Association Between Infection and Thrombosis After Coronary Artery Bypass Grafting: A Cohort Study

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Association between Infection and Thrombosis after Coronary Artery Bypass Grafting: A Cohort Study Xiaojie Liu , Lijuan Wang , Sudena Wang , Wenyuan Zhang , Yang Yu , Sipeng Chen , Hushan Ao PII: DOI: Reference:

S1053-0770(18)30884-X https://doi.org/10.1053/j.jvca.2018.09.008 YJCAN 4898

To appear in:

Journal of Cardiothoracic and Vascular Anesthesia

Received date:

27 July 2018

Please cite this article as: Xiaojie Liu , Lijuan Wang , Sudena Wang , Wenyuan Zhang , Yang Yu , Sipeng Chen , Hushan Ao , Association between Infection and Thrombosis after Coronary Artery Bypass Grafting: A Cohort Study, Journal of Cardiothoracic and Vascular Anesthesia (2018), doi: https://doi.org/10.1053/j.jvca.2018.09.008

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Association between Infection and Thrombosis after Coronary Artery Bypass Grafting: A Cohort Study Xiaojie Liu, Lijuan Wang, Sudena Wang, Wenyuan Zhang,Yang Yu, Sipeng Chen, Hushan Ao Xiaojie Liu: MD, Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular

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Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College. E-mail:[email protected]

Lijuan Wang: MD, Department of Anesthesiology, State Key Laboratory of

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Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College. E-mail: [email protected]

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Sedena Wang: MD, Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular

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Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.

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E-mail: [email protected]

Wenyuan Zhang: MD, Department of Anesthesiology, the First Affiliated Hospital,

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Nangchang University.

E-mail: [email protected]

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Yang Yu: MB, Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College. E-mail: [email protected] Sipeng Chen: MD, Information Center, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai 1

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Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College. E-mail: [email protected] Hushan Ao: MD, PhD, Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese

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Academy of Medical Sciences and Peking Union Medical College. Corresponding author: Name: Huanshan Ao

Postal address: No.167 North Lishi Road, Xicheng District, Beijing, China. 100037

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Telephone/fax: 0086-10-68006210 E-mail:[email protected] Abstract

Objective: Surgery related infection remains a major complication for patients

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undergoing cardiac surgery and its association with thrombosis is unclear. This study aimed to examine the association of postoperative infection with thrombosis and

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major adverse cardiovascular and cerebral events (MACCEs) in patients undergoing coronary artery bypass grafting (CABG).

performed.

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Design: This is a retrospective cohort study. Multiple variable regression analyses was

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Setting: The study was performed as a single institution. Participants: All patients underwent CABG.

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Intervention: No interventions were imposed on participants. Measurements and Main Results: Perioperative and postoperative follow-up data relating to all CABG patients from January 2001 to August 2006 were queried from an institutional electronic medical records of Fuwai Hospital. Patients were divided into two groups according to infection or not. 75 patients suffering from infection and 2926 from control comprised the study population. Primary outcomes were a composite outcome of perioperative thrombosis and long - term thrombosis related 2

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complications. Secondary outcomes were 5 years MACCEs postoperatively (including death, myocardial infarction, target vessel revascularization, and stroke. Risk factors for infection include old age, higher level of creatinine, chronic lung disease, cardiopulmonary bypass time, aortic cross-clamp time, the history of renal failure，cardiopulmonary bypass, left ventricular assist device or intra-aortic balloon pump , the length of stay in intensive care unit and length of tracheal intubation.

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Infection increased the odds of perioperative thrombosis by 5.132-fold (95% CI:

2.040 - 12.911; p-value<0.0001) compared to control. However, infection was not

associated with a significant increase in MACCEs (HR, 1.855; 95% CI, 0.929-3.704; p-value=0.080). Age was associated with a significant increase in MACCEs (HR,

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1.040; 95% CI, 1.026-1.054; p-value<0.0001).

Conclusion: There is association of postoperative infection and perioperative thrombosis after CABG. Several specific managements were associated with

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controlling infection risk, which offered targets for quality improvement in future.

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1. Introduction

Infectious complications after cardiac surgery occur in around 5% of cases.

