RESUMEN

There are controversies regarding the impact of sex on mortality and postoperative complications in patients undergoing on-pump coronary artery bypass grafting (CABG), although some studies demonstrate comparable outcomes. This study sought to evaluate sex differences regarding risk factors associated with hospital mortality and postoperative clinical outcomes among patients undergoing isolated on-pump CABG. We conducted a retrospective observational cohort study of patients who underwent isolated on-pump CABG from January 1996 to January 2020. Patients were divided into two groups (male and female) and compared regarding preoperative characteristics, surgical technical variables, and in-hospital outcomes. All-cause mortality between groups was compared using logistic regression. Risk factors for mortality, along with their respective odds ratios (OR), were separately assessed using a logistic regression model with p-values for interaction. We analyzed 4,882 patients, of whom 31.6% were female. Women exhibited a higher prevalence of age >75 years (12.2% vs 8.3%, p<0.001), obesity (22.6% vs 11.5%, p<0.001), diabetes (41.6% vs 32.2%, p<0.001), hypertension (85.2% vs 73.5%, p<0.001), and NYHA functional classes 3 and 4 (16.2% vs 11.2%, p<0.001) compared to men. Use of the mammary artery for revascularization was less frequent among women (73.8% vs 79.9%, p<0.001), who also received fewer saphenous vein grafts (2.17 vs 2.27, p = 0.002). A history of previous or recent myocardial infarction (MI) had an impact on women's mortality, unlike in men (OR 1.61 vs 0.94, p = 0.014; OR 1.86 vs 0.99, p = 0.015, respectively). After adjusting for several risk factors, mortality was found to be comparable between men and women, with an OR of 1.20 (95% CI 0.94-1.53, p = 0.129). In conclusion, female patients undergoing isolated on-pump CABG presented with a higher number of comorbidities. Previous and recent MI were associated with higher mortality only in women. In this cohort analysis, female gender was not identified as an independent risk factor for outcome after CABG.

Asunto(s)

Puente de Arteria Coronaria , Mortalidad Hospitalaria , Complicaciones Posoperatorias , Humanos , Masculino , Femenino , Anciano , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores Sexuales , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/mortalidad , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Caracteres Sexuales

RESUMEN

INTRODUCTION: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil. OBJECTIVE: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center. METHODS: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS). RESULTS: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients. CONCLUSION: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Humanos , Puente de Arteria Coronaria/mortalidad , Femenino , Masculino , Estudios Prospectivos , Brasil , Anciano , Persona de Mediana Edad , Medición de Riesgo/métodos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Factores de Riesgo , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/mortalidad , Mortalidad Hospitalaria , Reproducibilidad de los Resultados

RESUMEN

We provide an update regarding the differences between men and women in short-term postoperative mortality after coronary artery bypass grafting (CABG) and highlight the differences in postoperative risk of stroke, myocardial infarction, and new onset atrial fibrillation. We included 23 studies, with a total of 3,971,267 patients (70.7% men, 29.3% women), and provided results for groups of unbalanced studies and propensity matched studies. For short-term mortality, the pooled odds ratio (OR) from unbalanced studies was 1.71 (with 95% CI 1.69-1.74, I2 = 0%, p = 0.7), and from propensity matched studies was 1.32 (95% CI 1.14-1.52, I2 = 76%, p < 0.01). For postoperative stroke, the pooled effects were OR = 1.50 (95% CI 1.35-1.66, I2 = 83%, p < 0.01) and OR = 1.31 (95% CI 1.02-1.67, I2 = 81%, p < 0.01). For myocardial infarction, the pooled effects were OR = 1.09 (95% CI = 0.78-1.53, I2 = 70%, p < 0.01) and OR = 1.03 (95% CI = 0.86-1.24, I2 = 43%, p = 0.18). For postoperative atrial fibrillation, the pooled effect from unbalanced studies was OR = 0.89 (95% CI = 0.82-0.96, I2 = 34%, p = 0.18). The short-term mortality risk after CABG is higher in women, compared to men. Women are at higher risk of postoperative stroke. There is no significant difference in the likelihood of postoperative myocardial infarction in women compared to men. Men are at higher risk of postoperative atrial fibrillation after CABG.

Asunto(s)

Fibrilación Atrial , Puente de Arteria Coronaria , Infarto del Miocardio , Complicaciones Posoperatorias , Humanos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Masculino , Femenino , Infarto del Miocardio/etiología , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Fibrilación Atrial/etiología , Fibrilación Atrial/cirugía , Factores Sexuales , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/epidemiología , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

