Ammar S. Bafi

Stroke After Coronary Artery Bypass: Incidence, Predictors, and Clinical Outcome

Background and Purpose— Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG. Methods— We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis. Results— Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P <0.001), (2) recent myocardial infarction (P =0.01), (3) previous cerebrovascular accident (P <0.001), (4) carotid artery disease (P <0.001), (5) hypertension (P <0.001), (6) diabetes (P =0.001), (7) age >75 years (P =0.008), (8) moderate/severe left ventricular dysfunction (P =0.01), (9) low cardiac output syndrome (P <0.001), and (10) atrial fibrillation (P <0.001). Postoperative stroke was associated with longer postoperative stay (11±4 versus 7±3 days for patients without stroke, P <0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke;P <0.001). Conclusions— Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.

Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?

Background— Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Methods and Results— Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different. Conclusions— Clopidogrel administration in the cardiology suite increases the risk for hemostatic reoperation and the requirements for blood product transfusions during and after off-pump coronary artery bypass graft surgery.

Stroke after conventional versus minimally invasive coronary artery bypass

BACKGROUND Postoperative stroke is a serious complication after coronary artery bypass grafting with cardiopulmonary bypass (on-pump), and portends higher morbidity and mortality. It is unknown whether an off-pump cardiopulmonary bypass (OPCAB) approach may yield a lower stroke rate over conventional on-pump coronary artery bypass grafting. METHODS From June 1994 to December 2000, OPCAB was performed in 2,320 patients and compared with 8,069 patients who had on-pump coronary artery bypass grafting, during the same period of time. The patients undergoing OPCAB were randomly matched to on-pump patients by propensity score. A logistic regression model was used to test the difference in the postoperative stroke rate between OPCAB and on-pump procedures controlling for the correlation between matched sets. A multiple logistic regression model predicting the risk of stroke adjusted by stroke risk factors and operation type was also computed. RESULTS Matches by propensity score were found for 72% of the patients undergoing OPCAB. Patients undergoing on-pump coronary artery bypass grafting were 1.8 (95% confidence interval 1.0 to 3.1, p = 0.03) times more likely to suffer a stroke postoperatively than OPCAB patients after controlling for preoperative risk factors through matching. Independent predictors of stroke identified from the multiple logistic model included on-pump operation (versus OPCAB operation), female gender, 4 to 6 vessels grafted (versus <4 grafts), hypertension, history of previous cerebrovascular accident, carotid artery disease, chronic obstructive pulmonary disease, and depressed ejection fraction. CONCLUSIONS Off-pump cardiopulmonary bypass avoids the risks of cardiopulmonary bypass and atrial trauma. A substantially lower stroke rate suggests that OPCAB is a neurologically safe treatment option for revascularization.

Atrial Fibrillation After Beating Heart Surgery

Postoperative atrial fibrillation (AF) is a frequent adverse event after coronary artery bypass grafting (CABG) and may negatively affect the early clinical outcome. We sought to investigate the risk factors, prevalence, and prognostic implications of postoperative AF in patients submitted to CABG without cardiopulmonary bypass (off-pump). The study population comprised 969 patients, 645 men (67%) and 324 women (33%) who had off-pump CABG at the Washington Hospital Center from January 1987 to May 1999. Preoperative AF patients were excluded (n = 15). Two hundred six patients (age 69 +/- 10 years, 137 men [66%]) developed AF, whereas 763 patients (age 61 +/- 12 years, 508 men [67%]) did not. Predictors of AF included age >75 years (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.9 to 4.5; p <0.001), history of stroke (OR 2.1, CI 1.2 to 3.7; p = 0. 007), postoperative pleural effusion requiring thoracentesis (OR 3.2, CI 1.0 to 9.4; p = 0.03), and postoperative pulmonary edema (OR 5.1, CI 1.2 to 21; p = 0.02). Minimally invasive direct CABG was associated with a lower incidence of AF (OR 0.4, CI 0.3 to 0.7; p <0. 001). AF was associated with a prolonged postoperative hospital stay (9 +/- 6 days AF vs 6 +/- 5 days no AF, p <0.001). In-hospital mortality was significantly higher in AF patients (3% AF vs 1% no AF, p = 0.009). Patients with persistent AF had a higher postoperative in-hospital stroke rate than patients without persistent AF (9% vs 0. 6%, p <0.001). AF after beating heart surgery is associated with a higher in-hospital morbidity, mortality, and prolonged hospital stay. A minimally invasive surgical approach (minimally invasive direct CABG) is associated with a lower risk of AF.