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Major infectious complications increase postoperative mortality by more than five times and prolong recovery [1]. Nosocomial infections remain common after cardiac

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surgery despite numerous prevention measures, which can cause significant patient discomfort, morbidity, mortality, prolonged hospitalization and augment of total

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treatment cost. Long operative duration and greater complexity procedures, dyspnea, ascites, bleeding disorder, smoking, severe chronic obstructive pulmonary disease (COPD) history and longer mechanical ventilation time are risk factors for infection after cardiac surgery [2]. For cardiac surgery patients, the most common infection sites are respiratory tract (45.7%-57.8%), surgical site (27.7%), and catheters or other devices (20.5%-25.2%).If infection worsens, sepsis will occur. Despite advances in medicine 3

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from germ theory to advent of modern critical care medicine, sepsis, continues to be a leading cause of inpatient expenditures and death in the United States and China [3-4]. Donzé and colleagues evaluated the impact of preoperative sepsis on postoperative arterial and venous thrombosis and concluded that preoperative sepsis was an important independent risk factor for both arterial and venous thrombosis. The risk of thrombosis increases with increasing severity of the inflammatory which is higher in

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emergency operation. [5].

Previous studies have proved that inflammation played a major role in all phases of atherosclerosis. Proinflammatory cytokines, IL-1β, IL-6, MCP-1, and TNFα have been shown to regulate in setting of thrombosis [6]. Trauma-induced

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coagulopathy is associated with increased ventilator-associated pneumonia [7]. Case reports showed that three cases with systemic infectious disease caused cerebral infarction and coronary stent infection could cause recurrent stent thrombosis [8-9]. Septic emboli, infection-related hypercoagulopathy or both might cause it. Cohoon

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and colleagues showed the relationship between overall infection and venous thromboembolism and illustrated that infection was independent risk factors for

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venous thromboembolism as a whole [10]. Perioperative thrombosis and thrombosis related complications are not uncommon [11]. However, the relationship between

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overall infection and perioperative thrombosis and long-term thrombosis related complications after CABG is unknown.

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The aim of this study was to illustrate the incidence of early postoperative infection in patients undergoing CABG and to analyze the relationship between

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infection and perioperative thrombosis together with long-term thrombosis related complications, as well as the MACCEs in infection and control group.

2. Methods 2.1. Study design and population The study was a retrospective cohort study based on the retrospective Fuwai Hospital clinical database. The study protocol was approved by the Ethics Committee 4

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of Fuwai Hospital and was compliant to the Declaration of Helsinki and patient consenting was waived by the ethics committee as such a consent was not necessary in our study. 3003 continuously patients who underwent primary CABG between January 2001 and August 2006 at Fuwai Hospital were included in this study. After screening, 75 patients suffering from major infections were selected and two patients were

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excluded because of incomplete information, as shown in figure 1. Patients were followed up to the first documented MACCEs (including death, myocardial infarction, target vessel revascularization, and stroke) or 5 years after surgery. The last date of follow-up was August 29, 2011

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The definition of infection during the period of hospitalization after surgery are as follows: Pneumonia was defined with the following criteria: fever (>38℃), leukocytosis, chest radiograph with new infiltrate, increased sputum volume, and decreased oxygen index. Urinary tract infections: Urine WBC >10/high magnification

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or urine culture bacteria > 100 000/ml. The consensus definition of endocarditis was based on v. 2.81 STS Adult Cardiac Surgery Database Training Manual [12].

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The definition of surgical site infection (SSI) was based on the guideline [13-14]. Chronic disease: We collected data related to pre-existing diseases by reviewing the

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medical record, including admission history, physician consultations, and operative, laboratory and radiology. The consensus definition for sepsis was based on the 2012

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International Sepsis Guidelines [15]. The definition of thrombosis during the period of hospitalization after surgery are

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as follows: arterial thrombosis (myocardial infarction, stroke, cerebrovascular event), venous thrombosis (deep venous thrombosis or pulmonary embolism). Among them, cerebral vascular events include transient ischemic attack and coma caused by arterial thrombosis confirmed by computed tomography and transcranial Doppler. Long - term thrombosis related complications include stenosis of graft, cardiac infarction, cerebral vascular events and stroke. Among them, cerebral vascular events include transient ischemic attack and coma caused by arterial thrombosis confirmed 5

