Faculty Bibliography

BACKGROUND: We present the first prospective randomized study of primary coronary artery bypass grafting (CABG) patients who were analyzed for postoperative infections after undergoing blood and/or blood product transfusion (BBPT) with a Pall Purecell leukoreducing filter. METHODS AND RESULTS: One hundred and four patients were enrolled between March 1998 and March 1999. Seventy-two of the patients received BBPT (average 5.6 units BBPT/filter patient and 5.6 units/control patient). Three patients who had CABG without extracorporeal circulation or mixed transfusions of filtered and unfiltered BBPT were excluded. The remaining 69 transfused patients (38 filtered, 31 control) were analyzed and the incidence of culture proven infections was recorded. Mid-term survival data were obtained from the National Death Index and Kaplan-Meier survival plots were constructed. All patients were stratified and matched according to the EuroSCORE.Thirty-day mortality was 2.6% and 3.2% for the filtered and control patients, respectively. There were 5 cases of culture proven infections in 38 filtered patients (13.2%) and 8 in 31 controls (25.8%), P = 0.224. No pulmonary tract infections were recorded in the filter group vs. 4 (12.9%) in controls, P = 0.048. Reduced length for mechanical ventilation (16.3 hours vs. 57.8, P = 0.103), length of stay (9.1 vs. 10.8 days, P = 0.685), as well as increased 50-month actuarial survival, (45.5 vs. 42.3 months, P=0.695) in filtered vs. control, respectively, were recorded. CONCLUSIONS: The use of leukoreduced BBPT reduced the incidence of pulmonary tract infections in patients undergoing CABG.

We sought to determine risk factors for sepsis and/or endocarditis (S/E) and to identify their impact on long-term survival after coronary artery bypass grafting (CABG). We studied 3760 consecutive patients who underwent isolated CABG from 1992 to 2002. Patients with CABG without S/E were compared with those who developed S/E. Long-term survival data (mean follow-up 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for S/E was determined by logistic regression analysis and each patient with S/E was matched to one patient without S/E. Thirty-six patients (0.96%) developed S/E. Independent predictors for S/E were increased age (odds ratio [OR] 1.05 per year, 95% Confidence interval [95% CI] 1.00-1.09; p = 0.040) and the development of other major complications after CABG such as deep sternal wound infection (OR 30.80, 95% CI 9.50-99.82; p < 0.001), gastrointestinal complications (OR 19.48, 95% CI 7.14-53.18; p < 0.001), renal failure (OR 15.18, 95% CI 4.42-52.06; p < 0.001), intraoperative stroke (OR 13.11, 95% CI 4.81-35.69; p < 0.001) and respiratory failure (OR 12.95, 95% CI 5.69-29.45; p < 0.001). After adjustment for pre-, intra- and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with S/E was 3.33 (95% CI 2.17-5.10; p < 0.001). There was no difference in 30-day mortality between matched groups (25.0% vs. 19.4% in patients without S/E, p = 0.778), however patients without S/E had better 5-year survival rate (52.7 +/- 8.7% vs. 16.2 +/- 6.2%; p = 0.0004). We have identified risk factors for S/E following CABG and we found that there was increased mortality in patients with S/E during a 10-year follow-up period.

OBJECTIVE: We aimed to develop multivariable models of preoperative risk factors that predict long-term survival after coronary artery bypass grafting in patients with ejection fraction 25% or less. METHODS: We retrospectively evaluated 544 consecutive patients with ejection fraction 25% or less who underwent coronary artery bypass grafting from 1992 to 2002 at a single institution. Long-term survival data (mean follow-up 4.1 years) were obtained from the National Death Index. Multivariable Cox regression analysis was performed to construct a predictive score for long-term mortality. A split-sample approach was also used building a model on a training group (n = 360); this model was then tested on a separate validation group (n = 184). RESULTS: From the entire database, the predictive score was calculated according to the following equation: 0.430(if past congestive heart failure) + 0.049(age in years) + 0.507(if peripheral vascular disease) + 0.580(if emergency operation) + 0.366(if chronic obstructive pulmonary disease). The 5-year survivals of the predictive score quartiles were 82.3%, 78.2%, 65.5%, and 45.5% (P < .0001). The model based on the training group had four independent predictors for long-term mortality (the same as the listed equation except for past congestive heart failure). The 5-year survival rates of the quartiles were 90.1%, 75.4%, 64.3%, and 49.2% in the training group (P < .0001) and 77.4%, 71.2%, 65.8%, and 45.5% in the validation group (P = .0001). CONCLUSION: Coronary artery bypass grafting in patients with severe ischemic cardiomyopathy achieves satisfactory midterm and long-term survival in selected patients. This new score, which is based on long-term data from a large number of patients, may aid clinicians in selecting therapeutic interventions for patients with ischemic cardiomyopathy.