Beating heart surgery in octogenarians: perioperative outcome and comparison with younger age groups ☆

BACKGROUND Octogenarians have higher morbidity and mortality rates (9% to 16%) after coronary artery bypass grafting with cardiopulmonary bypass, compared with younger patients. METHODS We compared the perioperative outcome and hospital stay after coronary artery bypass grafting without cardiopulmonary bypass (off-pump) from January 1987 to May 1999, among patients older than 80 years (n = 71), patients between 70 and 79 years (n = 228), and patients whose age ranged from 60 to 69 years (n = 296). In comparison with younger patients, more octogenarians were female (51% versus 39% in patients aged 70 to 79 years and 35% in those aged 60 to 69 years, p = 0.04), they had previous myocardial infarction more frequently (48% versus 47% versus 34%, respectively, p = 0.008), and were operated on urgently (69% versus 56% versus 52%, respectively, p = 0.04). RESULTS Postoperative complications that were significantly higher in octogenarians compared with younger groups included pneumonia (6% in octogenarians versus 2% in patients aged 70 to 79 years and 0% in patients aged 60 to 69 years, p = 0.001) and atrial fibrillation (47% versus 32% versus 21%, respectively, p<0.001). By multivariate logistic regression analysis, age over 80 years was an independent predictor of prolonged hospital stay (odds ratio = 2.7, 95% confidence interval, 1.4 to 5, p<0.001). The in-hospital mortality rate was higher in octogenarians (6% versus 3% for 70 to 79 year-olds and 0.3% for 60 to 69 year-olds, p = 0.006). CONCLUSIONS When appropriately applied in patients older than 80 years, off-pump coronary artery bypass grafting can be done with acceptable postoperative morbidity, mortality, and hospital stay.

Beating heart versus conventional single-vessel reoperative coronary artery bypass

BACKGROUND Reoperative (redo) coronary artery bypass grafting (CABG) with cardiopulmonary bypass (on-pump) is associated with a higher morbidity and mortality than first-time CABG. It is unknown, however, whether CABG without cardiopulmonary bypass (off-pump) may yield an improved clinical outcome over conventional on-pump redo CABG. METHODS We compared the perioperative outcomes of patients with single-vessel disease who underwent on-pump (n = 41) versus off-pump (n = 91) redo CABG between April 1992 and July 1999. The two groups were similar with respect to baseline characteristics and risk stratification: mean Parsonnet scores were 26 +/- 9 for on-pump versus 24 +/- 8 for off-pump patients (p = nonsignificant). RESULTS On-pump redo patients had a higher rate of postoperative transfusions (58% on-pump versus 27% off-pump, p = 0.001), prolonged ventilatory support (17% on-pump versus 4% off-pump, p = 0.03), and a higher rate of postoperative atrial fibrillation (29% on-pump versus 14% off-pump, p = 0.04). On-pump redo CABG was also associated with prolonged postoperative length of stay (8 +/- 4 days on-pump versus 5 +/- 2 days off-pump, p < 0.001). In-hospital mortality was significantly higher in on-pump than in off-pump patients (10% versus 1%, p = 0.03). CONCLUSIONS Single-vessel off-pump redo CABG can be performed safely with a lower operative morbidity and mortality than on-pump CABG and an abbreviated hospital stay compared with conventional on-pump redo CABG.

Stroke After Coronary Artery Bypass

Background and Purpose— Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG. Methods— We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis. Results— Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P <0.001), (2) recent myocardial infarction (P =0.01), (3) previous cerebrovascular accident (P <0.001), (4) carotid artery disease (P <0.001), (5) hypertension (P <0.001), (6) diabetes (P =0.001), (7) age >75 years (P =0.008), (8) moderate/severe left ventricular dysfunction (P =0.01), (9) low cardiac output syndrome (P <0.001), and (10) atrial fibrillation (P <0.001). Postoperative stroke was associated with longer postoperative stay (11±4 versus 7±3 days for patients without stroke, P <0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke;P <0.001). Conclusions— Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.

