provide definitive evidence comparing patient, NHS and clinical outcomes in adult patients undergoing MVr surgery. It will establish the best surgical approach for MVr, setting a standard against which emerging percutaneous techniques can be measured. Findings will inform optimisation of cost-effective practice. METHODS AND ANALYSIS: UK Mini Mitral is a multicentre, expertise based randomised controlled trial of minimally invasive thoracoscopically guided right minithoracotomy versus conventional sternotomy for MVr. The trial is taking place in NHS cardiothoracic centres in the UK with established minimally invasive mitral valve surgery programmes. In each centre, consenting and eligible patients are randomised to receive surgery performed by consultant surgeons who meet protocol-defined surgical expertise criteria. Patients are followed for 1 year, and consent to longer term follow-up.Primary outcome is physical functioning 12 weeks following surgery, measured by change in Short Form Health Survey (SF-36v2) physical functioning scale. Early and 1 year echo data will be reported by a core laboratory. Estimates of key clinical and health economic outcomes will be reported up to 5 years.The primary economic outcome is cost effectiveness, measured as incremental cost per quality-adjusted life year gained over 52 weeks following index surgery. ETHICS AND DISSEMINATION: A favourable opinion was given by Wales REC 6 (16/WA/0156). Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer reviewed publication. TRIAL REGISTRATION NUMBER: ISRCTN13930454.
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Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Mitral , Adulto , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Medicina Estatal , Esternotomía , Resultado del Tratamiento , Reino Unido , GalesRESUMEN
Valvular heart disease is common and increasingly prevalent among the elderly. The end result of valvular pathologies is cardiac failure and can lead to sudden death; thus, diagnosis and interventions are very important in the early stages of these diseases. The usual treatment methods of mitral regurgitation include percutaneous mitral valve repair, mitral valve replacement and minimally invasive surgery, whereas the treatment methods of mitral stenosis include percutaneous transluminal mitral commissurotomy and mitral commissurotomy as well as open surgical repair. Nonetheless, ongoing clinical trials are a clear indicator that the management of valve diseases is ever evolving. The focus of this paper is on the various pathologies of the mitral valve, their etiology and clinical management, offering a comprehensive view of mitral valve diseases.
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Cateterismo Cardíaco , Endocarditis/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Anuloplastia de la Válvula Mitral , Insuficiencia de la Válvula Mitral/cirugía , Estenosis de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/instrumentación , Toma de Decisiones Clínicas , Endocarditis/diagnóstico por imagen , Endocarditis/fisiopatología , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Humanos , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/fisiopatología , Estenosis de la Válvula Mitral/diagnóstico por imagen , Estenosis de la Válvula Mitral/fisiopatología , Selección de Paciente , Medición de Riesgo , Factores de Riesgo , Esternotomía , Resultado del TratamientoAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Implantación de Prótesis de Válvulas Cardíacas , Insuficiencia de la Válvula Tricúspide , Humanos , Resultado del Tratamiento , Válvula Tricúspide/diagnóstico por imagen , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/cirugíaRESUMEN
OBJECTIVE: The SAR-COV-2 pandemic has had an unprecedented effect on the UK's healthcare systems. To reduce spread of the virus, elective treatments and surgeries have been postponed or canceled. There has been a rise in the use of telemedicine (TM) as an alternative way to carry outpatient consultations. This systematic review aims to evaluate the extent to which TM may be able to support cardiac and vascular surgery patients in the COVID-19 era. METHODS: We looked into how TM can support the management of patients via triaging, preoperative, and postoperative care. Evaluations targeted the clinical effectiveness of common TM methods and the feasibility of applying those methods in the UK during this pandemic. RESULTS: Several studies have published their evidence on the benefit of TM and its benefit during COVID-19, the data related to cardiovascular surgery and how this will impact future practice of this speciality is emerging and yet larger studies with appropriate timing of outcomes to be published. CONCLUSION: Overall, the use of virtual consultations and remote monitoring is feasible and best placed to support these patients via triaging and postoperative monitoring. However, TM can be limited by the need of sophisticated technological requirement and patients' educational and know-how computer literacy level.