BACKGROUND: Hospital- and physician-level variation for selection of percutaneous coronary intervention versus coronary artery bypass grafting (CABG) for patients with coronary artery disease has been associated with outcome differences. However, most studies excluded patients treated medically. METHODS AND RESULTS: From 2010 to 2019, adults with 3-vessel or left main coronary artery disease at 3 hospitals (A, B, C) in Alberta, Canada, were categorized by treatment with medical therapy, percutaneous coronary intervention, or CABG. Multilevel regression models determined the proportion of variation in treatment attributable to patient, physician, and hospital factors, and survival models assessed outcomes including death and major adverse cardiovascular events over 5 years. Of 22 580 patients (mean age, 67 years; 80% men): 6677 (29%) received medical management, 9171 (41%) percutaneous coronary intervention, and 6732 (30%) CABG. Hospital factors accounted for 10.8% of treatment variation. In adjusted models (site A as reference), patients at sites B and C had 49% (95% CI, 44%-53%) and 43% (95% CI, 37%-49%) lower rates of medical therapy, respectively, and 31% (95% CI, 24%-38%) and 32% (95% CI, 24%-40%) lower rates of CABG. During 5.0 years median follow-up, 3287 (14.6%) patients died, with no intersite mortality differences. There were no between-site differences in acute coronary syndromes or stroke; patients at sites B and C had 24% lower risk (95% CI, 13%-34% and 11%-35%, respectively) of heart failure hospitalization. CONCLUSIONS: Hospital-level variation in selection of percutaneous coronary intervention, CABG, or medical therapy for patients with complex coronary artery disease was not associated with differences in 5-year mortality rates. Research and quality improvement initiatives comparing revascularization practices should include medically managed patients.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Anciano , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/cirugía , Intervención Coronaria Percutánea/estadística & datos numéricos , Intervención Coronaria Percutánea/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Puente de Arteria Coronaria/mortalidad , Alberta/epidemiología , Persona de Mediana Edad , Toma de Decisiones Clínicas , Resultado del Tratamiento , Pautas de la Práctica en Medicina/tendencias , Hospitales/estadística & datos numéricos , Factores de Riesgo

RESUMEN

BACKGROUND: We used the Spanish national hospital discharge data from 2016 to 2022 to analyze procedures and hospital outcomes among patients aged ≥ 18 years admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) according to diabetes mellitus (DM) status (non-diabetic, type 1-DM or type 2-DM). METHODS: We built logistic regression models for STEMI/NSTEMI stratified by DM status to identify variables associated with in-hospital mortality (IHM). We analyzed the effect of DM on IHM. RESULTS: Spanish hospitals reported 201,950 STEMIs (72.7% non-diabetic, 0.5% type 1-DM, and 26.8% type 2-DM; 26.3% female) and 167,285 NSTEMIs (61.6% non-diabetic, 0.6% type 1-DM, and 37.8% type 2-DM; 30.9% female). In STEMI, the frequency of percutaneous coronary intervention (PCI) increased among non-diabetic people (60.4% vs. 68.6%; p < 0.001) and people with type 2-DM (53.6% vs. 66.1%; p < 0.001). In NSTEMI, the frequency of PCI increased among non-diabetic people (43.7% vs. 45.7%; p < 0.001) and people with type 2-DM (39.1% vs. 42.8%; p < 0.001). In NSTEMI, the frequency of coronary artery by-pass grafting (CABG) increased among non-diabetic people (2.8% vs. 3.5%; p < 0.001) and people with type 2-DM (3.7% vs. 5.0%; p < 0.001). In the entire population, lower IHM was associated with undergoing PCI (odds ratio [OR] [95% confidence interval] = 0.34 [0.32-0.35] in STEMI; 0.24 [0.23-0.26] in NSTEMI) or CABG (0.33 [0.27-0.40] in STEMI; 0.45 [0.38-0.53] in NSTEMI). IHM decreased over time in STEMI (OR = 0.86 [0.80-0.93]). Type 2-DM was associated with higher IHM in STEMI (OR = 1.06 [1.01-1.11]). CONCLUSIONS: PCI and CABG were associated with lower IHM in people admitted for STEMI/NSTEMI. Type 2-DM was associated with IHM in STEMI.

Asunto(s)

Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Mortalidad Hospitalaria , Infarto del Miocardio sin Elevación del ST , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Femenino , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/epidemiología , Masculino , España/epidemiología , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/tendencias , Anciano , Persona de Mediana Edad , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio sin Elevación del ST/mortalidad , Infarto del Miocardio sin Elevación del ST/diagnóstico , Infarto del Miocardio sin Elevación del ST/epidemiología , Resultado del Tratamiento , Factores de Riesgo , Factores de Tiempo , Medición de Riesgo , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/epidemiología , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 1/terapia , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/mortalidad , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Admisión del Paciente , Anciano de 80 o más Años , Bases de Datos Factuales , Diabetes Mellitus/epidemiología , Diabetes Mellitus/diagnóstico , Diabetes Mellitus/mortalidad , Diabetes Mellitus/terapia , Adulto , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/tendencias

