Michael Tolan

Effect of Smoking on Short-Term Outcome of Patients Undergoing Coronary Artery Bypass Surgery

BACKGROUND Data on the effect of smoking on short-term outcome in patients undergoing coronary artery bypass graft (CABG) surgery are limited. We sought to assess the morbidity and in-hospital mortality of smokers and former smokers compared with nonsmokers undergoing CABG. METHODS This is a retrospective review of prospectively collected departmental data base. In all, 2,587 consecutive patients underwent isolated CABG between February 2000 and June 2007. Of these, 475 patients were current smokers, 1,364 were former smokers of more than 4 weeks, and 748 were nonsmokers. RESULTS Current smokers had higher rates of postoperative pulmonary complications than former smokers and nonsmokers (30.1% versus 23.3% versus 19.9%, p < 0.001). Blood transfusion requirement was lower for current smokers group than for the other two groups (34.9% versus 37.5% versus 44.1%, p = 0.02). Adjusted odd ratios (OR) for early clinical outcomes showed that current smokers had 59% higher risk of developing pulmonary complications (OR 1.59) than nonsmokers, with former smokers showing an intermediate pattern (OR 1.17). Current smokers had 36% lower risk of postoperative blood transfusion than nonsmokers (OR 0.64), with former smokers showing an intermediate pattern (OR 0.94). Rates of other postoperative complications, intensive care unit readmission, postoperative length of stay, and mortality did not differ among the three groups. CONCLUSIONS Smoking is associated with significant pulmonary complications after CABG. In-hospital mortality is not influenced by smoking. Smokers should be encouraged to quit before undergoing CABG, and a period of 1 month may be beneficial, given that former smokers in our study seem to have better prognosis than current smokers.

Abiotrophia defectiva endocarditis and associated hemophagocytic syndrome—a first case report and review of the literature

In this manuscript we describe the first association in the literature between Abiotrophia defectiva endocarditis and the hemophagocytic syndrome. There are multiple important clinical points of information that must be highlighted from this case. A. defectiva is an aggressive organism with a high level of resistance to antibiotic pharmacotherapy with a high predilection for embolic complications and valvular destruction despite treatment with sensitive antibiotics. A. defectiva endocarditis has not been previously associated with the hemophagocytic syndrome. However, this case highlights the serious hematological complications that can occur with this dangerous bacterial pathogen.

Short-term and long-term outcome in low body mass index patients undergoing cardiac surgery

ObjectiveWe sought to assess the effect of low body mass index (BMI) on short- and long-term outcomes following cardiac surgery.MethodsThis is a retrospective review of a prospectively collected departmental database over a 6-year period. Patients were eligible for the study if the BMI was <25 kg/m2. All morbidities, length of hospital stay, and short- and long-term mortality were reviewed.ResultsThere were 704 patients divided into low (n = 71) and normal (n = 633) BMI. Postoperative pulmonary complications were higher in the low BMI group compared to the normal BMI group (24% vs. 11%, P < 0.001) with a higher incidence of in-hospital mortality (10% vs. 5%). Using multiple logistic regression, low BMI was an independent risk factor for in-hospital mortality. The 1-, 3-, and 5-year survivals for the low group were 90%, 78%, and 70% compared to 94%, 86%, and 81% in the normal BMI group.ConclusionLow BMI is associated with increased morbidity and mortality following cardiac surgery. Risk scoring systems should utilize the BMI in the preoperative risk assessment with special attention to low BMI.

Lack of correlation between smoking status and early postoperative outcome following valve surgery.

BACKGROUND We sought to assess the effect of smoking on early outcome following valve surgery. METHODS This is a retrospective review of a prospectively collected departmental database of all patients who underwent isolated aortic and/or mitral valve surgery (replacement and/or repair). Our cohort consisted of 590 patients stratified into three groups: current smokers (n = 94), ex-smokers (n = 243), and nonsmokers (n = 253). RESULTS There were no significant differences in the in-hospital mortality between the three groups. Likewise, the length of both hospital and intensive care unit stays were similar among the three groups with a similar rate of postoperative complications. These findings remained statistically not significant, even after adjusting for potential confounders such as age, gender, etc. CONCLUSION Smoking does not seem to be associated with an increased early postoperative risk in patients undergoing valve surgery. However, because of the known effect of smoking on the risk of cardiovascular disease and because the effect of smoking on long-term survival in patients undergoing valve surgery remains unknown, patients should still be encouraged to quit smoking.