Patients With Severe Asymptomatic Carotid Artery Stenosis Do Not Have a Higher Risk of Stroke and Mortality After Coronary Artery Bypass Surgery

Background and Purpose— Stroke development is a major concern in patients undergoing coronary artery bypass grafting (CABG). Whether asymptomatic severe carotid artery stenosis (CAS) contributes to the development of stroke and mortality in such patients remains uncertain. Methods— A retrospective analysis of 878 consecutive patients with documented carotid duplex ultrasound who underwent isolated CABG in our institution from January 2003 to December 2009 was performed. Patients with severe CAS (n=117) were compared with those without severe CAS (n=761) to assess the rates of stroke and mortality during hospitalization for CABG. The 30-day mortality rate was also assessed. Results— Patients with severe CAS were older and had a higher prevalence of peripheral arterial disease and heart failure. Patients with severe CAS had similar rates of in-hospital stroke (3.4% versus 3.6%; P=1.0) and mortality (3.4% versus 4.2%; P=1.0) compared with patients without severe CAS. The 30-day rate of mortality was also similar between the 2 cohorts (3.4% versus 2.9%; P=0.51). Conclusions— Severe CAS alone is not a risk factor for stroke or mortality in patients undergoing CABG. The decision to perform carotid imaging and subsequent revascularization in association with CABG must be individualized and based on clinical judgment.

Stroke After Coronary Artery Bypass : Incidence, Predictors, and Clinical Outcome Editorial Comment: Incidence, Predictors, and Clinical Outcome

Background and Purpose— Early postoperative stroke is a serious adverse event after coronary artery bypass grafting (CABG). This study sought to investigate risk factors, prevalence, and prognostic implications of postoperative stroke in patients undergoing CABG. Methods— We investigated the predictors of postoperative stroke (n=333, 2%) in 16 528 consecutive patients who underwent CABG between September 1989 and June 1999 in our institution. Predictors of postoperative stroke were identified by logistic regression analysis. Results— Among the preoperative and postoperative factors, significant correlates of stroke included (1) chronic renal insufficiency (P <0.001), (2) recent myocardial infarction (P =0.01), (3) previous cerebrovascular accident (P <0.001), (4) carotid artery disease (P <0.001), (5) hypertension (P <0.001), (6) diabetes (P =0.001), (7) age >75 years (P =0.008), (8) moderate/severe left ventricular dysfunction (P =0.01), (9) low cardiac output syndrome (P <0.001), and (10) atrial fibrillation (P <0.001). Postoperative stroke was associated with longer postoperative stay (11±4 versus 7±3 days for patients without stroke, P <0.001) and with higher in-hospital mortality (14% versus 2.7% for patients without stroke;P <0.001). Conclusions— Stroke after CABG is associated with high short-term morbidity and mortality. Increased stroke risk can be predicted by preoperative and postoperative clinical factors.

Is Cardiac Surgery Safe in Extremely Obese Patients (Body Mass Index 50 or Greater)

BACKGROUND We investigated the impact of extreme obesity (body mass index [kg/m(2)] 50 or greater) on short-term clinical outcomes and report 1-year mortality. METHODS Fifty-seven patients were found to have a body mass index of 50 or greater among 14,449 patients who underwent cardiac surgery between July 2000 and June 2007. Multivariable logistic regression analyses were used to assess the independent influence of extreme obesity on the major outcomes. RESULTS Of the 57 patients, the mean age was 58 +/- 11 years, mean body mass index was 55.1, and 63% of the patients were women. Forty patients underwent elective surgery. Forty-one patients had isolated coronary artery bypass graft surgery. The overall operative mortality was 9%; the mortality was 5% in isolated coronary artery bypass graft surgery and 5% in elective surgery. Fifteen patients had nonelective isolated coronary artery bypass graft surgery, and 2 patients had emergent active endocarditis surgery. Off-pump coronary artery bypass graft surgery was performed on 23 patients (23 of 41, 54%). After adjusting for known preoperative and operative risk factors through a multivariate logistic model, extreme obesity did not emerge as a significant risk factor for operative mortality (odds ratio, 1.75; p = 0.47) and other adverse outcomes (p > 0.05) after elective surgery; however, extreme obesity was marginally associated with increased mortality (odds ratio, 2.69; p = 0.05) and was a risk predictor for longer intensive care unit stays (odds ratio, 2.43; p = 0.01) in overall surgery. The 1-year survival rate was 82.5%. CONCLUSIONS Extreme obesity is not a contraindication to elective cardiac surgery. Studies stratifying the risk factors of mortality for nonelective surgery in extremely obese patients may be warranted.