RESUMEN

OBJECTIVES: The aim of the study was to investigate the potential prognostic role of preoperative measurement of erector spinae myosteatosis with Hounsfield unit average calculation as a marker for sarcopenia and frailty in patients undergoing coronary bypass surgery. METHODS: Preoperative computer tomography-derived measurements of 479 consecutive patients undergoing coronary bypass surgery between January 2017 and December 2019 were retrospectively performed. The erector spinae muscle at the level of the 12th vertebra was manually outlined bilaterally on the axial computer tomography slices and Hounsfield unit average calculation was performed. The lower quartile of muscle density values was defined as myosteatotic and thus sarcopenic. Sarcopenic (n = 121) versus non-sarcopenic patients (n = 358) were compared regarding postoperative morbidity and short- and long-term mortality. Results were adjusted for age, body mass index, atrial fibrillation and hypertension using inverse probability weighting. RESULTS: Sarcopenia was associated with higher 30-day mortality (4.1% vs 0.8%; P = 0.012), mid-term mortality after 1 year (9.3% vs 3.1%; P = 0.047) and 2 years (10.8% vs 4.2%; P = 0.047). Long-term mortality (5 years) was 20.8% for sarcopenic and 13.0% for non-sarcopenic patients but was not found to be significantly different (P = 0.089). Sarcopenia was associated with higher rates of reintubation (7.5% vs 1.1%; P < 0.001), sternal wound infections (7.5% vs 2.8%; P = 0.039) and acute kidney injury requiring haemodialysis (2.5% vs 0.4%; P = 0.021). CONCLUSIONS: In patients undergoing coronary bypass surgery, sarcopenia was associated with increased short-term mortality, mid-term mortality and morbidity. The measurement of erector spinae myosteatosis could be an easy and useful parameter in preoperative risk assessment.

Asunto(s)

Puente de Arteria Coronaria , Complicaciones Posoperatorias , Sarcopenia , Tomografía Computarizada por Rayos X , Humanos , Sarcopenia/epidemiología , Sarcopenia/mortalidad , Sarcopenia/diagnóstico por imagen , Sarcopenia/complicaciones , Masculino , Femenino , Anciano , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Estudios Retrospectivos , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/complicaciones , Pronóstico , Músculos Paraespinales/diagnóstico por imagen

RESUMEN

BACKGROUND: A multidisciplinary heart team (HT) approach to patients with complex coronary artery disease has a class IB recommendation, yet there are limited data on adherence to HT treatment recommendations and long-term clinical follow-up. The objective of this study was to assess adherence rates to HT recommendations and assess long-term mortality rates among patients with complex CAD. METHODS AND RESULTS: Six hundred eighty-four sequential HT cases for complex coronary artery disease from January 2015 to May 2017 were reviewed. After excluding cases with significant comorbid valve disease, baseline characteristics were compared based on HT treatment recommendations: optimal medical therapy, percutaneous coronary intervention, and coronary artery bypass grafting. Adherence rates were manually extracted, and 5-year mortality rates were obtained from the Michigan Death Registry. Seventy-two percent of 405 included patients were men (mean age 66±11 years), with high rates of medical comorbidities. Estimated surgical risk scores were lowest in the coronary artery bypass grafting group. Optimal medical therapy was recommended in 138 patients (34%), percutaneous coronary intervention in 95 (23%), and coronary artery bypass grafting in 172 (42%). Adherence to HT recommendations across groups was high (96%) and did not differ between treatment groups. Over 5 years of follow-up, there were 119 deaths, resulting in a cumulative mortality rate of 29%. CONCLUSIONS: In the largest HT cohort in the United States to date, high rates of adherence to HT recommendations were observed among high-risk patients with coronary artery disease. High rates of adherence to HT recommendations were observed irrespective of treatment group recommendation, suggesting that HT recommendations were individualized and acceptable to both patients and physicians alike.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Grupo de Atención al Paciente , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Anciano , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/terapia , Persona de Mediana Edad , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/estadística & datos numéricos , Factores de Tiempo , Estudios Retrospectivos , Sistema de Registros , Michigan/epidemiología , Adhesión a Directriz , Factores de Riesgo , Resultado del Tratamiento

RESUMEN

BACKGROUND: The very long-term outcomes of off-pump versus on-pump Coronary Artery Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) are largely unclear. We linked 20-years outcomes of two randomized trials to evaluate re-intervention and mortality outcomes for on-pump CABG, off-pump CABG and PCI. METHODS: A data linkage project was performed using data as registered within the Netherlands Heart Registration (NHR), Statistics Netherlands (CBS) and the Octopus trials. Between 1998 and 2000, these trials randomized patients with coronary artery disease to on-pump versus off-pump CABG (OctoPump trial), or to PCI versus off-pump CABG (OctoStent trial). With data linkage, the original 5 years follow-up time for clinical events was extended to 20 years, including mortality and coronary reinterventions. RESULTS: After 20 years, in the OctoPump trial all-cause mortality was 50.0% after on-pump, and 46.5% after off-pump CABG. There was no difference in the combined outcome of mortality and re-interventions (HR 0.82, 95% CI 0.59-1.12). In the OctoStent trial, all-cause mortality was 56.7% after PCI and 52.5% after off-pump CABG. There was no difference in the combined outcome of mortality and re-interventions (HR 0.76, 95% CI 0.57-1.04). Off-pump CABG patients underwent less re-interventions than PCI patients (HR 0.52, 95% CI 0.33-0.80). CONCLUSION: This study revealed no differences in 20-year survival between patients randomized to on-pump versus off-pump CABG, or to PCI versus off-pump-CABG. However, off-pump CABG patients underwent less re-interventions than PCI patients.

Asunto(s)

Puente de Arteria Coronaria Off-Pump , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Puente de Arteria Coronaria Off-Pump/métodos , Puente de Arteria Coronaria Off-Pump/mortalidad , Puente de Arteria Coronaria Off-Pump/tendencias , Estudios de Seguimiento , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/tendencias , Femenino , Masculino , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/tendencias , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Persona de Mediana Edad , Pronóstico , Anciano , Países Bajos/epidemiología , Resultado del Tratamiento , Factores de Tiempo

RESUMEN

BACKGROUND: Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD). OBJECTIVES: The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option. METHODS: A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance. RESULTS: The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22. CONCLUSIONS: In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG.

