Morteza Mohajeri

Contemporary Results Show Repeat Coronary Artery Bypass Grafting Remains a Risk Factor for Operative Mortality

BACKGROUND Reoperative coronary artery bypass grafting (redo CABG) shows improving outcomes, but with varying degrees of improvement. We assessed contemporary outcomes after redo CABG to determine if redo status is still a risk factor for early postoperative complications and midterm survival. METHODS Isolated CABG procedures (June 1, 2001 to May 31, 2008) within the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database were included. Redo status as a predictor for early outcomes was assessed with logistic regression analysis. Midterm survival was determined from the National Death Index. Effect of redo status on midterm survival was assessed using a Cox proportional hazards model. RESULTS Inclusion criteria were met by 13,436 patients, and 458 (3.4%) underwent redo CABG. Operative mortality was 4.8% for redo CABG and 1.8% for first-time CABG (p < 0.001). After adjustment, redo status remained a predictor for operative mortality (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 to 3.6), myocardial infarction (OR, 2.8; 95% CI, 1.6 to 6.0), and prolonged ventilation (OR, 1.5; 95% CI, 1.1 to 2.0). Unadjusted survival was lower for the redo CABG group vs the first-time CABG group at up to 6 years (p = 0.01, log-rank test. After adjusting for differences in patient variables, redo status was not a predictor of midterm survival (OR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85). CONCLUSIONS Early postoperative outcomes of redo CABG are encouraging. Midterm survival is excellent; however, redo remains a significant risk factor for operative mortality in contemporary practice.

An Australian risk prediction model for 30-day mortality after isolated coronary artery bypass: The AusSCORE

OBJECTIVE Our objective was to identify risk factors associated with 30-day mortality after isolated coronary artery bypass grafting in the Australian context and to develop a preoperative model for 30-day mortality risk prediction. SUMMARY BACKGROUND DATA Preoperative risk associated with cardiac surgery can be ascertained through a variety of risk prediction models, none of which is specific to the Australian population. Recently, it was shown that the widely used EuroSCORE model validated poorly for an Australian cohort. Hence, a valid model is required to appropriately guide surgeons and patients in assessing preoperative risk. METHODS Data from the Australasian Society of Cardiac and Thoracic Surgeons database project was used. All patients undergoing isolated coronary artery bypass grafting between July 2001 and June 2005 were included for analysis. The data were divided into creation and validation sets. The data in the creation set was used to develop the model and then the model was validated in the validation set. Preoperative variables with a P value of less than .25 in chi(2) analysis were entered into multiple logistic regression analysis to develop a preoperative predictive model. Bootstrap and backward elimination methods were used to identify variables that are truly independent predictors of mortality, and 6 candidate models were identified. The Akaike Information Criteria (AIC) and prediction mean square error were used to select the final model (AusSCORE) from this group of candidate models. The AusSCORE model was then validated by average receiver operating characteristic, the P value for the Hosmer-Lemeshow goodness-of-fit test, and prediction mean square error obtained from n-fold validation. RESULTS Over the 4-year period, 11,823 patients underwent cardiac surgery, of whom 65.9% (7709) had isolated coronary bypass procedures. The 30-day mortality rate for this group was 1.74% (134/7709). Factors selected as independent predictors in the preoperative isolated coronary bypass AusSCORE model were as follows: age, New York Heart Association class, ejection fraction estimate, urgency of procedure, previous cardiac surgery, hypercholesterolemia (lipid-lowering treatment), peripheral vascular disease, and cardiogenic shock. The average area under the receiver operating characteristic was 0.834, the P value for the Hosmer-Lemeshow chi(2) test statistic was 0.2415, and the prediction mean square error was 0.01869. CONCLUSION We have developed a preoperative 30-day mortality risk prediction model for isolated coronary artery bypass grafting for the Australian cohort.

Does Prior Percutaneous Coronary Intervention Adversely Affect Early and Mid-Term Survival After Coronary Artery Surgery?