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COVID-19/epidemiología , Procedimientos Quirúrgicos Cardiovasculares , Pandemias , Cuidados Posoperatorios/métodos , Cuidados Preoperatorios/métodos , Telemedicina , Procedimientos Quirúrgicos Cardiovasculares/rehabilitación , Humanos , Triaje/métodos , Reino UnidoRESUMEN
Background There is an ongoing debate on the benefits and risks of off-pump coronary artery bypass grafting (CABG) surgery. The fate of patients who start with their procedure being an off-pump one and then have to undergo conversion to an on-pump procedure is debated with regard to in-hospital mortality and unknown with regard to long-term survival. We investigated the in-hospital mortality and long-term survival of patients who underwent conversion from off- to on-pump surgery. Methods We performed a multivariate and propensity analysis on in-hospital mortality and long-term survival of postisolated CABG patients in a single institution having 15,704 patients of which 5,353 who underwent off-pump CABG were analyzed. Results In-hospital mortality was 2.15% for the study cohort, and 73 (1.4%) off-pump cases were converted. Univariate analysis demonstrated that patients undergoing conversion had a significantly increased in-hospital mortality (p < 0.001) and reduced long-term survival (p = 0.002). Logistic regression (receiver operating curve 0.77, Hosmer-Lemeshow test 0.46) and Cox analysis demonstrated that in-hospital mortality and long-term survival were not significantly affected by conversion. Propensity analysis (one:many match) demonstrated that in-hospital mortality was not significantly affected (p = 0.7), and long-term survival - univariate, and multivariate were also not significantly reduced in patients undergoing conversion. Conclusion Conversion from off- to on-pump by a team of surgeons and anesthetists who are dedicated off-pump specialists does not have an impact on in-hospital mortality or long-term survival.
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Puente Cardiopulmonar/mortalidad , Puente de Arteria Coronaria Off-Pump/mortalidad , Puente de Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Mortalidad Hospitalaria , Anciano , Puente Cardiopulmonar/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria Off-Pump/efectos adversos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/mortalidad , Femenino , Humanos , Estimación de Kaplan-Meier , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine if the use of cardiopulmonary bypass is associated with all-cause in-hospital and mid-term survival for patients undergoing left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass grafting (CABG) for single coronary vessel disease. METHODS: Data from the National Adult Cardiac Surgery Audit registry for all elective and urgent isolated CABG procedures performed between April 2003 and March 2013 in first-time cardiac surgery patients were extracted. Experienced surgeons (those with ≥300 records) were classified by their technique preference (as 'off-pump preference', 'mixed practice', 'on-pump preference') based on their entire isolated CABG data. In-hospital mortality and time to death were analysed using logistic and Cox proportional hazards regression models, respectively. RESULTS: From a total of 3402 records, 65.5% were performed off-pump. There were 16 (0.47%) in-hospital deaths: 6 (0.51%) in the on-pump group and 10 (0.45%) in the off-pump group. The risk-adjusted odds ratio of in-hospital mortality in the direction of on-pump was 1.09 [95% confidence interval (CI): 0.39-3.04; P = 0.86]. The overall 5-year survival in the on- and off-pump groups was 93.1 and 93.4%, respectively. The adjusted hazard ratio (HR) for mortality in the direction of on-pump CABG was 1.15 (95% CI: 0.89-1.49; P = 0.28). Comparing off-pump cases performed by experienced CABG surgeons with a preference for the off-pump technique with on-pump cases performed by surgeons with a preference for the on-pump technique indicated a significant difference (HR for on-pump = 1.72; 95% CI: 1.19-2.47; P = 0.004). CONCLUSIONS: Elective and urgent first-time CABG for isolated LAD disease is associated with excellent mid-term survival in the England and Wales population, conferring a 5-year survival rate of 93.1 and 93.4% in the on-pump and off-pump groups, respectively. There was no difference in risk-adjusted survival between the on-pump and off-pump techniques when analysing all procedures; however, supportive analysis demonstrated that off-pump surgery performed by experienced surgeons with a preference for the off-pump technique in their CABG caseload is associated with improved mid-term survival when compared with on-pump surgery performed by surgeons with a preference for the on-pump technique.