Asunto(s)

Toma de Decisiones Clínicas , Angiografía Coronaria , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Reserva del Flujo Fraccional Miocárdico , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Femenino , Masculino , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/fisiopatología , Persona de Mediana Edad , Anciano , Factores de Tiempo , Factores de Riesgo , Medición de Riesgo , Selección de Paciente , Técnicas de Apoyo para la Decisión , Índice de Severidad de la Enfermedad , Infarto del Miocardio/etiología , Infarto del Miocardio/mortalidad

RESUMEN

BACKGROUND: Postoperative myocardial infarction (POMI) is associated with major surgeries and remains the leading cause of mortality and morbidity in people undergoing vascular surgery, with an incidence rate ranging from 5% to 20%. Preoperative coronary interventions, such as coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), may help prevent acute myocardial infarction in the perioperative period of major vascular surgery when used in addition to routine perioperative drugs (e.g. statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents), CABG by creating new blood circulation routes that bypass the blockages in the coronary vessels, and PCI by opening up blocked blood vessels. There is currently uncertainty around the benefits and harms of preoperative coronary interventions. OBJECTIVES: To assess the effects of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery. SEARCH METHODS: We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and CINAHL EBSCO on 13 March 2023. We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) or quasi-RCTs that compared the use of preoperative coronary interventions plus usual care versus usual care for preventing acute myocardial infarction during major open vascular or endovascular surgery. We included participants of any sex or any age undergoing major open vascular surgery, major endovascular surgery, or hybrid vascular surgery. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes of interest were acute myocardial infarction, all-cause mortality, and adverse events resulting from preoperative coronary interventions. Our secondary outcomes were cardiovascular mortality, quality of life, vessel or graft secondary patency, and length of hospital stay. We reported perioperative and long-term outcomes (more than 30 days after intervention). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included three RCTs (1144 participants). Participants were randomised to receive either preoperative coronary revascularisation with PCI or CABG plus usual care or only usual care before major vascular surgery. One trial enrolled participants if they had no apparent evidence of coronary artery disease. Another trial selected participants classified as high risk for coronary disease through preoperative clinical and laboratorial testing. We excluded one trial from the meta-analysis because participants from both the control and the intervention groups were eligible to undergo preoperative coronary revascularisation. We identified a high risk of performance bias in all included trials, with one trial displaying a high risk of other bias. However, the risk of bias was either low or unclear in other domains. We observed no difference between groups for perioperative acute myocardial infarction, but the evidence is very uncertain (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.02 to 4.57; 2 trials, 888 participants; very low-certainty evidence). One trial showed a reduction in incidence of long-term (> 30 days) acute myocardial infarction in participants allocated to the preoperative coronary interventions plus usual care group, but the evidence was very uncertain (RR 0.09, 95% CI 0.03 to 0.28; 1 trial, 426 participants; very low-certainty evidence). There was little to no effect on all-cause mortality in the perioperative period when comparing the preoperative coronary intervention plus usual care group to usual care alone, but the evidence is very uncertain (RR 0.79, 95% CI 0.31 to 2.04; 2 trials, 888 participants; very low-certainty evidence). The evidence is very uncertain about the effect of preoperative coronary interventions on long-term (follow up: 2.7 to 6.2 years) all-cause mortality (RR 0.74, 95% CI 0.30 to 1.80; 2 trials, 888 participants; very low-certainty evidence). One study reported no adverse effects related to coronary angiography, whereas the other two studies reported five deaths due to revascularisations. There may be no effect on cardiovascular mortality when comparing preoperative coronary revascularisation plus usual care to usual care in the short term (RR 0.07, 95% CI 0.00 to 1.32; 1 trial, 426 participants; low-certainty evidence). Preoperative coronary interventions plus usual care in the short term may reduce length of hospital stay slightly when compared to usual care alone (mean difference -1.17 days, 95% CI -2.05 to -0.28; 1 trial, 462 participants; low-certainty evidence). We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision, and inconsistency. None of the included trials reported on quality of life or vessel graft patency at either time point, and no study reported on adverse effects, cardiovascular mortality, or length of hospital stay at long-term follow-up. AUTHORS' CONCLUSIONS: Preoperative coronary interventions plus usual care may have little or no effect on preventing perioperative acute myocardial infarction and reducing perioperative all-cause mortality compared to usual care, but the evidence is very uncertain. Similarly, limited, very low-certainty evidence shows that preoperative coronary interventions may have little or no effect on reducing long-term all-cause mortality. There is very low-certainty evidence that preoperative coronary interventions plus usual care may prevent long-term myocardial infarction, and low-certainty evidence that they may reduce length of hospital stay slightly, but not cardiovascular mortality in the short term, when compared to usual care alone. Adverse effects of preoperative coronary interventions were poorly reported in trials. Quality of life and vessel or graft patency were not reported. We downgraded the certainty of the evidence most frequently for high risk of bias, inconsistency, or imprecision. None of the analysed trials provided significant data on subgroups of patients who could potentially experience more substantial benefits from preoperative coronary intervention (e.g. altered ventricular ejection fraction). There is a need for evidence from larger and homogeneous RCTs to provide adequate statistical power to assess the role of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery.

