- Email: [email protected]
Impact of off Pump Coronary Artery Bypass Surgery (OPCAB) on Surgical Outcomes for Coronary Artery Bypass Grafting (CABG): The New Jersey Cardiac Surgery Database Experience
Vol. 225, No. 4S2, October 2017
Impact of off Pump Coronary Artery Bypass Surgery (OPCAB) on Surgical Outcomes for Coronary Artery Bypass Grafting (CABG): The New Jersey Cardiac Surgery Database Experience Glenn W Laub, MD, FACS, Genevieve A Fasano, Joseph A Costic, DO, Wade Fischer, MD, Joseph Garcia, MD Drexel University College of Medicine, Philadelphia, PA INTRODUCTION: The use of cardiopulmonary bypass (CPB) enables surgeons to suture on a motionless, bloodless field; however, CPB entails significant complexity, cost, and potential morbidity and mortality. To mitigate these factors, surgeons have selectively utilized CABG without CPB based on their judgment, technical ability, and preference. We examined if utilization rates impacted outcomes. METHODS: Logistic regression analysis was performed to determine mortality risk factors for all 32,773 patients comprising the comprehensive New Jersey Cardiac Surgery Database who underwent CABG by the 86 surgeons from 2005 to 2011. A model was developed and the ratio of the observed to expected mortality (O/E) calculated for each surgeon. The rate of OPCAB utilization and risk adjusted mortality rates (RAM) were examined for each surgeon and stratified into quintiles by OPCAB usage. RESULTS: The overall statewide mortality rate was 1.77%. Age, diabetes, renal failure, cerebrovascular disease, COPD, immunosuppressive therapy, and peripheral vascular disease were significant risk factors, as were prior MI, congestive heart failure, cardiogenic shock, arrhythmia, resuscitation, and reoperation. OPCAB was used in a minority of patients (32.76%) and usage (0 to 100%) and RAM (0% to 16%) varied widely by surgeon, but usage did not correlate with the RAM (p¼not significant). When grouped by quintile, the 10.5% of surgeons who used OPCAB the most frequently (81% to 100%) operated on the riskiest patients (O/E rate 1.864 vs 1.77%), but had the worst outcomes (O/E 1.124). CONCLUSIONS: In a large, real-world clinical experience, the use of OPCAB by surgeons varied widely; however, when used judiciously this difference did not influence short-term outcome.
Scientific Forum: 2017 Clinical Congress
e11
Incidence and Outcomes of Surgical Pulmonary Embolectomy in the United States: An Analysis of the Society of Thoracic Surgery Database Zachary N Kon, MD, Gregory J Bittle, Chetan Pasrija, Sreekanth Vemulapalli, Maria V Grau-Sepulveda, MD, MPH, Roland A Matsouaka, PhD, Bradley Taylor, MD, James S Gammie, Bartley P Griffith University of Maryland School of Medicine, Baltimore, MD INTRODUCTION: There has been renewed interest in surgical pulmonary embolectomy (SPE) for the treatment of pulmonary embolism, but the real-world incidence and outcomes of SPE have yet to be well described using a large, granular dataset. Moreover, tangible risk factors for mortality remain unclear. We, therefore, examined the modern experience with SPE in the US as reported to the Society of Thoracic Surgery (STS) database. METHODS: The STS database was queried for all isolated SPE for the treatment of acute pulmonary embolism (2011 to 2015). Groups were stratified based on patient presentation: no cardiogenic shock (NCS), cardiogenic shock without arrest (CS), and cardiogenic shock with cardiac arrest (CS/CA). Preoperative characteristics, intraoperative variables, postoperative in-hospital complications, and operative mortality were compared. Multivariable logistic regression was performed to identify risk factors for operative mortality. RESULTS: Of the 1,144 centers reporting during the study period, only 310 performed at least 1 SPE (mean 0.911.36 cases/year/center). One thousand seventy-five eligible SPE were identified (NCS¼719, CS¼203, CS/CA¼153). Median age was 57 years (IQR 45-67), 54% were male, and preoperative thrombolysis was used in 8%. Overall, operative mortality was 16%, but increased with presenting acuity (NCS¼8%, CS¼23%, CS/ CA¼44%, chi-squared p<0.001). Independent predictors of operative mortality included age, obesity, cardiogenic shock, preoperative arrest, chronic lung disease, unresponsive neurologic state, and prolonged cardiopulmonary bypass time. CONCLUSIONS: Although SPE is uncommonly performed in the US, outcomes appear favorable. Nevertheless, significant associated mortality exists, and future work is necessary to determine which patients derive the greatest benefit from SPE vs medical therapy for acute PE.