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by computed tomography and transcranial Doppler. 2.2. Data collection Data were collected on patient characteristics (demographics, baseline laboratory values, comorbidities), surgery-related factors (such as whether CPB or not, CPB time, ACC time), and postoperative factors (such as tracheal intubation time, the length of stay in ICU，left ventricular assisted, postoperative IABP)

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2.3. Long-term clinical follow-up

All patients were followed by telephone contact or E-mail until 5 years for long - term thrombosis related complications and combined major adverse cardiovascular and cerebral end-points (MACCEs) by a trained nurse who was blind to the patients'

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baseline clinical status. Some patients dropped out in 5 years follow up and we treated these data as censored data. Long - term thrombosis related complications include stenosis of graft, cardiac infarction, cerebral vascular events and stroke. Among them, stenosis of graft was assessed by coronary angiography and computed tomography

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angiography and cerebral vascular events include transient ischemic attack and coma caused by arterial thrombosis confirmed by computed tomography and transcranial

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doppler. These MACCEs included death, myocardial infarction, target vessel revascularization, and stroke. All clinical MACCEs were validated by a review of

results.

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medical records by a senior cardiologist who was blind to the endothelial function

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2.4. Statistical methods

Descriptive statistics were used to analyze the demographic data and compared

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by categorical variables which were treated as frequency and percentages, and then compared by Chi-square test or Fisher’s exact test. Continuous variables were described in the form of interquartile range and compared by analysis of Mann-Whitney U test as non-parametric test. The cumulative 5-year event-free survival was estimated by Kaplan-Meier method and survival curves compared by log-rank test. Univariable and multivariable logistic analyses were performed in order to assess 6

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the associations of thrombosis (perioperative) and thrombosis related complications with infection using Odds Ratio(OR) after adjusting by covariates including age, Cr, ACC, CPB, renal failure, cardiac arrest, chronic lung disease, CPB, IABP, ICU time, tracheal intubation time and distalanastomosis of IMA. Hazard ratios (HR) of MACCEs were estimated by Cox proportional hazards regression. All comparisons were two-sided, with statistical significance defined as p less than 0.05. All statistical

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analyses were performed with SAS 9.4 software (SAS Institute, Cary, NC, USA). 3. Results 3.1 Group screening

3003 patients with CABG procedure in 2001–2006 were identified from the

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hospital. Two patients were excluded because of the loss information. After screening, 75 patients suffering from infection and 2926 from control comprised the study population (Figure 1). 3.2 Baseline characteristics

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The demographic and clinical characteristics of patients are shown in Table 1. The mean age of this study was 61(54, 67) years in control group vs 65(59, 71) years

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in infection group, the mean body mass index was 25.4 (23.5, 27.4) kg/m2 vs 25.02(23.1, 27.7) kg/m2 in control group, and the proportion of male was 16.13%.

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The smokers accounted for 53.25% in the control group vs 61.33% in infection group. In the infection group. 53.11% of patients had undergone previous cardiac infarction

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in the control group vs 54.67% in the infection group. Renal failure in the control group was 0.92 % vs 4 % in the infection group. In addition, the creatinine values was

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87μmol/L in the control group vs 97.0 μmol/L in the infection group. 3.3 Intraoperative factors 1941 (66.34%) patients underwent cardiopulmonary bypass (CPB) in the control

group and 58(77.33%) in the infection group (P<0.05). Moreover, the bypass time and aortic cross-clamp (ACC) time in control group and infection group were 90(0,117) min vs 112(75,149) min and 57(0, 77) min vs 65(35, 85) min respectively. The use of blood products did not affect infection [2546(87.01) vs 66(88.0), P, 0.802]. 7

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[142(4.89%) vs 2(2.67%) and 161(5.50%) vs 11(14.67%)] patients did not accepting saphenous vein and internal mammary artery respectively. The percentage of patients accepted two saphenous veins were 1883(64.35%) vs 51(68.00%) in the control and infection group. The percentage of accepting one distal anastomosis of IMA were 2707(92.52%) vs 63(84.00%) in the two groups. 3.4 Postoperative factors

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The percentage use of Intra-aortic balloon pumping (IABP) were 25(0.85%) vs

8(10.67%) in the control and infection group. The length of stay in intensive care unit (ICU) and tracheal intubation were 65(41, 92) hour vs 114(66, 222) hour and 12(9, 17) hour vs 17(14, 66) hour in the two groups.