Propensity analysis of outcome in coronary artery bypass graft surgery patients >75 years old

PurposeWe looked at the complications and hospital resources of an elderly population undergoing first-time isolated coronary artery bypass graft surgery (CABG) in comparison to a younger counterpart for a propensity matched cohort.MethodsA retrospective analysis of prospectively collected data was conducted on 2804 CABG patients. Two age groups, >75 years and ≤75 years, were generated. Potential differences in demographic, baseline, preoperative, and intraoperative characteristics were investigated. A propensity score based on these differences was calculated and used to create a matched set of patients. Major postoperative complications were recorded, and data on indicators of resource utilization were collected.ResultsIn all, 311 (11.1%) patients were identified as >75 years of age. The observed complication rate was significantly higher in overall, pulmonary, cardiac, renal, gastrointestinal (GI), neurological, infective, and mortality categories (P < 0.0001). Observed hospital resource utilization was significant in the elderly group in terms of initial stay in the intensive care unit (ICU) and ICU readmission (P < 0.05) and in all preoperative, postoperative, cardiac surgery, and total hospital stays (P < 0.001). However, after propensity matching to 311 patients ≤75 years, the overall postoperative complication rate maintained its significance (P < 0.0001), in addition to atrial fibrillation and neurological, renal, and GI complications (P < 0.05). Elderly patients required longer duration of ventilation postoperatively and longer postoperative stay, cardiac surgery stay, and total hospital stay; and they maintained a higher surgical mortality rate (6.1% vs. 2.6%) (P < 0.05).ConclusionElderly patients undergoing CABG had significantly higher rates of postoperative complications. Their prolonged hospital stay and consequently higher resources utilization need to be adequately highlighted to heath care officials and appropriately addressed.

Troponin T elevation after coronary bypass surgery: clinical relevance and correlation with perioperative variables.

Objective Elevation in markers of myocardial necrosis is a common feature following coronary artery bypass surgery, but its relevance is unclear. The objective of this study was to evaluate the association between postoperative troponin T elevation, perioperative variables and clinical outcomes. Methods We evaluated 100 low-risk patients undergoing first-time elective on-pump coronary artery bypass surgery. The mean age was 62 ± 9.8 years and 83% were male; patients with diabetes mellitus, renal failure and impaired left ventricular function (ejection fraction < 40%) were excluded. Troponin levels were measured at baseline and 12 and 24 h following the onset of cardiopulmonary bypass. Predefined clinical endpoints included death, new Q waves on 12-lead electrocardiogram and inotropic requirement. Results Postoperative troponin elevation occurred in 95%. Troponin T elevation was related to the duration of cardiopulmonary bypass (P = 0.0001) and aortic cross-clamp time (P = 0.0003). There was also an inverse relationship with perioperative core temperature (P = 0.0001). There was no association between postoperative troponin elevation and clinical outcomes. Conclusions Postoperative troponin T elevation occurs in the majority of patients undergoing elective on-pump coronary artery bypass surgery. In this low-risk cohort, troponin T elevation was associated with procedural duration but not with clinical outcome.

Should cardiac surgery be delayed among carriers of methicillin-resistant Staphylococcus aureus to reduce methicillin-resistant Staphylococcus aureus-related morbidity by preoperative decolonisation?

OBJECTIVES Preoperative methicillin-resistant Staphylococcus aureus (MRSA) carriage is associated with higher rates of postoperative MRSA infection. Carriage can be eradicated but this requires delaying surgery, which presents a dilemma when the surgery is urgent. We analysed the incidence of preoperative MRSA carriage and the impact on postoperative outcomes in a cardiac surgery population. PATIENTS AND METHODS Patient data were collected prospectively from 2000 to 2007 (n=3789). MRSA screening is performed at a preadmission clinic for elective patients and on admission to the hospital for all patients. Three groups of MRSA carriers were identified: patients who were identified as carriers at a preadmission clinic (n=22, group 1), patients whose admission screening was positive but where the result was received postoperatively (n=103, group 2) and patients who acquired an MRSA infection or colonisation more than 48 h after admission (n=60, group 3). RESULTS MRSA eradication measures prior to admission were successful in 21 of 22 in group 1 (95.4%). There were no MRSA infections in group 1. However, in group 2 there were 11 patients with an MRSA infection (10%) even though eradication measures were started on confirmation of carriage. In group 3, 19 of the 60 patients had an MRSA infection. The intensive care stay and mortality were significantly greater in groups 2 and 3 than in group 1 or compared with the overall patient population. However, groups 2 and 3 also had a significantly higher risk profile (European System for Cardiac Operative Risk Evaluation (EuroSCORE)). When matched with similar risk patients, patients in groups 2 and 3 had mortality outcomes that were consistent with matched risk patients. CONCLUSION Patients who were MRSA carriers were older, more likely to have been on haemodialysis and to have been admitted from another hospital and underwent more complex surgical procedures. Carriage of MRSA was associated with a very high rate of MRSA infection, particularly among patients with diabetes. This suggests that delaying surgery may be warranted in patients expected to require implantation of prosthetic material such as valves, especially with diabetes. However, the survival outcomes for MRSA carriers are determined by their EuroSCORE rather than their MRSA status. This suggests that urgent cardiac surgery should not be delayed in patients with MRSA carriage.

