John D. Puskas

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

L. David Hillis, MD, FACC, Chair†; Peter K. Smith, MD, FACC, Vice Chair*†; Jeffrey L. Anderson, MD, FACC, FAHA*‡; John A. Bittl, MD, FACC§; Charles R. Bridges, MD, SCD, FACC, FAHA*†; John G. Byrne, MD, FACC†; Joaquin E. Cigarroa, MD, FACC†; Verdi J. DiSesa, MD, FACC†; Loren F. Hiratzka, MD, FACC, FAHA†; Adolph M. Hutter, Jr, MD, MACC, FAHA†; Michael E. Jessen, MD, FACC*†; Ellen C. Keeley, MD, MS†; Stephen J. Lahey, MD†; Richard A. Lange, MD, FACC, FAHA†§; Martin J. London, MD ; Michael J. Mack, MD, FACC*¶; Manesh R. Patel, MD, FACC†; John D. Puskas, MD, FACC*†; Joseph F. Sabik, MD, FACC*#; Ola Selnes, PhD†; David M. Shahian, MD, FACC, FAHA**; Jeffrey C. Trost, MD, FACC*†; Michael D. Winniford, MD, FACC†

2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation

BACKGROUND Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. METHODS We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. RESULTS At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. CONCLUSIONS We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).

Clinical outcomes, angiographic patency, and resource utilization in 200 consecutive off-pump coronary bypass patients

BACKGROUND This retrospective study compared clinical outcomes and resource utilization in patients having off-pump coronary artery bypass grafting (OPCAB) versus conventional coronary artery bypass grafting (CABG). Angiographic patency was documented in the OPCAB group. METHODS From April 1997 through November 1999, OPCAB was performed in 200 consecutive patients, and the results were compared with those in a contemporaneous matched control group of 1,000 patients undergoing CABG. Patients were matched according to age, sex, preexisting disease (renal failure, diabetes, pulmonary disease, stroke, hypertension, peripheral vascular disease, previous myocardial infarction, and primary or redo status. Follow-up in the OPCAB patients was 93% and averaged 13.4 months. RESULTS Hospital death (1.0%), postoperative stroke (1.5%), myocardial infarction (1.0%), and re-entry for bleeding (1.5%) occurred infrequently in the OPCAB group. There were reductions in the rates of transfusion (33.0% versus 70.0%; p < 0.001) and deep sternal wound infection (0% versus 2.2%; p = 0.067) in the OPCAB group compared with the CABG group. Angiographic assessment of 421 grafted arteries was performed in 167 OPCAB patients (83.5%) prior to hospital discharge. All but five were patent (98.8%) (93.3% FitzGibbon A, 5.5% FitzGibbon B, 1.2% FitzGibbon O). All 163 internal mammary artery grafts were patent. Off-pump coronary artery bypass grafting reduced postoperative hospital stay from 5.7 +/- 5.3 days in the CABG group to 3.9 +/- 2.6 days (p < 0.001), with a decrease in hospital cost of 15.0% (p < 0.001). CONCLUSIONS Off-pump coronary artery bypass grafting reduces hospital cost, postoperative length of stay, and morbidity compared with CABG on cardiopulmonary bypass. Off-pump coronary bypass grafting is safe, cost effective, and associated with excellent graft patency and clinical outcomes.

601 octogenarians undergoing cardiac surgery: outcome and comparison with younger age groups

BACKGROUND Cardiac valve replacement and coronary artery bypass graft surgery (CABG) are being applied with increasing frequency in patients 80 years of age and older. METHODS Six hundred one consecutive patients older than 80 years, undergoing cardiac surgery between 1976 and 1994 (CABG with saphenous vein graft, 329 [54.7%]; CABG with left internal mammary artery, 101 [16.8%]; CABG + valve, 80 [13.3%]; isolated aortic valve replacement, 71 [11.8%]; isolated mitral valve replacement, 18 [3.0%]), were studied retrospectively to assess short- and long-term survival. They were compared with 11,386 patients aged 60 to 69 years and 5,698 patients aged 70 to 79 years undergoing similar procedures during the same time interval. RESULTS In comparison with patients 60 to 69 years old, more octogenarians were women (44.4% versus 25.6%, p<0.0001), had class IV angina (54.1% versus 38.9%, p<0.0001), and had congestive heart failure class IV (4.9% versus 3.0%, p = 0.0001). In-hospital death rates (9.1% versus 3.4%, p<0.0001) and stroke (5.7% versus 2.6%, p<0.0001) reflected these adverse clinical risk factors. However, Q-wave infarction tended to be less frequent (1.5% versus 2.6%, p = 0.102). Interestingly, hospital mortality (9.1% versus 6.7%, p = 0.028) was only slightly increased, and stroke (5.7% versus 4.7%, p = 0.286) was not more common in octogenarians than in patients 70 to 79 years old. Late-survival curves have similar slopes for the first 5 years in all clinical subgroups. However, after 5 years there is a more rapid decline in octogenarians than in younger age groups. Median 5-year survival was 55% for patients older than 80 years, 69% for patients 70 to 79 years, and 81% for patients 60 to 69 years old. CONCLUSIONS When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and excellent 5-year survival.