OBJECTIVES To determine the association between previous percutaneous coronary intervention (PCI) and results after coronary artery bypass graft surgery (CABG). BACKGROUND Increasing numbers of patients undergoing CABG have previously undergone PCI. METHODS We analyzed consecutive first-time isolated CABG procedures within the Australasian Society of Cardiac and Thoracic Surgeons Database from June 2001 to May 2008. Logistic regression and propensity score analyses were used to assess the risk-adjusted impact of prior PCI on in-hospital mortality and major adverse cardiac events. Cox regression model was used to assess the effect of prior PCI on mid-term survival. RESULTS Of 13,184 patients who underwent CABG, 11,727 had no prior PCI and 1,457 had prior PCI. Mean follow-up was 3.3 +/- 2.1 years. Patients without prior PCI had a higher EuroSCORE value (4.4 +/- 3.3 vs. 3.6 +/- 3.0, p < 0.001), were older, and more likely to have left main stem stenosis and recent myocardial infarction. There was no difference in unadjusted in-hospital mortality (1.65% vs. 1.55%, p = 0.78) or major adverse cardiac events (3.0% vs. 3.0%, p = 0.99) between patients with or without prior PCI. After adjustment, prior PCI was not a predictor of in-hospital (odds ratio: 1.22, 95% confidence interval [CI]: 0.76 to 2.0, p = 0.41) or mid-term mortality at 6-year follow-up (hazard ratio: 0.94, 95% CI: 0.75 to 1.18, p = 0.62). CONCLUSIONS In this large registry study, prior PCI was not associated with increased short- or mid-term mortality after CABG. Good outcomes can be obtained in the group of patients undergoing CABG who have had previous PCI.

Validation of Euroscore model in an Australian patient population.

Background:  The purpose of the present paper was to assess the performance of the European system for cardiac operative risk evaluation (EuroSCORE) model in an Australian adult cardiac surgical population.

OUTCOME AND QUALITY OF LIFE AFTER CARDIAC SURGERY IN OCTOGENARIANS

Background:  Cardiac surgery is being performed with increasing frequency in octogenarians. The purpose of the present study was to determine the outcome and quality of life of octogenarians after cardiac surgery in a single surgeon series and in a newly established cardiac surgery unit.

Short- and midterm outcomes of coronary artery bypass surgery performed by surgeons in training

OBJECTIVE The effect of training on outcomes in cardiac surgery is poorly studied. We aimed to study the results of coronary artery bypass grafting procedures performed by surgeons in training across our state with respect to short- and midterm postoperative outcomes. METHODS All coronary artery bypass grafting surgeries performed by trainee surgeons between July 2001 and December 2006 were compared with those performed by consultant surgeons using mandatory prospectively collected statewide data. Early mortality; prolonged ventilation or intensive care unit stay; return to operating theater for bleeding, stroke, myocardial infarction, or renal failure; and 5-year survival were compared using propensity score analysis. RESULTS A total of 7745 surgeries were included in this study. Trainees performed 983 (13%) surgeries. Trainee surgeries had longer perfusion and crossclamp times. Crude early postoperative outcomes were similar between trainee and consultant surgeries. After propensity score adjustment, early outcomes remained similar, with the exception of myocardial infarction (0.8% in trainee surgeries vs 0.4% in consultant surgeries, P = .046). Adjusted 1-, 3-, and 5-year survivals were similar between trainee and consultant surgeries: 95.3% versus 95.5%, 90.8% versus 92.0%, and 86.3% versus 87.1%, respectively. CONCLUSION Coronary artery bypass grafting performed by trainee surgeons within a supervised program is safe with acceptable short- and midterm outcomes.

CT15 RISK STRATIFICATION MODELS FOR HEART VALVE SURGERY

Purpose  Risk stratification models may be useful in aiding surgical decision‐making, preoperative informed consent, quality assurance and healthcare management. While several overseas models exist, no model has been well‐validated for use in Australia. We aimed to assess the performance of two valve surgery risk stratification models in an Australian patient cohort.

Intraoperative suspicion of phaeochromocytoma during elective coronary artery surgery

Abstract A patient with an unsuspected phaeochromocytoma survived elective coronary artery bypass grafting due to aggressive pharmacological therapy for episodes of severe hypertension during surgery. The favourable result was probably attributable to an early suspicion during surgery that a phaeochromocytoma may be present and the prompt commencement of aggressive pharmacological therapy. After tests which confirmed the presence of the tumour, the patient underwent surgery to remove a phaeochromocytoma from the right adrenal gland. He recovered uneventfully, his blood pressure returning to normal. Surgery on an unprepared patient with a phaeochromocytoma is hazardous and carries a high mortality.