Asunto(s)

Puente de Arteria Coronaria , Procedimientos Endovasculares , Infarto del Miocardio , Intervención Coronaria Percutánea , Complicaciones Posoperatorias , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Infarto del Miocardio/prevención & control , Infarto del Miocardio/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos Endovasculares/métodos , Procedimientos Endovasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/efectos adversos , Procedimientos Quirúrgicos Vasculares/mortalidad , Cuidados Preoperatorios/métodos , Sesgo , Periodo Perioperatorio , Tiempo de Internación

RESUMEN

BACKGROUND: Type I and type II diabetes mellitus (DM) patients have a higher prevalence of cardiovascular diseases, as well as a higher mortality risk of cardiovascular diseases and interventions. This study provides an update on the impact of DM on clinical outcomes, including mortality, complications and reinterventions, using data on percutaneous and surgical cardiac interventions in the Netherlands. METHODS: This is a retrospective, nearby nationwide study using real-world observational data registered by the Netherlands Heart Registration (NHR) between 2015 and 2020. Patients treated for combined or isolated coronary artery disease (CAD) and aortic valve disease (AVD) were studied. Bivariate analyses and multivariate logistic regression models were used to evaluate the association between DM and clinical outcomes both unadjusted and adjusted for baseline characteristics. RESULTS: 241,360 patients underwent the following interventions; percutaneous coronary intervention(N = 177,556), coronary artery bypass grafting(N = 39,069), transcatheter aortic valve implantation(N = 11,819), aortic valve replacement(N = 8,028) and combined CABG and AVR(N = 4,888). The incidence of DM type I and II was 21.1%, 26.7%, 17.8%, 27.6% and 27% respectively. For all procedures, there are statistically significant differences between patients living with and without diabetes, adjusted for baseline characteristics, at the expense of patients with diabetes for 30-days mortality after PCI (OR = 1.68; p <.001); 120-days mortality after CABG (OR = 1.35; p <.001), AVR (OR = 1.5; p <.03) and CABG + AVR (OR = 1.42; p =.02); and 1-year mortality after CABG (OR = 1.43; p <.001), TAVI (OR = 1.21; p =.01) and PCI (OR = 1.68; p <.001). CONCLUSION: Patients with DM remain to have unfavourable outcomes compared to nondiabetic patients which calls for a critical reappraisal of existing care pathways aimed at diabetic patients within the cardiovascular field.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Intervención Coronaria Percutánea , Sistema de Registros , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Masculino , Femenino , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/efectos adversos , Factores de Riesgo , Factores de Tiempo , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/cirugía , Persona de Mediana Edad , Medición de Riesgo , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Países Bajos/epidemiología , Diabetes Mellitus Tipo 2/mortalidad , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/terapia , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/mortalidad , Diabetes Mellitus Tipo 1/mortalidad , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/complicaciones , Diabetes Mellitus Tipo 1/terapia , Incidencia , Enfermedad de la Válvula Aórtica/cirugía , Enfermedad de la Válvula Aórtica/mortalidad , Complicaciones Posoperatorias/mortalidad , Hospitales de Alto Volumen

RESUMEN

BACKGROUND: Patients requiring coronary artery bypass grafting (CABG) have multiple co-morbidities which need to be considered in totality when determining surgical risks. The objective of this study is to evaluate short-term and long-term mortality rates of CABG surgery, as well as to identify the most significant risk factors for mortality after isolated CABG. METHODS: All patients with complete dataset who underwent isolated CABG between January 2008 and December 2017 were included. Univariate and multivariate Cox regression was performed to determine the risk factors for all-cause mortality. Classification and regression tree analysis was performed to identify the relative importance of these risk factors. RESULTS: 3,573 patients were included in the study. Overall mortality rate was 25.7%. In-hospital mortality rate was 1.62% overall. 30-day, 1-year, 5-year, 10-year and 14.5-year mortality rates were 1.46%, 2.94%, 9.89%, 22.79% and 36.30% respectively. Factors associated with death after adjustment for other risk factors were older age, lower body mass index (BMI), hypertension, diabetes mellitus, chronic obstructive pulmonary disease, pre-operative renal failure on dialysis, higher last pre-operative creatinine level, lower estimated glomerular filtration rate (eGFR), heart failure, lower left ventricular ejection fraction and New York Heart Association class II, III and IV. Additionally, female gender and logistic EuroSCORE were associated with death on univariate Cox analysis, but not associated with death after adjustment with multivariate Cox analysis. Using CART analysis, the strongest predictor of mortality was pre-operative eGFR < 46.9, followed by logistic EuroSCORE ≥ 2.4. CONCLUSION: Poorer renal function, quantified by a lower eGFR, is the best predictor of post-CABG mortality. Amongst other risk factors, logistic EuroSCORE, age, diabetes and BMI had a relatively greater impact on mortality. Patients with chronic kidney disease stage 3B and above are at highest risk for mortality. We hope these findings heighten awareness to optimise current medical therapy in preserving renal function upon diagnosis of any atherosclerotic disease and risk factors contributing to coronary artery disease.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Humanos , Puente de Arteria Coronaria/mortalidad , Masculino , Femenino , Factores de Riesgo , Anciano , Persona de Mediana Edad , Estudios Retrospectivos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/complicaciones , Mortalidad Hospitalaria , Factores de Tiempo

