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Off-Pump Coronary Artery Bypass Improves Postoperative Morbidity in Aboriginal and Torres Strait Islander (ATSI) Australians
792
Abstracts Scientific sessions abstract presentations
Heart, Lung and Circulation 2011;20:778–806
ABSTRACTS
late complications, not addressed by conventional surgical repair of acute DeBakey I aortic dissection. These results provide important evidence to support a more universal application of this technique in patients affected by acute DeBakey I dissection. doi:10.1016/j.hlc.2011.08.039 POSTER PRESENTATIONS 2011 Poster Presentation/Panel 1 Morbidity and Morality Outcomes of Aboriginal and Torres Strait Islander Peoples After Isolated Cornary Artery Bypass Graft Surgery Anil Prabhu, Phillip J. Tully, Sigrid Bennetts ∗ , Robert A. Baker
Tuble, Jayme
Cardiac and Thoracic Surgical Unit, Department of Medicine, Flinders Medical Centre and Flinders University of South Australia, Adelaide, South Australia, Australia Background: Aboriginal and Torres Strait Islander (ATSI) peoples have been known for their poorer outcomes after cardiac surgery. This study compared the outcomes of ATSI peoples undergoing isolated coronary artery bypass graft (CABG) procedure to the non-ATSI population and evaluated whether the differences persist after propensity matching the groups for major cardiovascular risk factors. Methods: From January 1998 to September 2008, N = 2748 consecutive patients underwent isolated CABG surgery at the Flinders Medical Centre, South Australia, Australia. From n = 297 ATSI patients (10.8% of total), 180 were matched based on age, sex, left ventricular ejection fraction, recent myocardial infarction, tobacco smoking, diabetes, renal disease and history of stroke. Postoperative cardiac morbidity was confirmed after surgery during the index hospitalisation and included stroke, renal failure, ventilation >24 h, sternal wound infection, reoperation, myocardial infarction and 30-day mortality at any location. Long-term all-cause survival was analysed with the log-rank test and Cox proportional hazard model. Results: In the total sample, ATSI patients experienced a greater proportion of renal dialysis, extended ventilation and the combined morbidity endpoint (p < 10). There were 14,121 person years of survival for analysis with a median follow-up of 4.9 years (interquartile range 2.6–7.5). In the total sample ATSI patients were found to experience poorer survival by comparison to non-ATSI patients [16.5% vs. 14.2%, log-rank test χ2 (1) 5.92, p = .02]. Amongst the matched sample (n = 360) it was found that ATSI patients generally experienced a greater proportion of reoperation and the combined morbidity endpoint (p < 10). Poorer survival by comparison to non-ATSI patients was also found [14.4% vs. 6.7%, log-rank χ2 (1) 6.28, p = .01]. Kaplan–Meier graph for all cause mortality by race in matched sample
Conclusion: Australian ATSI experienced greater in hospital morbidity and poorer long term survival after isolated CABG surgery. After propensity matching, this reduction in survival was more marked. doi:10.1016/j.hlc.2011.08.040 2011 Poster Presentations/Panel 2 Off-Pump Coronary Artery Bypass Improves Postoperative Morbidity in Aboriginal and Torres Strait Islander (ATSI) Australians Paul De Sciscio, Robert A. Baker, Jayme Bennetts ∗ Cardiac and Thoracic Surgical Unit, Department of Medicine, Flinders Medical Centre and Flinders University of South Australia, Adelaide, South Australia, Australia Introduction: Coronary artery disease (CAD) is the leading cause of morbidity, mortality and reduced life expectancy in Aboriginal and Torres Strait Islander (ATSI) Australians. CABG is considered a highly effective revascularisation strategy, however previous studies have reported increased postoperative adverse events and reduced five year survival after conventional CABG in ATSI. Off Pump CAG (OPCAB) has been shown to have improved outcomes in high risk groups, namely diabetics and female sex. This study sought to investigate whether off-pump coronary artery bypass (OPCAB) reduces postoperative morbidity and mortality in ATSI Australians. Methods: The Flinders Medical Centre Cardiac Database was searched for all ATSI patients who underwent primary isolated CABG from 2000 to 2010. Periperative cardiac morbidity was confirmed during the index hospitalisation including stroke, renal failure, ventilation >24 h, deep sternal wound infection, reoperation, myocardial infarction (AMI) and 30-day all cause mortality at any location (reported as STS defined combined endpoint and AMI). Results: 320 consecutive patients were identified of which, 57 (18%) underwent OPCAB and 263 (82%) underwent conventional CABG. Combined endpoint and AMI
Abstracts Scientific sessions abstract presentations
was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 pts (28.9%), p < 0.05).