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3.5 Infection and thrombosis

Univariable analysis: Among the 75 cases of infection [pneumonia (34, 45.3%), SSI (39, 52%), urinary tract infection (3, 4%), sepsis (10, 13.3%), among them infection above two sites (11, 14.6%)] and 2926 cases of control, 19 (25.33%) and 46

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(1.57%) had thrombosis in perioperative respectively. There is statistical significant difference in the relationship between infection and perioperative thrombus (OR,

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21.242; 95% CI, 11.701-38.565). As for long - term thrombosis related complications; there is no relationship with perioperative infection. Multivariate analysis: Adjusted

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for other infection risk factors, any infection increased the odds of thrombosis by 5.132-fold (95%CI: 2.040, 12.911; p-value<0.0001) compared to control (Table 2).

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3.6 Infection and MACCEs Ninety-seven patients (1.9%) suffered from MACCEs during follow-up. Table 3

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showed infection was not associated with a marked increase in MACCEs (HR, 1.855; 95% CI, 0.929-3.704; p-value=0.080). Age was associated with a marked increase in MACCEs (HR, 1.040; 95% CI, 1.026-1.054; p-value<0.0001), after we adjusted for patient’s Age, creatinine, ACC, CPB, renal failure, cardiac arrest, saphenous vein and Distal anastomosis of IMA by adjusted multifactor analysis . Figure 2 depicts the unadjusted time-varying effect of infection on MACCEs. Extended Kaplan-Meier curve with 95% confidence intervals for MACCEs showed there was no statistical 8

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difference (p-value= 0.649). 4. Discussion The study demonstrated that overall infection was an independent predictor of perioperative thrombosis after coronary artery bypass grafting for the first time. The current study did not support the effect of perioperative infection on the long-term thrombosis related complications and MACCEs.

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There are many studies regarding infection occurred in ICU especially in low and middle-income countries [10, 16-18]. Nevertheless, studies of infection in patients after cardiac surgery were rare [19]. The risk factors including elder age, prematurity, younger age, presence of congenital anomaly and open sternum. Besides,

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extracorporeal membrane oxygenation was independently associated with infection. Our study demonstrated that age, creatinine, ACC, CPB, renal failure, cardiac arrest, saphenous vein and distal anastomosis of IMA, length of stay in ICU, tracheal intubation time, use of left ventricular assist and IABP were the risks factors of

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infection in CABG patients. Which is similar with previous studies [20]. CPB maybe one of the reasons accounting for the infection after CABG. Other studies

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contradictory illustrated leukodepletion during CPB results in neutrophil sequestration by a short time, decreased IL-10 serum levels, and lower worsening of lung function

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only temporarily [21].

Previous studies have shown that infectious patients from trauma increased the

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risk of developing cardiac injury, which may contribute to higher mortality subsequently [22]. In addition, once such patients were infected, the prognosis was

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poor with significant higher rates of myocardial damage compared to those without infection [23]. The findings of the current study were in accord with studies showing infection had no effect on MACCEs. Lola Levdiotou and colleagues illustrated that proportion of CABG patients at high-risk for infection was increasing because of the aging population and more conditions conferring both cardiovascular and infectious risks (obesity, diabetes mellitus) among this population [24]. As for cardiac surgery, the postoperative infectious complications were associated with a high-risk patient 9

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profile, and elevated risk of early death after hospital discharge [23]. Nevertheless, the reasons for this prolonged effects are unclear. Recent study revealed the mechanisms, consequences, and prevention of coronary graft failure [25]. They suggested that early coronary graft failure was caused by acute thrombosis, secondary to either direct endothelial injury or endothelial activation, leading to prothrombotic phenotype [26]. Endothelial injury is caused by surgical manipulations and endothelial cell activation

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because of hemodynamic stress or transient ischemia resulting release of prothrombotic and proinflammatory molecules that trigger the thrombotic cascade causing acute occlusion [27]. However, the graft stenosis in our study did not related with perioperative infection. Maybe there were too many uncontrollable factors

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affecting the graft stenosis during the long-term follow-up, such as smoking, lipid levels, inflammation, stress, arrhythmia, etc. Therefore, it is understandable that short-term infection cannot affect long-term graft stenosis.