RESUMEN

Importance: Despite widespread use to guide patients to hospitals providing the best care, it remains unknown whether Centers for Medicare & Medicaid Services (CMS) hospital star ratings are a reliable measure of hospital surgical quality. Objective: To examine the CMS hospital star ratings and hospital surgical quality measured by 30-day postoperative mortality, serious complications, and readmission rates for Medicare beneficiaries undergoing colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, and incisional hernia repair. Design, Setting, and Participants: This cohort study evaluated 100% Medicare administrative claims for nonfederal acute care hospitals with a CMS hospital star rating for calendar years 2014-2018. Data analysis was performed from January 15, 2022, to April 30, 2023. Participants included fee-for-service Medicare beneficiaries aged 66 to 99 years who underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair with continuous Medicare coverage for 3 months before and 6 months after surgery. Exposure: Centers for Medicare & Medicaid Services hospital star rating. Main Outcomes and Measures: Risk- and reliability-adjusted hospital rates of 30-day postoperative mortality, serious complications, and 30-day readmissions were measured and compared across hospitals and star ratings. Results: A total of 1 898 829 patients underwent colectomy, coronary artery bypass graft, cholecystectomy, appendectomy, or incisional hernia repair at 3240 hospitals with a CMS hospital star rating. Mean (SD) age was 74.8 (7.0) years, 50.6% of the patients were male, and 86.5% identified as White. Risk- and reliability-adjusted 30-day mortality rate decreased in a stepwise fashion from 6.80% (95% CI, 6.79%-6.81%) in 1-star hospitals to 4.93% (95% CI, 4.93%-4.94%) in 5-star hospitals (adjusted odds ratio, 1.86; 95% CI, 1.73-2.00). There was wide variation in the rates of hospital mortality (variation, 1.89%; range, 2.4%-16.2%), serious complications (variation, 1.97%; range, 5.5%-45.1%), and readmission (variation, 1.27%; range, 9.1%-22.5%) across all hospitals. After stratifying hospitals by their star rating, similar patterns of variation were observed within star rating groups for 30-day mortality: 1 star (variation, 1.91%; range, 3.6%-12.0%), 2 star (variation, 1.86%; range, 2.8%-16.2%), 3 star (variation, 1.84%; range, 2.9%-12.3%), 4 star (variation, 1.76%; range, 2.9%-11.5%), and 5 star (variation, 1.79%; range, 2.4%-9.1%). Similar patterns were observed for serious complications and readmissions. Conclusion and Relevance: Although CMS hospital star rating was associated with postoperative mortality, serious complications, and readmissions, there was wide variation in surgical outcomes within each star rating group. These findings highlight the limitations of the CMS hospital star rating system as a measure of surgical quality and should be a call for continued improvement of publicly reported hospital grade measures.

Asunto(s)

Readmisión del Paciente , Complicaciones Posoperatorias , Humanos , Estados Unidos/epidemiología , Anciano , Masculino , Femenino , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Anciano de 80 o más Años , Readmisión del Paciente/estadística & datos numéricos , Medicare , Hospitales/estadística & datos numéricos , Colecistectomía/estadística & datos numéricos , Puente de Arteria Coronaria/mortalidad , Centers for Medicare and Medicaid Services, U.S. , Indicadores de Calidad de la Atención de Salud , Colectomía/efectos adversos , Colectomía/mortalidad , Apendicectomía , Mortalidad Hospitalaria

RESUMEN

OBJECTIVES: Endoscopic vein harvesting (EVH) is an alternative technique to obtain the saphenous vein for coronary artery bypass grafting (CABG) surgery. We aimed to evaluate the early and mid-term outcomes of patients with EVH in CABG. METHODS: This cohort study included consecutive isolated CABG patients in Nanjing First Hospital from July 2020 to December 2022 using propensity score matching methods. Patients were classified to EVH group and open vein harvesting (OVH) group according to the vein harvesting methods. The primary outcome was the all-cause death, and the secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, heart failure, myocardial infarction and revascularization and asymptomatic survival in the follow-up. RESULTS: Totally 1247 patients were included in the study with 849 in OVH group and 398 in EVH group. Patients with EVH were more female, diabetes, higher body mass index, more multi-vessel and left main diseases. 308 pairs were formed after the matching. There was no significant difference in the rates of in-hospital death (EVH vs. OVH, 2.3% vs. 1.3%, P = 0.543). During the 3 years follow-up, EVH grafts were considered not inferior to OVH grafts, no differences were found in all-cause death [8.5% vs. 5.0%, hazard ratio (HR) 1.565, 95% confidence interval (CI): 0.77-3.17, P = 0.21], MACEs (8.1% vs. 7.1%, HR 1.165, 95CI: 0.51-2.69, P = 0.71) and asymptomatic survival (66.7% vs. 72.5%, HR 1.117, 95%CI: 0.65-1.92, P = 0.68). CONCLUSIONS: EVH grafts were considered comparable to OVH grafts in patients following CABG in the 3 years follow-up.