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Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Anciano , Puente de Arteria Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/epidemiología , Femenino , Humanos , Estimación de Kaplan-Meier , Masculino , Auditoría Médica , Persona de Mediana Edad , Oportunidad Relativa , Sistema de Registros , Estudios Retrospectivos , Reino Unido/epidemiologíaRESUMEN
OBJECTIVES: To determine whether patient sex makes a difference to in-hospital mortality and survival in patients undergoing isolated coronary artery bypass graft surgery (CABG) receiving a radial artery graft. METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Uni- and multivariate analyses were performed for in-hospital mortality and long-term survival. A propensity analysis was also performed. RESULTS: Overall mortality was 2.1% (n = 284) for all cases, n = 13 369. Median follow-up was 7.0 (interquartile range 4.1-10.1) years. Of the cases 28.2% of males (n = 384) and 29.7% of females (n = 764) had a radial artery utilized. Univariate analysis demonstrated that in-hospital mortality was significantly lower in male patients, P < 0.001, and radial artery use was associated with increased survival in males, P < 0.0001, but not in females, P = 0.82. In male patients, multivariate analysis failed to identify the radial artery as a risk factor for in-hospital death. The radial artery was identified as a significant prognostic factor, associated with improved long-term survival (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.69-0.88, P = 0.0001). Propensity analysis confirmed this finding (HR 0.76, 95% CI 0.67-0.86, P < 0.0001). In female patients, multivariate analysis failed to identify the radial artery as a significant factor determining in-hospital mortality or long-term survival. Propensity analysis confirmed these findings. CONCLUSION: Males derive a significant survival advantage if they receive a radial artery graft when undergoing isolated CABG. The radial artery makes no difference to long-term survival in female patients. Radial artery use does not affect in-hospital mortality regardless of patient sex.
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Puente de Arteria Coronaria/mortalidad , Arteria Radial/trasplante , Anciano , Análisis de Varianza , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Humanos , Masculino , Arterias Mamarias/trasplante , Persona de Mediana Edad , Análisis Multivariante , Puntaje de Propensión , Factores SexualesRESUMEN
OBJECTIVES: To determine if on- or off-pump coronary artery bypass grafting (CABG) makes a difference to in-hospital mortality and long-term survival in obese patients. METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Obesity was defined as a body mass index (BMI) >30 kg/m(2). Uni- and multivariate analyses were performed for in-hospital mortality and long-term survival. A propensity analysis was also performed. RESULTS: The overall mortality rate was 2.1% (N = 284) for all cases, N = 13 369. The mortality rate for obese patients (N = 4289) was 2.3%, and for non-obese patients (N = 9080) it was 2.0%; P = 0.4. The median follow-up was 7.0 (interquartile range 4.1-10.1) years. Univariate analysis identified that in-hospital mortality was significantly lower in obese patients undergoing off-pump CABG; P = 0.01. No significant difference existed with regard to non-obese patients; P = 0.55. Kaplan-Meier survival analysis identified that off-pump CABG was associated with improved survival in obese patients; P = 0.01. Multivariate analysis of non-obese patients did not identify on- or off-pump CABG as a significant factor determining in-hospital mortality or long-term survival. Multivariate analysis of obese patients identified off-pump CABG as being associated with significantly reduced in-hospital mortality (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.34-0.93, P = 0.03), and significantly improved long-term survival (hazard ratio 0.81, 95% CI 0.67-0.98, P = 0.03). In-hospital mortality and long-term survival were significantly affected by the era of surgery, regardless of patients' BMI. Propensity matching of non-obese patients (N = 6088, 1:1 matching) did not identify on- or off-pump CABG as a significant factor determining in-hospital mortality or long-term survival. Propensity matching of obese patients (N = 2980, 1:1 matching) identified on-pump CABG as a significant factor determining in-hospital mortality (OR 0.50, 95% CI 0.26-0.98, P = 0.04), but having no effect on long-term survival. CONCLUSIONS: Univariate, multivariate and propensity matching suggest that obese patients undergoing CABG have reduced in-hospital mortality if they undergo revascularization with the off-pump technique.
