Kathleen R. Petro

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.

Surgical revascularization in women: Unique intraoperative factors and considerations

See related articles on pages 929, 932, 950, and 959. C ardiovascular disease (CVD) is the leading cause of morbidity and mortality for women in the United States, Canada, and most developed countries. In developing countries it will be the leading cause of death in the next 20 years. It is a costly disease both in terms of health care dollars spent and patient lives. Approximately 250,000 women die each year in the United States, and women are 3 times as likely to die of CVD as they are of breast cancer. With the publication 10 years ago of 2 sentinel studies detailing the differences between men and women in the delivery of care to patients with CVD, there has been an increased awareness in the health care community and the lay public of issues relevant to the assessment and management of CVD in women. Perception of CVD by both communities is still evolving and is often influenced by insufficient or, worse, inaccurate information. The androcentric focus of much of cardiovascular research contributes to this problem. Only recently have women been included in sufficient numbers in clinical trials and databases or has there been a requirement for sex-based analysis of data such that specific information pertaining to results in women has been available. The problem is compounded when trying to analyze the results of coronary artery bypass grafting (CABG) in women because only 30% of all CABG operations are performed on women and fewer women than men are referred for operation, resulting in small sample sizes. Numerous studies have demonstrated increased hospital mortality after CABG in women when compared with men. Increased mortality in women in these studies has often been attributed to referral bias, smaller vessels, decreased body size, and an increased incidence of comorbidities. More recently, studies suggest that despite the obvious premorbid differences between men and women, women still clearly benefit from surgical revascularization. Despite good long-term results for women undergoing CABG, misperception of results still clearly influences their surgical treatment. For example, proportionally fewer women receive arterial grafts or reoperation. We review the intraoperative factors and considerations that are unique to women facing CABG in an attempt to raise awareness and to support the use of surgical revascularization in women.

Comparison of the quality of life after conventional versus off-pump coronary artery bypass surgery.

Abstract  Purpose: Numerous studies have focused on off‐pump coronary artery bypass graft (off‐pump CABG) morbidity and mortality outcomes, but few looked at the patients perception of the technique and its effect on postoperative quality of life (QOL). We investigated and compared postoperative QOL in patients who had undergone either conventional or off‐pump CABG myocardial revascularization. Methods: During a six‐month period, 191 patients who underwent CABG surgery were prospectively studied through preoperative and six‐month postoperative short‐form 36 (SF‐36) general health status surveys. One hundred‐sixteen (60.7%) off‐pump CABG patients and 75 (39.3%) conventional on‐pump CABG patients were enrolled. Results: Sixteen (13.8%) off‐pump patients reported improvement in physical score QOL, 84 (72.4%) reported no change, and 16 (13.8%) reported a decrease. In comparison, 20 (80.0%) patients in the on‐pump CABG group reported an improvement in QOL, 42 (56.0%) were unchanged, and 13 (17.3%) reported deterioration (p = 0.28). For postoperative change in mental score, 19 (16.4%) off‐pump patients reported an improvement, 85 (73.3%) stayed unchanged, and 12 (10.3%) reported a decrease compared with 8 (10.7%) conventional CABG patients reporting improvement, 60 (80.0%) showing no change, and 7 (9.3%), having a score decline (p = 0.52). In multivariate logistic regression analysis, hypertension (odds ratio [OR] 2.2, 95% confidence intervals [CI], 1.08 to 4.40, p = 0.03) and multivessel coronary artery disease (OR 2.1, 95% CI, 1.11 to 4.13, p = 0.02) emerged as independent predictors of worse physical score component score. Diabetes was associated with an improved physical score component score after CABG (OR 0.4, 95% CI, 0.17 to 0.76, p = 0.01), regardless of the surgical approach. Conclusion: This prospective study reveals no significant differences in the expected QOL at six months after either on‐pump or off‐pump CABG. Patients with hypertension and multivessel coronary artery disease were more likely to have worse, while patients with diabetes have improved physical score component scores six months after CABG.

Early readmission of low-risk patients after coronary surgery.

BACKGROUND Early readmission after coronary artery bypass grafting (CABG) is an expensive adverse outcome. Although the perioperative experience of high-risk CABG patients has been studied extensively, little attention has been paid to low-risk CABG patients. The primary goal of this study was to identify the preoperative characteristics and to define risk predictors of readmission and preventive factors for readmission in low-risk isolated-CABG patients. METHODS We identified 2157 patients who underwent CABG between January 2000 and December 2005 at Washington Hospital Center, Washington, DC, and defined as low risk patients who had a Parsonnet bedside risk score lower than the 25th percentile. Patients who were rehospitalized within 30 days after surgery were compared with those who were not rehospitalized during this period. RESULTS The overall readmission rate for this study cohort was 6.3%. Compared with non-readmitted patients, early-readmitted patients were more likely to have diabetes mellitus (27.94% versus 20.88%, P = .05) and less likely to have hypertension (42.65% versus 51.36%, P = .05). Blood product transfusion (P < .01), postoperative length of intensive care unit stay (P = .01), and length of hospital stay (P = .05) were all significantly increased in the readmitted patients. The use of beta-blockers (P = .03) and angiotensin-converting enzyme inhibitors (P = .04) was significantly lower at discharge in this group of patients; however, multivariate regression analysis demonstrated diabetes (odds ratio, 1.59; 95% confidence interval, 1.08-2.42) to be the only independent predictor of early readmission. CONCLUSIONS For low-risk CABG patients, diabetes mellitus is the risk predictor of early readmission. Early discharge was not associated with early readmission.

Response to Letters Regarding Article, “Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery: Are We Forfeiting the Benefits of Reduced Hemorrhagic Sequelae?”

Because our initial goal was to generate interest in the hemorrhagic complications caused by the use of clopidogrel in cardiac surgery patients, it was with satisfaction that we read the comments of Poston and van der Linden et al regarding our own contribution to the discussion.1 Both Poston and …