The effect of preoperative renal dysfunction with or without dialysis on early postoperative outcome following cardiac surgery.

OBJECTIVES Although previous studies have shown increased mortality in renal dysfunction patients undergoing cardiac surgery, there is lack of data on the pattern of postoperative complications that occur in such patients and their distribution among dialysis and non-dialysis dependent renal dysfunction. METHODS This is a retrospective review of prospectively collected data over 8 year period of cardiac surgery patients. Our cohort consisted of 3598 consecutive patients divided into: normal kidneys (n = 3276, 91%), renal dysfunction (n = 277, 8%) and dialysis (n = 45, 1%). Postoperative complications and mortality were analysed. Multivariate analysis was conducted to adjust for the potential confounders in the association between renal dysfunction and postoperative complications. RESULTS Univariate analysis showed increased risk of the following complications among renal dysfunction and dialysis patients: low cardiac output, arrhythmias, reoperation, prolonged ventilation, readmission to intensive care, blood transfusion and prolonged hospital stay. Mortality rate was highest in dialysis patients compared to renal dysfunction and normal kidney patients (11% vs. 7% vs. 3%, respectively p-value <0.001). Multivariate analysis showed that renal dysfunction with or without dialysis is an independent predictor of postoperative low cardiac output, blood transfusion, prolonged ventilation, and mortality. The odd ratios were higher for dialysis than non-dialysis dependent patients. This effect persisted after adjusting for potential confounders such as age and gender. CONCLUSION The presence of renal dysfunction preoperatively increases the rate of postoperative complications and mortality following cardiac surgery. Prior knowledge of these complications can help in developing preventative strategies to reduce the associated risk.

The risk of arrhythmias following coronary artery bypass surgery: do smokers have a paradox effect?

Smoking is reported to increase the risk of arrhythmias. However, there are limited data on its effects on arrhythmias following coronary artery bypass graft (CABG). This is a retrospective review of a prospective database of all CABG patients over an eight-year period. Our cohort (n=2813) was subdivided into: current (n=1169), former (n=837), and non-smokers (n=807). Predictors of arrhythmias following CABG in relation to smoking status were analysed. Atrial arrhythmias occurred in 942 patients (33%). Ventricular arrhythmias occurred in 48 patients (2%) and high-grade atrioventricular block occurred in five patients (0.2%). Arrhythmias were lower in current smokers than former and non-smokers (29% vs. 40% vs. 39%, respectively P<0.001). Logistic regression analysis showed 30% arrhythmia risk reduction in smokers compared to non-smokers [odds ratio (OR) 0.7, 95% confidence intervals (CI) 0.5-0.8] and this effect persisted after accounting for potential confounders while former smokers had the same risk as non-smokers (OR 1.04, CI 0.9-1.3). There were no significant differences in mortality. Smokers are less prone to develop arrhythmias following CABG. This paradox effect is lost in former smokers. This effect is possibly due to a lower state of hyper adrenergic stimulation observed in smokers than non-smokers following the stress of surgery.

Surgical resection of a renal cell carcinoma involving the inferior vena cava: the role of the cardiothoracic surgeon

BackgroundThe techniques for the resection of renal tumors with IVC extension are based on the experience of individual units. We attempt to provide a logical approach of the surgical strategies in a stepwise fashion.MethodsOver 6-years 9 patients with renal cell carcinoma invading the IVC, underwent surgery. There were 6 males. The extension was at level IV in 4 and III in 5 cases. CPB used in 8 and hypothermia and circulatory arrest in all patients with level IV disease. The results and an algorithm of the plan of action, as per level of extension are presented.ResultsPlan of action: For level I-II disease: No Cardiothoracic involvement, For level III: Cardiopulmonary Bypass (CPB) & control of the cavo-atrial junction. For level IV: use of brief periods of Circulatory Arrest & repair of the Cavotomy with a pericardial patch. Postoperative morbidity: prolonged ICU stay, 3 patients (33.3%); tracheostomy, 1 (11.1%); Sepsis, 2 (22.2%); CVA 1, (11.1%). Mortality: 2 patients (22.2%)ConclusionsTotal clearance of the IVC from an adherent tumor is important, therefore extensive level IV disease presents a surgical challenge.We recommend CPB for level III and brief periods of Total Circulatory Arrest (TCA) for level IV disease.