Impact of off Pump Coronary Artery Bypass Surgery (OPCAB) on Surgical Outcomes for Coronary Artery Bypass Grafting (CABG): The New Jersey Cardiac Surgery Database Experience Glenn W Laub, MD, FACS, Genevieve A Fasano, Joseph A Costic, DO, Wade Fischer, MD, Joseph Garcia, MD Drexel University College of Medicine, Philadelphia, PA INTRODUCTION: The use of cardiopulmonary bypass (CPB) enables surgeons to suture on a motionless, bloodless field; however, CPB entails significant complexity, cost, and potential morbidity and mortality. To mitigate these factors, surgeons have selectively utilized CABG without CPB based on their judgment, technical ability, and preference. We examined if utilization rates impacted outcomes. METHODS: Logistic regression analysis was performed to determine mortality risk factors for all 32,773 patients comprising the comprehensive New Jersey Cardiac Surgery Database who underwent CABG by the 86 surgeons from 2005 to 2011. A model was developed and the ratio of the observed to expected mortality (O/E) calculated for each surgeon. The rate of OPCAB utilization and risk adjusted mortality rates (RAM) were examined for each surgeon and stratified into quintiles by OPCAB usage. RESULTS: The overall statewide mortality rate was 1.77%. Age, diabetes, renal failure, cerebrovascular disease, COPD, immunosuppressive therapy, and peripheral vascular disease were significant risk factors, as were prior MI, congestive heart failure, cardiogenic shock, arrhythmia, resuscitation, and reoperation. OPCAB was used in a minority of patients (32.76%) and usage (0 to 100%) and RAM (0% to 16%) varied widely by surgeon, but usage did not correlate with the RAM (p¼not significant). When grouped by quintile, the 10.5% of surgeons who used OPCAB the most frequently (81% to 100%) operated on the riskiest patients (O/E rate 1.864 vs 1.77%), but had the worst outcomes (O/E 1.124). CONCLUSIONS: In a large, real-world clinical experience, the use of OPCAB by surgeons varied widely; however, when used judiciously this difference did not influence short-term outcome.
Scientific Forum: 2017 Clinical Congress
e11
Incidence and Outcomes of Surgical Pulmonary Embolectomy in the United States: An Analysis of the Society of Thoracic Surgery Database Zachary N Kon, MD, Gregory J Bittle, Chetan Pasrija, Sreekanth Vemulapalli, Maria V Grau-Sepulveda, MD, MPH, Roland A Matsouaka, PhD, Bradley Taylor, MD, James S Gammie, Bartley P Griffith University of Maryland School of Medicine, Baltimore, MD INTRODUCTION: There has been renewed interest in surgical pulmonary embolectomy (SPE) for the treatment of pulmonary embolism, but the real-world incidence and outcomes of SPE have yet to be well described using a large, granular dataset. Moreover, tangible risk factors for mortality remain unclear. We, therefore, examined the modern experience with SPE in the US as reported to the Society of Thoracic Surgery (STS) database. METHODS: The STS database was queried for all isolated SPE for the treatment of acute pulmonary embolism (2011 to 2015). Groups were stratified based on patient presentation: no cardiogenic shock (NCS), cardiogenic shock without arrest (CS), and cardiogenic shock with cardiac arrest (CS/CA). Preoperative characteristics, intraoperative variables, postoperative in-hospital complications, and operative mortality were compared. Multivariable logistic regression was performed to identify risk factors for operative mortality. RESULTS: Of the 1,144 centers reporting during the study period, only 310 performed at least 1 SPE (mean 0.911.36 cases/year/center). One thousand seventy-five eligible SPE were identified (NCS¼719, CS¼203, CS/CA¼153). Median age was 57 years (IQR 45-67), 54% were male, and preoperative thrombolysis was used in 8%. Overall, operative mortality was 16%, but increased with presenting acuity (NCS¼8%, CS¼23%, CS/ CA¼44%, chi-squared p<0.001). Independent predictors of operative mortality included age, obesity, cardiogenic shock, preoperative arrest, chronic lung disease, unresponsive neurologic state, and prolonged cardiopulmonary bypass time. CONCLUSIONS: Although SPE is uncommonly performed in the US, outcomes appear favorable. Nevertheless, significant associated mortality exists, and future work is necessary to determine which patients derive the greatest benefit from SPE vs medical therapy for acute PE.