Asunto(s)

Puente de Arteria Coronaria , Endoscopía , Vena Safena , Recolección de Tejidos y Órganos , Humanos , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/mortalidad , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Vena Safena/trasplante , Endoscopía/métodos , Recolección de Tejidos y Órganos/métodos , Anciano , Enfermedad de la Arteria Coronaria/cirugía , Resultado del Tratamiento , Puntaje de Propensión

RESUMEN

OBJECTIVES: Regional disparities in cardiovascular care in Korea have led to uneven patient outcomes. Despite the growing need for and access to procedures, few studies have linked regional service availability to mortality rates. This study analyzed regional variation in the utilization of major cardiovascular procedures and their associations with short-term mortality to provide better evidence regarding the relationship between healthcare resource distribution and patient survival. METHODS: A cross-sectional study was conducted using nationwide claims data for patients who underwent coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), stent insertion, or aortic aneurysm resection in 2022. Regional variation was assessed by the relevance index (RI). The associations between the regional RI and 30-day mortality were analyzed. RESULTS: The RI was lowest for aortic aneurysm resection (mean, 26.2; standard deviation, 26.1), indicating the most uneven regional distribution among the surgical procedures. Patients undergoing this procedure in regions with higher RIs showed significantly lower 30-day mortality (adjusted odds ratio [aOR], 0.73; 95% confidence interval, 0.55 to 0.96; p=0.026) versus those with lower RIs. This suggests that cardiovascular surgery regional availability, as measured by RI, has an impact on mortality rates for certain complex surgical procedures. The RI was not associated with significant mortality differences for more widely available procedures like CABG (aOR, 0.96), PCI (aOR, 1.00), or stent insertion (aOR, 0.91). CONCLUSIONS: Significant regional variation and underutilization of cardiovascular surgery were found, with reduced access linked to worse mortality for complex procedures. Disparities should be addressed through collaboration among hospitals and policy efforts to improve outcomes.

Asunto(s)

Puente de Arteria Coronaria , Disparidades en Atención de Salud , Humanos , Estudios Transversales , República de Corea/epidemiología , Masculino , Femenino , Anciano , Persona de Mediana Edad , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/tendencias , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Puente de Arteria Coronaria/tendencias , Intervención Coronaria Percutánea/estadística & datos numéricos , Intervención Coronaria Percutánea/mortalidad , Procedimientos Quirúrgicos Cardiovasculares/estadística & datos numéricos , Procedimientos Quirúrgicos Cardiovasculares/mortalidad , Procedimientos Quirúrgicos Cardiovasculares/tendencias , Oportunidad Relativa

RESUMEN

Importance: Concern has been raised about persistent sex disparities after coronary artery bypass grafting, with female patients having higher mortality. However, whether these disparities persist across hospitals of different qualities is unknown. Objective: To evaluate sex disparities in 30-day mortality after coronary artery bypass grafting across high- and low-quality hospitals. Design, Setting, and Participants: This cross-sectional, retrospective cohort study evaluated Medicare beneficiaries undergoing coronary artery bypass grafting between October 1, 2015, and March 31, 2020. Data analysis was performed from July 1, 2023, to December 1, 2023. Exposures: The primary exposures were hospital quality and sex. For hospital quality, hospitals were placed into rank order by their overall risk-adjusted mortality rate and divided into quintiles. Main Outcome and Measures: Risk-adjusted 30-day mortality using a logistic regression model accounting for patient factors, including sex, age, comorbidities, elective vs unplanned admission, number of bypass grafts, use of arterial graft, and year of surgery. Results: A total of 444 855 beneficiaries (mean [SD] age, 71.5 [7.5] years; 120 333 [27.1%] female and 324 522 [72.9%] male) were studied. Compared with male beneficiaries, female beneficiaries were more likely to have an unplanned admission (66 425 [55.2%] vs 157 895 [48.7%], P < .001) and receive care at low-quality (vs high-quality) hospitals (odds ratio, 1.26; 95% CI, 1.23-1.29; P < .001). Overall, risk-adjusted female mortality was 4.24% (95% CI, 4.20%-4.27%), and male mortality was 2.75% (95% CI, 2.75%-2.77%), with an absolute difference of 1.48 (95% CI, 1.45-1.51) percentage points (P < .001). At the highest-quality hospitals, male mortality was 1.57% (95% CI, 1.56%-1.59%), and female mortality was 2.58% (95% CI, 2.54%-2.62%), with an absolute difference of 1.01 (95% CI, 0.97-1.04) percentage points (P < .001). At the lowest-quality hospitals, male mortality was 4.94% (95% CI, 4.88%-5.01%), and female mortality was 7.02% (95% CI, 6.90%-7.13%), with an absolute difference of 2.07 (95% CI, 1.95-2.19) percentage points (P < .001). Female beneficiaries receiving care at low-quality hospitals had a higher mortality than male beneficiaries receiving care at the high-quality hospitals (7.02% vs 1.57%, P < .001). Conclusions and Relevance: In this cohort study of Medicare beneficiaries undergoing coronary artery bypass grafting, female beneficiaries were more likely to receive care at low-quality hospitals, where the sex disparity in mortality was double that of high-quality hospitals. Quality improvement targeting low-quality hospitals as well as equitable referral of female beneficiaries to higher-quality hospitals may narrow the sex disparity after coronary artery bypass grafting.