Age (years) Male sex, n (%) Mortality Stroke AMI, n (%) New onset renal failure, n (%) Prolonged ventilation, n (%) Deep sternal wound infection, n (%) Reoperation, n (%)
OPCAB (n = 57)
CABG (n = 263)
49.6 34 (59.6%) 1 (1.7%) 0 (0) 0 (0) 2 (3.5%)
51.7 190 (72.2%) 5 (1.9%) 1 (0.3%) 14 (5.3%) 21 (8.0%)
8 (14%)
45 (17.1%)
0 (0)
2 (0.7%)
3 (5.2%)
17 (6.5%)
Conclusions: OPCAB reduced postoperative morbidity in ATSI patients. Short-term mortality was comparable between OPCAB and CABG groups. These findings suggest that OPCAB may be a better technique for surgical revascularisation in this group of patients.
793
factors, intraoperative variables and post operative complications analysed. Results: There were 94 males and 41 females. Age range varied from 30 years to 73 years with a mean age of 54.11 years. 128 (94.8%) patients underwent elective procedure while seven (5.18%) patients were operated on an urgent basis. There was a high incidence of diabetes (84.4%), hypertension (76.2%), hypercholesterolaemia (63.7%) and smoking (91.1%). 128 patients (94.8%) had left internal mammary artery as conduit. The number of grafts varied between one and six with the average number of grafts being 3.3. The major morbidities were Atrial Fibrillation in 43 patients (31.8%), reexploration for bleeding in 5 (3.7%) and sternal wound breakdown in six patients (4.4%). There were four in hospital deaths (2.9%). Conclusion: Early outcome of CABG in Indigenous Australians is encouraging considering the high association of multiple comorbidities in this cohort of patients. Further analysis is required to analyse this group of patients with a propensity matched non-Indigenous population. Moreover we need to have long term follow up in this group of patients to analyse whether this initial promising result translates into a good long term outcome in terms of cardiovascular function and quality of life.
Reference doi:10.1016/j.hlc.2011.08.041 2011 Poster Presentations/Panel 3 Outcome of Coronary Artery Bypass Grafting Surgery in Indigenous Australian Population Ritwick Raj Bhuyan ∗ , Gareth Crouch, Krishanu Chaudhuri, James R.M. Edwards, Michael Worthington, Robert G. Stuklis Darcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia Introduction: Cardiovascular disease is more prevalent among Indigenous Australians than non-Indigenous Australians and was the leading cause of death, accounting for 27% of all Indigenous deaths (based on data from Queensland, Western Australia, South Australia and the Northern Territory) [1]. Moreover, Indigenous Australians with cardiovascular disease are more likely to have multiple risk factors than those without cardiovascular disease and they present for Cardiac Surgery 20 years earlier, on average [2]. To date there has been several published reports pertaining to the outcome of open heart surgery in Australian Aboriginal patients. However, none of them specifically investigated the outcome of isolated Coronary Artery Bypass Grafting (CABG) surgery. The aim of this study is to analyse the risk factors, intraoperative variables and the early outcome in this complex cohort of patients undergoing isolated CABG surgery. Methods: The records of 135 consecutive aboriginal patients who underwent isolated CABG in our institution over a 10 year period (January 2001 till December 2010) were retrospectively reviewed. All the preoperative risk
[1] Elizabeth Penm, Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–2005. Canberra: Australian Institute of Health and Welfare; June 2008. [2] Lehman SJ, Baker RA, Aylward PE, Knight JL, Chew DP. Outcome of cardiac surgery in Indigenous Australians. MJA 2009;190:588–93.
doi:10.1016/j.hlc.2011.08.042 2011 Poster Presentations/Panel 4 Challenges in the Diagnosis and Management of Stanford Type A Dissection in Pregnancy Stephanie Ch’ng ∗ , Andrew Goldstein, Julian A. Smith
D.
Cochrane, Jacob
Monash Medical Centre, Melbourne, Australia Background: Stanford type A aortic dissection in pregnancy is potentially catastrophic to both mother and child. With an incidence of 0.0145/1000 pregnancies [1] it is much less common than diseases such as thrombopulmonary embolism (3–40/1000 pregnancies) [2] and pre-eclampsia (50/1000 pregnancies) [3], it is responsible for 10% of direct maternal mortality [4]. Time to diagnosis is often delayed by a low degree of suspicion, atypical presentation and difficulties associated with investigating pregnant women. Management requires early involvement of multiple medical teams and appreciation of potential complications. The ultimate goal is to save both the mother and the child. We describe a nine-year experience of Stanford type A aortic dissections occurring in pregnant women, highlighting potential pitfalls in diagnosis and propose a surgical strat-
ABSTRACTS
Heart, Lung and Circulation 2011;20:778–806
Abstracts Scientific sessions abstract presentations
Heart, Lung and Circulation 2011;20:778–806
ABSTRACTS
late complications, not addressed by conventional surgical repair of acute DeBakey I aortic dissection. These results provide important evidence to support a more universal application of this technique in patients affected by acute DeBakey I dissection. doi:10.1016/j.hlc.2011.08.039 POSTER PRESENTATIONS 2011 Poster Presentation/Panel 1 Morbidity and Morality Outcomes of Aboriginal and Torres Strait Islander Peoples After Isolated Cornary Artery Bypass Graft Surgery Anil Prabhu, Phillip J. Tully, Sigrid Bennetts ∗ , Robert A. Baker