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Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Obesidad/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria Off-Pump , Femenino , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Obesidad/mortalidad , Puntaje de Propensión , Adulto JovenRESUMEN
OBJECTIVES: EuroSCORE II, despite improving on the original EuroSCORE system, has not solved all the calibration and predictability issues. We investigated the sensitivity, specificity and predictability of original EuroSCORE and EuroSCORE II system in elderly patients. METHODS: The original logistic EuroSCORE and EuroSCORE II were assessed via receiver operator characteristic (ROC) and Hosmer-Lemeshow test probability analysis with regard to accuracy of predicting in-hospital mortality. Analysis was performed on isolated coronary artery bypass graft (CABG) (n = 2913), aortic valve replacement (AVR) (n = 814), mitral valve surgery (MVR) (n = 340), combined AVR and CABG cases (n = 517) and the above cases combined (n = 4584). Elderly was defined as ≥70 years old. Age <70 was used for comparative purposes. RESULTS: Institutional mortality was 2.9%, for all isolated CABG, AVR, MVR and combined AVR and CABG cases. In all patients aged ≥70 neither the original EuroSCORE nor EuroSCORE II had a ROC c-statistic above 0.7. For isolated CABG, the ROC c-statistic was not acceptable in patients ≥70 years of age, but was fine for patients under the age of 70 years. For isolated AVR the ROC c-statistic was good for patients aged less than 70 years of age for both risk models; however, the ROC was unacceptably low in patients aged ≥70 for both models. For isolated MVR, the ROC c-statistic and Hosmer-Lemeshow test probability was good for all patients regardless of age. For combined AVR and CABG, the ROC c-statistic was unacceptably low for all patients, regardless of age group using the original EuroSCORE, and in those aged ≥70 using the EuroSCORE II risk model. The original EuroSCORE had no issues with the Hosmer-Lemeshow test probability; however, EuroSCORE II had poor model predictability for all patients, P < 0.0001, and for isolated CABG, P = 0.05 and AVR, P = 0.06. CONCLUSIONS: The original EuroSCORE and the EuroSCORE II risk models should be used with caution in patients aged 70 or older undergoing cardiac surgery in the modern era. Below the age of 70, both models are sensitive, specific and have good predictive power. Our work needs validation by other large groups.
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Puente de Arteria Coronaria/efectos adversos , Técnicas de Apoyo para la Decisión , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Factores de Edad , Anciano , Válvula Aórtica/cirugía , Área Bajo la Curva , Puente de Arteria Coronaria/mortalidad , Inglaterra , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Valor Predictivo de las Pruebas , Curva ROC , Reproducibilidad de los Resultados , Medición de Riesgo , Factores de Riesgo , Resultado del TratamientoRESUMEN
OBJECTIVES: To determine in the modern era if cardiopulmonary bypass (CPB) time has a significant effect on postoperative morbidity, mortality and long-term survival in patients undergoing isolated aortic valve replacement (AVR) surgery. METHODS: Analysis of a prospectively collected cardiac surgery database was performed. Uni- and multivariate analysis on the need of resternotomy for bleeding, mediastinal blood loss, intensive care unit (ICU) length of stay, hospital length of stay, in-hospital mortality and long- term survival was performed. Only patients with a cross-clamp time <90 min were analysed to exclude technical issues confounding the results. RESULTS: A total of 1863 isolated first-time AVR procedures were analysed, with an in-hospital mortality rate of 2.4%. The rate of long-term follow-up achieved was 100%. Univariate analysis revealed that CPB time (minutes) had no significant effect on resternotomy (P = 0.5), creatinine kinase muscle-brain isoenzyme (CKMB) release (P = 0.8) and long-term survival (P = 0.06), but was significantly associated with mediastinal blood loss (P = 0.01), ICU length of stay (P = 0.02), hospital length of stay (P = 0.03) and in-hospital mortality (P < 0.001). Multivariate analysis identified that bypass time (min) was a significant factor associated with mediastinal blood loss (P < 0.001), ICU length of stay (P = 0.01), postoperative length of stay (P < 0.001) and in-hospital mortality (odds ratio [OR] 1.02, 95% CI 1.01-1.04, P = 0.01), but not long-term survival. Multivariate analysis identified that era of surgery had no significant effect on CKMB release (P = 0.2), mediastinal blood loss (P = 0.4) and in-hospital mortality (P = 0.9), but the latter era of this study was significantly associated with a reduced postoperative length of stay (P < 0.001), reduced ICU length of stay (P < 0.001), reduced need for resternotomy for bleeding (OR 0.62, 95% CI 0.41-0.94, P = 0.02) and improved long-term survival (hazard ratio 0.76, 95% CI 0.59-0.96, P = 0.02). Adjusting for era made no difference with respect to the above study findings. CONCLUSIONS: Despite improvements over time with regard to morbidity, mortality and long-term survival, CPB time remains a significant factor determining mediastinal blood loss, ICU and hospital length of stay, and in-hospital mortality.