Numerous studies illustrated that low-grade inflammation involved the

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pathophysiological process of coronary artery disease. Danesh and colleagues proved that C - reactive protein, the erythrocyte sedimentation rate and von Willebrand factor,

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as inflammatory biomarkers, were sufficiently stable for potential use in prediction of long-term coronary heart disease [6]. Moreover, there is a strong relationship of

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cholesterol levels and sepsis in coronary atherosclerosis patients [28]. However, there are a limited number of studies examining the relationship between overall infection

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and thrombosis in patients accepting CABG or PCI. A case report illustrated that coronary stent infection presented as recurrent stent thrombosis after PCI [9].And the

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higher white blood cell (WBC) may predict a poor functional outcome and severe stroke in patients after acute ischemia. Many studies involved inflammation in cardiopulmonary bypass and the cross talk

between inflammation and coagulation [29]. Similarity of coagulation and inflammation happened in that process. The effect of neutrophil extracellular trap (NET) on deep vein thrombosis provided us the thought of interaction of thrombosis and neutrophil [30]. NETs are large, extracellular, web-like structures composed of 10

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cytosolic and granule proteins. Although the majority of DNA in NETs originates from the nucleus, meanwhile, these structures contain mitochondrial DNA. NETs trap, neutralize and kill bacteria, fungi, viruses. Besides, it can participate in the process of atherosclerosis [31]. That most of the vein thrombosis occurred after infection in our study maybe support this mechanism. Therefore, neutrophils may play a bridging role between infection and thrombosis, which will need further study.

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The current study has some limitations: First, although we did our best to get the data, the number in this study is not very large and not the latest. Second, as this is a clinical retrospective study, the mechanism was unsubstantiated, such as the function of endothelial function and its interaction with the leukocyte. Moreover, since this is a

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single-center retrospective study, it is limited to Asian populations and does not represent all races all over the world. We will try to discover it in the future. In summary, our findings suggested that infection maybe one of the risk factors of thrombosis after CABG. Controlling perioperative infection might be an method

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for reducing perioperative thrombosis. Conflict of interest:

Acknowledgements

Fowler VGJ, O’Brien SM, Muhlbaier LH, et al. Clinical predictors of major

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1.

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Figure 1. Flow diagram detailing the selection of patients included in the retrospective analysis.

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after excluding 2 patients.

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75 patients suffering from infection and 2926 control comprised the study population

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Figure 2. Kaplan-Meier for survival probability following-up 5 years. Extended Kaplan-Meier curve with 95% confidence intervals for MACCES showed there was

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no statistical difference (p-value= 0.649).

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Table 1 Baseline Characteristic of Infection cases and controls Control Infection Characteristic N=2926 N=75 Age, medians(IQRs) 61(54,67) 65(59,71) Gender, n (%) 472 (16.13) 11(14.67) BMI, medians(IQRs) 25.4(23.5,27.4) 25.0(23.1,27.7) Smoking, n (%) 1558(53.25) 46(61.33) Creatinine, medians(IQRs) 87(76.5,100.0) 97.0(84.6,109.5) Hbg, medians(IQRs) 135.0(123.0,145.0) 132.5(121.0,144.5) Glucose, medians(IQRs) 5.4(4.8,6.3) 5.4(4.2,5.4) Infective endocarditis, n (%) 1(0.03) 0(0.00) Heart failure, n (%) 75(2.56) 2(2.67) Angina, n (%) 131(4.48) 3(4.00) Arrhythmia, n (%) 309(10.56) 13(17.33) Myocardial infarction, n (%) 1554(53.11) 41(54.67) Ef, medians(IQRs) 60.0(53.0,66.0) 59(52,66) ACC, medians(IQRs) 57(0,77) 65(35,85) CPB, medians(IQRs) 90(0,117) 112(75,149) Surgery or PCI History, n (%) 616(21.05) 14(18.67) 17