OBJECTIVES: To identify the impact of deep sternal wound infection (DSWI) on long-term survival after coronary artery bypass grafting (CABG). BACKGROUND: DSWI following CABG is an infrequent, yet devastating complication with increased morbidity and mortality. However, little has been published regarding the impact of DSWI on long-term mortality. METHODS: We studied 3,760 consecutive patients who underwent isolated CABG between 1992 and 2002. Patients with CABG and no DSWI were compared with those in whom DSWI developed. Long-term survival data (mean follow-up, 5.2 years) were obtained from the National Death Index. Groups were compared by Cox proportional hazard models and Kaplan-Meier survival plots. The propensity for DSWI was determined by logistic regression analysis, and each patient with DSWI was then matched to 10 patients without DSWI. RESULTS: DSWI developed in 40 of 3,760 patients (1.1%). Independent predictors for DSWI were diabetes (odds ratio [OR], 5.5; 95% confidence interval [CI], 2.7 to 11.6; p < 0.001), hemodynamic instability preoperatively (OR, 4.0; 95% CI, 1.2 to 13.9; p = 0.026), preoperative renal failure on dialysis (OR, 3.4; 95% CI, 1.0 to 13.6; p = 0.049), use of bilateral internal thoracic arteries (OR, 2.6; 95% CI, 1.3 to 5.3; p = 0.010), and sepsis and/or endocarditis after CABG (OR, 29.9; 95% CI, 11.7 to 76.4; p < 0.001). Patients with DSWI had prolonged length of stay (35.0 days vs 16.4 days; p < 0.001); however, there was no difference in early mortality between matched groups. After adjustment for preoperative, intraoperative, and postoperative factors, the adjusted hazard ratio of long-term mortality for patients with DSWI was 2.44 (95% CI, 1.51 to 3.92; p < 0.001). Patients without DSWI had a better 5-year survival rate (72.8 +/- 2.4% vs 50.8.6 +/- 8.5% [mean +/- SE]; p = 0.0007 between matched groups). CONCLUSIONS: We found that DSWI following CABG was associated with increased long-term mortality during a 10-year follow-up study.

OBJECTIVE: To evaluate the performance of EuroSCORE in the prediction of in-hospital postoperative length of stay and specific major postoperative complications after cardiac surgery. METHODS: Data on 5051 consecutive patients (isolated [74.4%] or combined coronary artery bypass grafting [11.1%], valve surgery [12.0%] and thoracic aortic surgery [2.5%]) were prospectively collected. The EuroSCORE model (standard and logistic) was used to predict in-hospital mortality, 3-month mortality, prolonged length of stay (>12 days) and major postoperative complications (intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, re-exploration for bleeding, sepsis and/or endocarditis, gastrointestinal complications, postoperative renal failure and respiratory failure). A C statistic (or the area under the receiver operating characteristic curve) was used to test the discrimination of the EuroSCORE. The calibration of the model was assessed by the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: In-hospital mortality was 3.9% and 16.1% of patients had one or more major complications. Standard EuroSCORE showed very good discriminatory ability and good calibration in predicting in-hospital mortality (C statistic: 0.76, Hosmer-Lemeshow: P=0.449) and postoperative renal failure (C statistic: 0.79, Hosmer-Lemeshow: P=0.089) and good discriminatory ability in predicting sepsis and/or endocarditis (C statistic: 0.74, Hosmer-Lemeshow: P=0.653), 3-month mortality (C statistic: 0.73, Hosmer-Lemeshow: P=0.097), prolonged length of stay (C statistic: 0.71, Hosmer-Lemeshow: P=0.051) and respiratory failure (C statistic: 0.71, Hosmer-Lemeshow: P=0.714). There were no differences in terms of the discriminatory ability in predicting these outcomes between standard and logistic EuroSCORE. However, logistic EuroSCORE showed no calibration (Hosmer-Lemeshow: P<0.05) except for sepsis and/or endocarditis (Hosmer-Lemeshow: P=0.078). EuroSCORE was unable to predict other major complications such as intraoperative stroke, stroke over 24 h, postoperative myocardial infarction, deep sternal wound infection, gastrointestinal complications and re-exploration for bleeding. CONCLUSIONS: EuroSCORE can be used to predict not only in-hospital mortality, for which it was originally designed, but also 3-month mortality, prolonged length of stay and specific postoperative complications such as renal failure, sepsis and/or endocarditis and respiratory failure in the whole context of cardiac surgery. These outcomes can be predicted accurately using the standard EuroSCORE which is very simple and easy in its calculation.

BACKGROUND: We examined whether bilateral internal thoracic artery revascularization (BITA) is safe for reoperative coronary revascularization (reop CABG) or primary CABG at age > or = 80 (CABG > or = 80 yrs) as, these two groups are thought to be at higher risk for death or sternal infection. METHODS: We analyzed 329 such patients between January 1, 1993 and March 31, 2002. These are subgroups of 3200 prospectively New York State risk stratified patients for BITA or SITA (single internal thoracic artery revascularization) of equivalent preoperative risk. In 37/39, BITA > or = 80 since 1996 (1996 > or = 80) the microscope was used and the free right internal thoracic artery was anastomosed to the aorta. Long-term survival was analyzed by Kaplan-Meier curves and in particular among the 36 patients between 1996 and 1997, who were operated five and six years ago (1997 > or = 80). CONCLUSIONS: Mortality and recuperative difference of BITA versus SITA in the reop CABG and CABG > or = 80 years are negligible, as there was no significant difference in hospital mortality, sternal infections, LOS, or Kaplan-Meier survival curves and average long-term survival. However BITA appears to have long-term advantage over SITA in the newer period and beyond 48 months (1996-1997 > or = 80).