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Válvula Aórtica/cirugía , Puente Cardiopulmonar , Implantación de Prótesis de Válvulas Cardíacas , Tempo Operativo , Anciano , Pérdida de Sangre Quirúrgica , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/mortalidad , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Estimación de Kaplan-Meier , Tiempo de Internación , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Oportunidad Relativa , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/terapia , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: To investigate whether valve position, type and procedure are important factors in determining the beneficial effects of statin therapy with regard to long-term survival in patients undergoing isolated single valve surgery. METHODS: A prospective single-institution cardiac surgery database was analysed. Univariate, multivariate stepwise linear, logistic and Cox regression analysis and propensity matching were performed to identify if statins were associated with increased survival post-valve surgery. RESULTS: Overall mortality was 3.4% (n = 172) for all cases, n = 5013. The median follow-up was 5.8 years. Kaplan-Meier survival analysis indicated that statin therapy was beneficial for all patients undergoing isolated valve surgery, n = 5013, P = 0.03 and isolated aortic valve surgery, n = 3220, P = 0.03, but not isolated mitral valve surgery n = 1793, P = 0.4. Cox regression analysis of the study cohort revealed that statin therapy was a significant factors determining long-term survival in the study cohort, postisolated aortic valve replacement and postisolated biological aortic valve replacement. Statins therapy was not associated with an increased long-term survival post-mitral valve replacement or repair. Propensity matching resulted in 1555 patients receiving statins being matched 1:1 with those not receiving statins. The results after propensity matching concurred with that of the Cox regression analyses, demonstrating that statin therapy was significantly associated with reduced in-hospital mortality, hospital length of stay and postoperative creatinine kinase, muscle-brain isoenzyme release. CONCLUSIONS: Previous publications have not distinguished valve type, position and repair as possible factors influencing statin-therapy outcomes. Statin therapy is associated with increased long-term survival postaortic valve replacement with a biological valve only. Statin therapy had no survival benefit in patients undergoing mitral valve repair or a mechanical valve replacement. A randomized trial is necessary to confirm or refute our findings.
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Anticolesterolemiantes/uso terapéutico , Enfermedades de las Válvulas Cardíacas , Implantación de Prótesis de Válvulas Cardíacas , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Anciano , Enfermedades de las Válvulas Cardíacas/mortalidad , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Hipercolesterolemia/tratamiento farmacológico , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
OBJECTIVES: Publications in the surgical literature are very consistent in their conclusions that blood is dangerous with regard to in-hospital mortality, morbidity and long-term survival. Blood is frequently used as a volume expander while simultaneously increasing the haematocrit. We investigated the effects of a single-unit blood transfusion on long-term survival post-cardiac surgery in isolated coronary artery bypass grafting patients. METHODS: A prospective single-institution cardiac surgery database was analysed involving 4615 patients. Univariate, multivariate stepwise Cox regression analysis and propensity matching were performed to identify whether a single-unit blood transfusion was detrimental to long-term survival. RESULTS: Univariate analysis revealed that blood was significantly associated with a reduced long-term survival even with a single-unit transfused, P = 0.0001. Cox multivariate regression analysis identified age, ejection fraction, preoperative dialysis, logistic EuroSCORE, postoperative CKMB, blood transfusion, urgent operative status and atrial fibrillation as significant factors determining long-term survival. When the Cox regression was repeated with patients who received no blood or only one unit of blood, transfusion was not a risk factor for long-term survival. An interaction analysis revealed that blood transfusion was significantly interacting with preoperative haemoglobin levels, P = 0.02. Propensity analysis demonstrated that a single-unit transfusion is not associated with a detrimental long-term survival, P = 0.3. CONCLUSIONS: Cox regression and propensity matching both indicate that a single-unit transfusion is not a significant cause of reduced long-term survival. Preoperative anaemia is a significant confounding factor. Despite demonstrating the negligible risks of a single-unit blood transfusion, we are not advocating liberal transfusion and would recommend changing from a double-unit to a single-unit transfusion policy. We speculate that blood is not bad, but that the underlying reason that it is given might be.