Off-Pump Coronary Artery Bypass Disproportionately Benefits High-Risk Patients

BACKGROUND It is not known which patient subgroups may benefit most from off-pump coronary artery bypass grafting (OPCAB) rather than coronary artery bypass grafting on cardiopulmonary bypass (CPB). METHODS The Society of Thoracic Surgeons database was queried for all isolated, primary coronary artery bypass graft cases between January 1, 1997, and December 31, 2007, at a US academic center. The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) was calculated by a formula based on 30 preoperative risk factors. It was used in three ways to compare 30-day operative mortality between patients treated with OPCAB versus CPB. First, patients were divided into quartiles based on their PROM, and mortality rates were compared between OPCAB and CPB patients within each PROM quartile. Second, a logistic regression model tested for an interaction between surgery type and PROM; a significant interaction would indicate that the relative mortality risk of OPCAB versus CPB varied with different PROM levels. Finally, locally smoothed kernel regression curves were used to visually estimate a threshold PROM point at which mortality rates diverge for the surgery types. RESULTS There were 14,766 consecutive patients, 7,083 OPCAB (48.0%) and 7,683 CPB (52.0%). There was no difference in operative mortality between OPCAB and CPB for patients in the lower two risk quartiles. In the higher risk quartiles there was a mortality benefit for OPCAB (odds ratio, 0.62 and 0.45 for OPCAB in the third and fourth risk quartiles). Logistic regression analysis confirmed a significant interaction between surgery type and PROM (p = 0.005) meaning that OPCAB is especially beneficial to patients with higher PROM. This benefit is most significant for patients with PROM values above 2.5% to 3%, where mortality curves sharply diverge. CONCLUSIONS Off-pump coronary artery bypass grafting is associated with lower operative mortality than coronary artery bypass grafting on CPB for higher risk patients. This mortality benefit increases with increasing PROM.

New-Onset Atrial Fibrillation Predicts Long-Term Mortality After Coronary Artery Bypass Graft

OBJECTIVES We sought to investigate the association between new-onset atrial fibrillation after coronary artery bypass graft (CABG) (post-operative atrial fibrillation [POAF]) and long-term mortality in patients with no history of atrial fibrillation. BACKGROUND POAF predicts longer hospital stay and greater post-operative mortality. METHODS A total of 16,169 consecutive patients with no history of AF who underwent isolated CABG at our institution between January 1, 1996, and December 31, 2007, were included in the study. All-cause mortality data were obtained from Social Security Administration death records. A multivariable Cox proportional hazards regression model was constructed to determine the independent impact of new-onset POAF on long-term survival after adjusting for several covariates. The covariates included age, sex, race, pre-operative risk factors (ejection fraction, New York Heart Association functional class, history of myocardial infarction, index myocardial infarction, stroke, chronic obstructive pulmonary disease, peripheral arterial disease, smoking, diabetes, renal failure, hypertension, dyslipidemia, creatinine level, dialysis, redo surgery, elective versus emergent CABG, any valvular disorder) and post-operative adverse events (stroke, myocardial infarction, acute respiratory distress syndrome, and renal failure), and discharge cardiac medications known to affect survival in patients with coronary disease. RESULTS New-onset AF occurred in 2,985 (18.5%) patients undergoing CABG. POAF independently predicted long-term mortality (hazard ratio: 1.21; 95% confidence interval: 1.12 to 1.32) during a mean follow-up of 6 years (range 0 to 12.5 years). This association remained true after excluding from the analysis those patients who died in-hospital after surgery (hazard ratio: 1.21; 95% confidence interval: 1.11 to 1.32). Patients with POAF discharged on warfarin experienced reduced mortality during follow-up. CONCLUSIONS In this large cohort of patients, POAF predicted long-term mortality. Warfarin anticoagulation may improve survival in POAF.

Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery

OBJECTIVE Diabetes mellitus has been associated with an increased risk of adverse outcomes after coronary artery bypass grafting. Hemoglobin A1c is a reliable measure of long-term glucose control. It is unknown whether adequacy of diabetic control, measured by hemoglobin A1c, is a predictor of adverse outcomes after coronary artery bypass grafting. METHODS Of 3555 consecutive patients who underwent primary, elective coronary artery bypass grafting at a single academic center from April 1, 2002, to June 30, 2006, 3089 (86.9%) had preoperative hemoglobin A1c levels obtained and entered prospectively into a computerized database. All patients were treated with a perioperative intravenous insulin protocol. A multivariable logistic regression model was used to determine whether hemoglobin A1c, as a continuous variable, was associated with in-hospital mortality, renal failure, cerebrovascular accident, myocardial infarction, and deep sternal wound infection after coronary artery bypass grafting. Receiver operating characteristic curve analysis identified the hemoglobin A1c value that maximally discriminated outcome dichotomies. RESULTS In-hospital mortality for all patients was 1.0% (31/3089). An elevated hemoglobin A1c level predicted in-hospital mortality after coronary artery bypass grafting (odds ratio 1.40 per unit increase, P = .019). Receiver operating characteristic curve analysis revealed that hemoglobin A1c greater than 8.6% was associated with a 4-fold increase in mortality. For each unit increase in hemoglobin A1c, there was a significantly increased risk of myocardial infarction and deep sternal wound infection. By using receiver operating characteristic value thresholds, renal failure (threshold 6.7, odds ratio 2.1), cerebrovascular accident (threshold 7.6, odds ratio 2.24), and deep sternal wound infection (threshold 7.8, odds ratio 5.29) occurred more commonly in patients with elevated hemoglobin A1c. CONCLUSION Elevated hemoglobin A1c level was strongly associated with adverse events after coronary artery bypass grafting. Preoperative hemoglobin A1c testing may allow for more accurate risk stratification in patients undergoing coronary artery bypass grafting.

Off-pump multivessel coronary bypass via sternotomy is safe and effective

BACKGROUND In an attempt to avoid the deleterious effects of cardiopulmonary bypass, off-pump coronary artery bypass grafting has been rediscovered and refined. The purpose of this study was to compare clinical outcomes, length of stay, and hospital costs with coronary artery bypass grafting on cardiopulmonary bypass. METHODS Coronary artery bypass was performed on 51 patients without cardiopulmonary bypass. Patients were selected on the basis of coronary anatomy, with significant stenoses in the left anterior descending, ramus intermedius, diagonal, right coronary, acute marginal, or posterior descending territories. Outcomes were compared with those of a computer-generated matched control group having coronary artery bypass grafting on cardiopulmonary bypass (n = 248) during the same time period. RESULTS No preoperative differences were noted between groups. There were no deaths in the off-pump group and a mortality rate of 1.6% (4/248) in the control group. There was no incidence of stroke, myocardial infarction, or reentry for bleeding among patients in the off-pump group. There was a reduction in length of stay by 3 days (p = 0.01), blood transfusions by 50% (p = 0.0001), and hospital charges by one third (p = 0.05) in the off-pump group. Twenty-six patients had repeat coronary angiography before discharge; 41/43 grafts were widely patent, 1/43 was totally occluded, and 1/43 was narrowed by more than 50%. All internal mammary artery grafts were widely patent. CONCLUSIONS Off-pump multivessel cardiopulmonary bypass grafting is a safe and effective means of revascularization for patients with coronary stenoses in the anterior or inferior regions, with excellent short-term patency rates and minimal morbidity.

Off-pump coronary bypass provides reduced mortality and morbidity and equivalent 10-year survival.

BACKGROUND This study compared in-hospital major adverse cardiac events (MACE) and long-term survival after off-pump (OPCAB) vs on-pump (CPB) coronary artery bypass grafting (CABG). METHODS Reviewed were 12,812 consecutive isolated CABG patients from 1997 to 2006. A propensity score (PS), including 40 preoperative risk factors, balanced characteristics between OPCAB and CPB groups. Multiple logistic regression models tested whether gender or surgery type, or their interaction, were associated with in-hospital mortality and MACE. A proportional hazards regression model and Kaplan-Meier curves related long-term survival with gender, surgery type, and their interaction, adjusted for PS and age. RESULTS OPCAB was associated with a significant reduction in operative mortality (adjusted odds ratio [AOR], 0.68; p = 0.045), stroke (AOR, 0.48; p < 0.001), and MACE (AOR, 0.66; p = 0.018). Female gender was associated with higher rates of death (AOR, 1.93), stroke (AOR, 1.82), myocardial infarction (AOR, 2.19), and MACE (AOR, 1.97; each p < 0.001). Women disproportionately benefited from OPCAB in operative mortality (p = 0.04). Odds of death for women on CPB were higher than for women treated with OPCAB (AOR, 2.07, p = 0.005). Odds of death for men on CPB were not significantly higher than for men treated with OPCAB (AOR, 1.16, p = 0.51). Male gender was associated with longer-term survival (p = .011), but surgery type (OPCAB vs CPB) was not (p = 0.23). CONCLUSIONS OPCAB provides significant early mortality and morbidity advantages, especially for women. During the 10-year follow-up, OPCAB and CPB result in similar survival, regardless of gender.