P-value <0.001 0.733 0.364 0.166 <0.001 0.347 0.327 0.873 0.955 0.843 0.061 0.790 0.890 0.016 <0.001 0.616

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2419(83.67) 414(14.15) 83*(2.84) 10(0.34) 760(25.97)

57(76.00) 10(13.33) 7(9.33) 1(1.33) 22(29.33)

0.513

215(7.35)

6(8.00)

0.831

27(0.92) 1941(66.34) 1940(66.30)

3(4.00) 58(77.33) 58(77.33)

0.008 0.046 0.046 <0.001

142(4.89) 585(19.99) 1883(64.35)

2(2.67) 9(12.00) 51(68.00)

315(10.77)

13(17.33)

CR IP T

≥3

0.005

AN US

Chronic Lung disease, n (%) No Mild Moderate Severe Diabetes, n (%) Peripheral Vascular disease, n (%) Renal failure, n (%) On-pump CPB, n (%) Cardiac arrest, n (%) Saphenous vein, n (%) 0 1 2

161(5.50) 2707(92.52)

11(14.67) 63(84.00)

≥2

58(1.98)

1(1.33)

M

Distal anastomosis of IMA, n (%) 0 1

0.009

AC

CE

PT

ED

Blood products n (%) 2546(87.01) 66(88.0) 0.802 IABP, n (%) 25(0.85) 8(10.67) <0.001 ICU time, n (%) 65(41, 92) 114(66, 222) <0.001 Tracheal intubation time 12(9, 17) 17(14, 66) <0.001 n (%) BMI: body mass index; Hbg: hemoglobin ; Ef: left ventricular ejection fraction; ACC: aortic cross-clamp; CPB:cardiopulmonary bypass; IMA:internal mammary artery; IABP: intra-aortic balloon counterpulsation Table 2. The relationship between infection and thrombosis and thrombosis related complications Adjusted 95% CI for OR 95% CI for OR P-value P-value OR* adjusted OR 21.24 (11.701, (2.040, Thrombosis <0.001 5.132 <0.001 2 38.565) 12.911) (0.249, Stenosis of graft 0.744 (0.180, 3.071) 0.683 1.082 0.916 4.703) (0.084, Cardiac Infarction 1.116 (0.151, 8.257) 0.914 0.774 0.779 7.172) Cerebral vascular (0.386, 1.653 (0.813, 3.361) 0.165 0.910 0.828 events 2.143) Stroke 0.842 (0.262, 2.706) 0.773 0.480 (0.130, 0.271 18

ACCEPTED MANUSCRIPT

1.772) *: OR adjusted by age, ACC, CPB, Renal failure, Cardiac arrest, Chronic Lung disease, On-pump CPB, IABP, ICU time, traceal intubation time and Distal anastomosis of IMA. Table 3. Long-term survival analysis of MACCEs for the patients Adjusted HR 95% CI for adjusted HR P-value 0.929

3.704

0.080

age

1.040

1.026

1.054

<0.001

Cr

1.000

0.995

1.006

0.882

ACC

1.000

0.997

1.003

0.978

CPB

0.999

0.997

1.002

0.639

Chronic lung disease

1 1.000

0.752

1.330

0.999

Chronic lung disease

2 1.180

0.696

2.001

0.538

Chronic lung disease

3 1.338

0.331

5.407

0.682

2.931

1.313

6.543

0.009

>999

<0.001

>999

0.976

<0.001

<0.001

>999

0.974

M ED

Renal failure

PT

Cardiac arrest

CR IP T

0 1.855

AN US

Infection

CE

On-pump CPB

1 1.128

0.706

1.802

0.615

Distal anastomosis of IMA

2 1.117

0.443

2.820

0.815

IABP

1.454

0.632

3.344

0.378

ICU time

1.002

1.001

1.003

0.005

Tracheal intubation time

1.001

0.999

1.003

0.448

AC

Distal anastomosis of IMA

19