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Puente de Arteria Coronaria/efectos adversos , Reacción a la Transfusión , Anciano , Anemia/sangre , Anemia/complicaciones , Anemia/mortalidad , Anemia/terapia , Biomarcadores/sangre , Transfusión Sanguínea/mortalidad , Puente de Arteria Coronaria/mortalidad , Inglaterra , Femenino , Hemoglobinas/metabolismo , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Puntaje de Propensión , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: The red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with coronary artery disease with or without heart failure. We sought to investigate the role of RDW in patients undergoing isolated coronary artery bypass graft surgery (CABG). METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Univariate and multivariate analysis was performed for in hospital mortality, long-term survival, length of hospital stay, length of intensive care unit stay and creatinine kinase muscle-brain (CKMB) release. RESULTS: Overall mortality was 2.1% for all cases, N = 8615. Median follow up was 5.8 years. Univariate analysis demonstrated that the RDW has a significant effect on CKMB release, P = 0.001, in-hospital mortality, P < 0.0001, and long-term survival, P < 0.0001, but no significant effect on the ITU length of stay, P = 0.9, or hospital length of stay, P = 0.2. Multivariate analysis revealed that the RDW was a significant factor determining in-hospital mortality and long-term survival, but had no significant effect on CKMB release, ITU or hospital length of stay. Confounding factor analysis revealed that in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival. CONCLUSIONS: The RDW is a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated CABG. The mechanism of association requires further study.
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Puente de Arteria Coronaria/mortalidad , Índices de Eritrocitos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Forma MB de la Creatina-Quinasa/sangre , Femenino , Mortalidad Hospitalaria , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Análisis de Regresión , Factores de Riesgo , Análisis de SupervivenciaRESUMEN
OBJECTIVES: Renal failure post-cardiac surgery is associated with an increased in hospital morbidity and mortality. We investigated the effect of new onset renal risk, injury or failure [risk, injury, failure, loss and end-stage kidney disease (RIFLE)] post-coronary artery bypass graft (CABG) on long-term survival, in patients with normal preoperative renal function. METHODS: The effect of developing postoperative renal risk, injury or failure as defined by the RIFLE criteria on the long-term survival of patients undergoing isolated CABG with a normal renal function was studied. Two separate multivariate analyses were performed based on preoperative serum creatinine or glomerular filtration rate (GFR). Univariate, multivariate, interaction and confounding factor analyses were performed. RESULTS: A total of 4029 isolated CABG patients were included in the study. 46.5% of patients had chronic kidney disease (CKD) stage 1 (GFR ≥90 ml/min/1.73 m(2)), 50.4% had CKD stage 2 (GFR 60-89 ml/min/1.73 m(2)) and 3.1% had CKD stage 3 (GFR 30-59 ml/min/1.73 m(2)) on admission, despite having a normal serum creatinine. The study group had a median follow-up of 3.6 years (95% CI 0-13.7). Renal risk, injury and failure were associated with a significantly reduced long-term survival (P < 0.001). In patients with normal preoperative serum creatinine, Cox regression analysis revealed that age (P = 0.026), preoperative creatinine (P =0.006) and logistic EuroSCORE (P < 0.0001) were significant factors in addition to the development of postoperative renal risk, injury or failure (P < 0.0001), with regard to determining long-term survival. A confounding factor analysis revealed that discharge creatinine (P = 0.0001) and discharge GFR (P = 0.0006) were significant determinants of long-term survival. In patients with a preoperative GFR >90 ml/min, Cox regression analysis revealed that diabetes (P = 0.004) sex (P = 0.019) and logistic EuroSCORE (P < 0.0001), were also significant factors in addition to the development of postoperative renal risk, injury or failure (P = 0.0001) with regard to determining long-term survival. A significant interaction between diabetes and the development of renal risk, injury or failure exists (P = 0.04). A confounding factor analysis revealed that discharge creatinine was a significant determinant (P = 0.0001) of long-term survival, and discharge GFR was not. CONCLUSIONS: Despite being a biochemically reversible process, the development of renal risk, injury and failure as defined by the RIFLE criteria post-cardiac surgery in patients with a normal preoperative renal function is associated with a significantly worse long-term outcome.
