Gunnar Brandrup-Wognsen

Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women

Abstract. Herlitz J, Brandrup‐Wognsen G, Karlson BW, Sjöland H, Karlsson T, Caidahl K, Hartford M, Haglid M (Sahlgrenska University Hospital, Göteborg, Sweden). Mortality, risk indicators of death, mode of death and symptoms of angina pectoris during 5 years after coronary artery bypass grafting in men and women. J Intern Med 2000; 247: 500–506.

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: early and late results.

AIM To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone. PATIENTS AND METHODS All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988-1991. RESULTS Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%). The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P < 0.0001 and P = 0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG. CONCLUSION Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.

Difficulties in the interpretation of coronary angiogram early after coronary artery bypass surgery on the beating heart

OBJECTIVE The major objective of this study was to evaluate the findings in early postoperative coronary angiography in patients who underwent coronary revascularization on the beating heart without cardiopulmonary bypass. METHODS Eighty-four consecutive patients receiving 113 grafts were studied. A coronary angiography was performed 0 to 5 days postoperatively. All the grafts were reviewed and classified in the following way: grade A (unimpaired run-off); grade B1 (<50 stenosis); grade B2 (>50% stenosis); grade O (occlusion). A second coronary angiography was performed in patients with a stenosis grade B2, 4 to 30 months postoperatively. An exercise test was performed by patients with B1 stenosis. RESULTS Overall graft patency was 96% in the 113 grafts. None of the 14 patients with B1 stenosis in the early coronary angiography had any clinical signs of ischemia. Eight of the 12 patients who exhibited B2 stenosis either at the anastomotic site, in the graft or in the distal coronary artery at the first coronary angiography had a normal angiogram at the re-angiography. CONCLUSION A majority of stenoses visualized at the early coronary angiography could not be seen at a later coronary angiography, which makes the interpretation of the angiogram unreliable as a tool for the decision as to redo-procedure in the early postoperative period.

Long term prognosis after CABG in relation to preoperative left ventricular ejection fraction

AIM To evaluate the mortality rate, risk indicators for death, mode of death and symptoms of angina pectoris during 5 years after coronary artery by pass grafting (CABG) in relation to the preoperative left ventricular ejection fraction (LVEF). PATIENTS All patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991. RESULTS In all 1904 patients were included in the analysis, of whom 173 (9%) had a LVEF < 40%. Patients with LVEF > or = 40% had a 5-year mortality of 12.5%. LVEF < 40% was associated with an increased risk of death (RR 2.3; 95% cl 1.7-3.1). There was no significant interaction between age, sex or any other factor in terms of clinical history and LVEF. However, left main stenosis was a strong independent predictor of death among patients with LVEF < 40% but not in those with a higher LVEF. Patients with a low LVEF more frequently died a cardiac death and a death associated with myocardial infarction (AMI). Furthermore they more frequently died in association with congestive heart failure and ventricular fibrillation. Among survivors, symptoms of angina pectoris were similar regardless of the preoperative LVEF. CONCLUSION Patients with a low preoperative LVEF have a more than two-fold increased risk of death during 5 years after CABG. Their increased risk of death includes cardiac death, death associated with AMI, congestive heart failure and ventricular fibrillation.

Predictors of Death and Other Cardiac Events within 2 Years after Coronary Artery Bypass Grafting

Results: In 1,841 patients who underwent coronary artery bypass grafting (CABG) we evaluated risk indicators for death and other cardiac events during 2 years of follow-up. Independent predictors of death were: a history of congestive heart failure, diabetes mellitus and renal dysfunction prior to CABG. Independent predictors of death, acute myocardial infarction (AMI), CABG or percutaneous transluminal coronary angioplasty (PTCA) were: a small body surface area, a history of congestive heart failure, diabetes mellitus and smoking prior to CABG. Independent predictors of death, AMI, CABG, PTCA or rehospitalization for a cardiac reason were: angina functional class, previous AMI, a history of congestive heart failure and renal dysfunction prior to CABG. Conclusion: When using various definitions of a cardiac event after CABG, various risk indicators for death or such an event can be found. Our data suggest that anamnestic information prior to CABG indicating a depressed myocardial function or severe myocardial ischemia are more important predictors of outcome than the information gained from cardioangiography.

Predictors of death during 5 years after coronary artery bypass grafting

AIM To describe predictors of death during five years of follow-up after coronary artery bypass grafting (CABG). METHODS All patients who underwent CABG during a period of three years in Western Sweden were included in the analysis and were prospectively followed for five years. Mortality was related to preoperative and peroperative factors as well as findings at physical examination and medication 4-7 days after the operation. RESULTS In all 2121 patients underwent CABG without simultaneous valve surgery during the study period. The overall five-year mortality was 14.6%. The following appeared as independent predictors of death during five years but >30 days after CABG: Current smoking (relative risk ratio 2.43 [95% Ci 1.64-3.61]) degree of impairment of left ventricular function (1.51 [1.23-1.86]), a history of congestive heart failure (1.91 [1.35-2.701), age (1.04 [1.02-1.06]) arrhythmia 4-7 days after CABG (1.89 [1.26-2.83]), intermittent claudication (1.73 [1.19-2.52]), a history of diabetes (1.71 [1.16-2.51]), time in respirator (1.43 [1.13-1.81]), a history of cerebrovascular disease (1.72 [1.13-2.64]), treatment with digitalis at day 4-7 (1.48 [1.07-2.05]), enzyme release (1.49 [1.03-2.16]). CONCLUSION Among patients who underwent CABG 11 independent predictors for mortality were found including smoking habits at CABG, history of cardiovascular diseases, left ventricular dysfunction, age, post operative complications and medication after CABG.