Asunto(s)

Puente de Arteria Coronaria , Disparidades en Atención de Salud , Hospitales , Medicare , Calidad de la Atención de Salud , Humanos , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Masculino , Anciano , Estudios Transversales , Estudios Retrospectivos , Estados Unidos/epidemiología , Hospitales/estadística & datos numéricos , Hospitales/normas , Disparidades en Atención de Salud/estadística & datos numéricos , Medicare/estadística & datos numéricos , Calidad de la Atención de Salud/estadística & datos numéricos , Calidad de la Atención de Salud/normas , Factores Sexuales , Mortalidad Hospitalaria , Anciano de 80 o más Años

RESUMEN

BACKGROUND: The internal thoracic artery (ITA) is the most important conduit for coronary artery bypass grafting. Recent evidence suggests that skeletonized ITA harvesting yields long-term outcomes inferior to those of pedicled harvesting. The aim was to investigate the impact of the ITA harvesting method on 10-year mortality and major adverse cardiovascular events. METHODS AND RESULTS: In this observational cohort study, we identified all patients from the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) register who underwent isolated coronary artery bypass grafting using at least 1 ITA at Karolinska University Hospital from 2012 to 2021. The main outcome was all-cause mortality, and the secondary outcomes were a combination of myocardial infarction, repeat revascularization, heart failure, and stroke. Outcomes were ascertained using national health data registers and compared between the skeletonized and pedicled groups using weighted flexible parametric survival models. Among 3267 patients, 1657 (51%) underwent pedicled ITA harvesting and 1610 (49%) underwent skeletonized ITA harvesting. The patients' mean age was 66 years, and 15% were women. The weighted all-cause mortality incidence rate in the pedicled versus skeletonized ITA group was 2.6% (95CI, 2.2%-3.0%) versus 2.6% (95% CI, 2.2%-3.1%), respectively (hazard ratio (HR), 1.01 [95% CI, 0.81-1.27]). The weighted major adverse cardiovascular events incidence rate was 7.8% (95% CI, 7.1%-8.6%) versus 7.5% (95% CI, 6.7%-8.4%), respectively (HR, 0.94 [95% CI, 0.82-1.08]). CONCLUSIONS: We found no significant differences in all-cause mortality or major adverse cardiovascular events rates between the 2 ITA harvesting methods.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Arterias Mamarias , Recolección de Tejidos y Órganos , Humanos , Femenino , Masculino , Anciano , Arterias Mamarias/trasplante , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Persona de Mediana Edad , Recolección de Tejidos y Órganos/métodos , Recolección de Tejidos y Órganos/efectos adversos , Resultado del Tratamiento , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Suecia/epidemiología , Factores de Tiempo , Sistema de Registros , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Factores de Riesgo

RESUMEN

INTRODUCTION: We sought to explore the relationship between various surgeon-related and hospital-level characteristics and clinical outcomes among patients requiring cardiac surgery. METHODS: We searched the New York State Cardiac Data Reporting System for all coronary artery bypass grafting (CABG) and valve cases between 2015 and 2017. The data were analyzed without dichotomization. RESULTS: Among CABG/valve surgeons, case volume was positively correlated with years in practice (P = 0.002) and negatively correlated with risk-adjusted mortality ratio (P = 0.014). For CABG and CABG/valve surgeons, our results showed a negative association between teaching status and case volume (P = 0.002, P = 0.018). Among CABG surgeons, hospital teaching status and presence of cardiothoracic surgery residency were inversely associated with risk-adjusted mortality ratio (P = 0.006, P = 0.029). CONCLUSIONS: There is a complex relationship between case volume, teaching status, and surgical outcomes suggesting that balance between academics and volume is needed.

Asunto(s)

Puente de Arteria Coronaria , Bases de Datos Factuales , Cirujanos , Humanos , New York/epidemiología , Bases de Datos Factuales/estadística & datos numéricos , Puente de Arteria Coronaria/estadística & datos numéricos , Puente de Arteria Coronaria/mortalidad , Cirujanos/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad , Hospitales de Alto Volumen/estadística & datos numéricos , Anciano , Hospitales de Bajo Volumen/estadística & datos numéricos , Mortalidad Hospitalaria , Internado y Residencia/estadística & datos numéricos , Hospitales de Enseñanza/estadística & datos numéricos , Hospitales/estadística & datos numéricos , Resultado del Tratamiento

Asunto(s)

Biomarcadores , Puente de Arteria Coronaria , Hemodinámica , Humanos , Biomarcadores/sangre , Puente de Arteria Coronaria/mortalidad , Puente de Arteria Coronaria/efectos adversos , Hemodinámica/fisiología , Valor Predictivo de las Pruebas , Pronóstico

RESUMEN

There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78-0.95), 0.88 (0.80-0.97), 0.88 (0.80-0.97), and 0.87(0.85-0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.

Asunto(s)

Puente de Arteria Coronaria Off-Pump , Humanos , Masculino , Puente de Arteria Coronaria Off-Pump/efectos adversos , Puente de Arteria Coronaria Off-Pump/mortalidad , Femenino , Persona de Mediana Edad , Anciano , Funciones de Verosimilitud , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/mortalidad , Irán/epidemiología , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Resultado del Tratamiento , Puntaje de Propensión , Puente Cardiopulmonar/efectos adversos