Asunto(s)
Puente de Arteria Coronaria/efectos adversos , Insuficiencia Renal Crónica/etiología , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/estadística & datos numéricos , Creatinina/sangre , Femenino , Tasa de Filtración Glomerular , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Modelos de Riesgos Proporcionales , Insuficiencia Renal Crónica/sangre , Insuficiencia Renal Crónica/epidemiología , Riesgo , Índice de Severidad de la Enfermedad , Reino Unido/epidemiologíaRESUMEN
OBJECTIVE: We aimed to validate the new EuroSCORE II risk model in a contemporary cardiac surgery practice in the United Kingdom (UK). METHODS: The original logistic EuroSCORE was compared to EuroSCORE II with regard to accuracy of predicting in-hospital mortality. Analysis was performed on isolated coronary artery bypass grafts (CABG; n = 2913), aortic valve replacement (AVR; n = 814), mitral valve surgery (MVR; n = 340), combined AVR and CABG (n = 517), aortic (n = 350) and miscellaneous procedures (n = 642), and the above cases combined (n = 5576). RESULTS: In a single-institution experience, EuroSCORE II is a reasonable risk model for in-hospital mortality from isolated CABG (C-statistic 0.79, Hosmer-Lemeshow P = 0.052) and aortic procedures (C-statistic 0.81, Hosmer-Lemeshow P = 0.43), and excellent for mitral valve surgery (C-statistic 0.87, Hosmer-Lemeshow P = 0.6). EuroSCORE II is better than the original EuroSCORE, using contemporaneous data for combined AVR and CABG operations (C-statistic 0.74, Hosmer-Lemeshow P = 0.38). However, EuroSCORE II failed to improve on the original EuroSCORE model for isolated AVR (C-statistic 0.69, Hosmer-Lemeshow P = 0.07) and miscellaneous procedures (C-statistic 0.70, Hosmer-Lemeshow P = 0.99). EuroSCORE II has better calibration than the original EuroSCORE or the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) modified EuroSCORE for cumulative sum survival (CUSUM) curves. CONCLUSIONS: EuroSCORE II improves on the original logistic EuroSCORE, though mainly for combined AVR and CABG cases. Concerns still exist, however, over its use for isolated AVR procedures, aortic surgery and miscellaneous procedures. There is still room for improvement in risk modelling.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos/métodos , Indicadores de Salud , Medición de Riesgo/métodos , Anciano , Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Reino UnidoRESUMEN
OBJECTIVES: Coronary artery bypass graft (CABG) is performed for symptomatic and prognostic reasons. We aimed to determine the factors that contribute to in-hospital mortality and long-term survival in young patients (aged less than 65) undergoing CABG. METHODS: A prospective database was retrospectively analysed and cross-correlated with the United Kingdom's Strategic Tracing Service to evaluate survival in patients under the age of 65, following isolated primary CABG. Univariate-, multivariate logistic with Cox regression- and neural network analyses were performed. RESULTS: Patients under the age of 65, who had undergone isolated CABG between April 1997 and March 2010 were studied;n = 5967. In-hospital mortality was 1.1% and long-term mortality was 13.5%; median follow-up 7.9 years. Multivariate analysis demonstrated that atrial fibrillation, 'urgent' operation status, postoperative creatinine kinase (CKMB), moderate or poor left ventricular (LV) function, and female sex were significant factors predicting in-hospital mortality. Cox regression demonstrated that age, diabetes (oral and insulin controlled), moderate and poor LV function, cerebrovascular disease, dialysis, left internal mammary artery (LIMA) usage, postoperative CKMB, atrial fibrillation, 'urgent' operation status, and peripheral vascular disease were significant factors determining long-term survival. Radial artery use, off-pump surgery, composite arterial grating and graft number had no effect on in-hospital mortality or long-term survival. Neural network analysis confirmed the factors identified by logistic and Cox multivariate analysis. CONCLUSIONS: The risk factors for in-hospital mortality in patients under the age of 65 include postoperative CKMB, urgent operation status, LV function, female sex and atrial fibrillation. Significant factors determining long-term survival in the under-65 age group include age, atrial fibrillation, diabetes (diet and insulin controlled), LV function, cerebrovascular disease, dialysis, LIMA usage, 'urgent' operation status, CKMB and peripheral vascular disease.