Mortality during the two years after coronary artery bypass grafting in relation to perioperative factors and urgency of operation.

The purpose of this study was to describe mortality during the 2-year-period after coronary artery bypass surgery (CABG) in relation to perioperative risk factors and urgency of operation. All the patients in western Sweden were included in whom CABG was performed between June 1988 and June 1991, without concomitant procedures or re-operations. The study was prospective in design. In all, 2000 patients were operated upon and 186 (9.3%) of the operations were acute. There was a significant relationship between the urgency of the operation and mortality. Early mortality was 2.4% in elective operations and 5.4-62.5% in urgent to emergency operations. The 30-day to 2-year mortality was 4.2%. The perioperative risk indicators independently associated with early mortality were neurologic complications, serum-aspartate aminotransferase (S-ASAT) more than 2.0 microkat/l, urgency of operation, the use of circulatory assist devices, re-operation and ventilator time more than 24 h. The risk indicators for mortality after 30 days were pneumothorax, longer intensive care unit (ICU) time, the use of inotropic drugs and neurologic complications. In conclusion, the multivariate analysis reveals the urgency of the operation as a predictor of early mortality after CABG, but no significant association with mortality was found after 30 days. When excluding death within 30 days, three additional independent predictors of mortality were identified.

Short-term sinus rhythm predicts long-term sinus rhythm and clinical improvement after intraoperative ablation of atrial fibrillation

AIMS Our aim was to compare the long-term effects on rhythm and quality of life (QoL) after left atrial epicardial radiofrequency (RF) ablation vs. no ablation in patients undergoing cardiac surgery. METHODS AND RESULTS Thirty-nine patients with ECG documented atrial fibrillation (AF) scheduled for coronary artery bypass grafting (CABG) with or without concomitant valve surgery were consecutively elected for epicardial RF ablation. Thirty-nine age- and gender-matched patients scheduled for CABG with or without concomitant valve surgery only and with documented AF served as controls. The follow-up after ablation was 32 +/- 11 months. The percentage of patients in sinus rhythm (SR) at long-term follow-up was 62 vs. 33% (P = 0.03) after ablation and no ablation, respectively. SR at 3 months was highly predictive of that at 32 months (sensitivity 95%, positive predictive value 86%). Long-term SR was associated with better QoL, fewer symptoms, higher ejection fraction, and smaller left and right atria than AF. CONCLUSION SR at 3 months was highly predictive of long-term SR that was associated with clinical improvement when compared with patients still in AF. AF at 3 months did not preclude a later stabilization to SR.

Quality of Life 15 Years after Coronary Artery Bypass Grafting

ObjectivesTo describe changes in quality of life (QoL) during 15 years after coronary artery bypass grafting (CABG) and prediction of impaired QoL after 15 years. MethodsAll patients in western Sweden who underwent primary CABG without simultaneous valve surgery between 1988 and 1991 were included. QoL during a period of 15 years after CABG was evaluated with three instruments: the Nottingham Health Profile, the Psychological General Well-Being Index, and the Physical Activity Score. ResultsA total of 2000 patients took part in the survey, (none excluded) of whom 808 were still alive after 15 years and 79% answered the inquiry. Despite an ongoing decline in QoL over the years, an improvement in QoL was maintained in most sub-dimensions at the 15-year follow-up compared with that prior to surgery. Seven factors emerged as predictors of impaired QoL 15 years after CABG. They are as follows: (i) high age, (ii) female sex, (iii) history of diabetes, (iv) obesity, (v) prolonged stay in the intensive care unit, (vi) prolonged treatment on a ventilator, (vii) need for inotropic drugs at the time of surgery; of which the latter three might be secondary to left ventricular dysfunction. ConclusionDespite an ongoing decline in QoL over the years, there was still an improvement in most aspects of QoL 15 years after CABG compared with that before surgery. Intensified early treatment of diabetes, obesity, and left ventricular dysfunction in CABG patients might allow an even better long-term QoL.

Cause of death during 13 years after coronary artery bypass grafting with emphasis on cardiac death

Objective—To describe the cause of death in the long term after coronary artery bypass grafting (CABG) with particular emphasis on cardiac death. Patients and setting—All the patients in western Sweden without simultaneous valve surgery and without previous CABG who underwent CABG in 1988–1991 in Göteborg, Sweden. Design—Prospective, observational study for 10.6–13.6 years (i.e. until the end of 2001). Various factors contributing to death were described, with the emphasis on cardiac death. Results—In all, 2000 patients were included in the survey. The all‐cause mortality rate was 39%. Fifty‐eight per cent of all deaths were judged as cardiac deaths. The most frequent cause of death was heart failure (65% among patients who died within 30 days after CABG and 36% among those who died >30 days after CABG). The second most common cause of death was myocardial infarction (56 and 29%, respectively), followed by cancer (0 and 24%, respectively), stroke (21 and 18%, respectively) and infection (8 and 11%, respectively). Conclusion—The factors most commonly contributing to death in the long term after CABG were, in order of frequency, heart failure, myocardial infarction, cancer, stroke and infection.