Tuble, Jayme
Cardiac and Thoracic Surgical Unit, Department of Medicine, Flinders Medical Centre and Flinders University of South Australia, Adelaide, South Australia, Australia Background: Aboriginal and Torres Strait Islander (ATSI) peoples have been known for their poorer outcomes after cardiac surgery. This study compared the outcomes of ATSI peoples undergoing isolated coronary artery bypass graft (CABG) procedure to the non-ATSI population and evaluated whether the differences persist after propensity matching the groups for major cardiovascular risk factors. Methods: From January 1998 to September 2008, N = 2748 consecutive patients underwent isolated CABG surgery at the Flinders Medical Centre, South Australia, Australia. From n = 297 ATSI patients (10.8% of total), 180 were matched based on age, sex, left ventricular ejection fraction, recent myocardial infarction, tobacco smoking, diabetes, renal disease and history of stroke. Postoperative cardiac morbidity was confirmed after surgery during the index hospitalisation and included stroke, renal failure, ventilation >24 h, sternal wound infection, reoperation, myocardial infarction and 30-day mortality at any location. Long-term all-cause survival was analysed with the log-rank test and Cox proportional hazard model. Results: In the total sample, ATSI patients experienced a greater proportion of renal dialysis, extended ventilation and the combined morbidity endpoint (p < 10). There were 14,121 person years of survival for analysis with a median follow-up of 4.9 years (interquartile range 2.6–7.5). In the total sample ATSI patients were found to experience poorer survival by comparison to non-ATSI patients [16.5% vs. 14.2%, log-rank test χ2 (1) 5.92, p = .02]. Amongst the matched sample (n = 360) it was found that ATSI patients generally experienced a greater proportion of reoperation and the combined morbidity endpoint (p < 10). Poorer survival by comparison to non-ATSI patients was also found [14.4% vs. 6.7%, log-rank χ2 (1) 6.28, p = .01]. Kaplan–Meier graph for all cause mortality by race in matched sample
Conclusion: Australian ATSI experienced greater in hospital morbidity and poorer long term survival after isolated CABG surgery. After propensity matching, this reduction in survival was more marked. doi:10.1016/j.hlc.2011.08.040 2011 Poster Presentations/Panel 2 Off-Pump Coronary Artery Bypass Improves Postoperative Morbidity in Aboriginal and Torres Strait Islander (ATSI) Australians Paul De Sciscio, Robert A. Baker, Jayme Bennetts ∗ Cardiac and Thoracic Surgical Unit, Department of Medicine, Flinders Medical Centre and Flinders University of South Australia, Adelaide, South Australia, Australia Introduction: Coronary artery disease (CAD) is the leading cause of morbidity, mortality and reduced life expectancy in Aboriginal and Torres Strait Islander (ATSI) Australians. CABG is considered a highly effective revascularisation strategy, however previous studies have reported increased postoperative adverse events and reduced five year survival after conventional CABG in ATSI. Off Pump CAG (OPCAB) has been shown to have improved outcomes in high risk groups, namely diabetics and female sex. This study sought to investigate whether off-pump coronary artery bypass (OPCAB) reduces postoperative morbidity and mortality in ATSI Australians. Methods: The Flinders Medical Centre Cardiac Database was searched for all ATSI patients who underwent primary isolated CABG from 2000 to 2010. Periperative cardiac morbidity was confirmed during the index hospitalisation including stroke, renal failure, ventilation >24 h, deep sternal wound infection, reoperation, myocardial infarction (AMI) and 30-day all cause mortality at any location (reported as STS defined combined endpoint and AMI). Results: 320 consecutive patients were identified of which, 57 (18%) underwent OPCAB and 263 (82%) underwent conventional CABG. Combined endpoint and AMI
Abstracts Scientific sessions abstract presentations
was significantly reduced in patients who underwent OPCAB compared to CABG (9 pts (15.8%) vs. 76 pts (28.9%), p < 0.05).
Age (years) Male sex, n (%) Mortality Stroke AMI, n (%) New onset renal failure, n (%) Prolonged ventilation, n (%) Deep sternal wound infection, n (%) Reoperation, n (%)
OPCAB (n = 57)
CABG (n = 263)
49.6 34 (59.6%) 1 (1.7%) 0 (0) 0 (0) 2 (3.5%)
51.7 190 (72.2%) 5 (1.9%) 1 (0.3%) 14 (5.3%) 21 (8.0%)
8 (14%)
45 (17.1%)
0 (0)
2 (0.7%)
3 (5.2%)
17 (6.5%)
Conclusions: OPCAB reduced postoperative morbidity in ATSI patients. Short-term mortality was comparable between OPCAB and CABG groups. These findings suggest that OPCAB may be a better technique for surgical revascularisation in this group of patients.
793
factors, intraoperative variables and post operative complications analysed. Results: There were 94 males and 41 females. Age range varied from 30 years to 73 years with a mean age of 54.11 years. 128 (94.8%) patients underwent elective procedure while seven (5.18%) patients were operated on an urgent basis. There was a high incidence of diabetes (84.4%), hypertension (76.2%), hypercholesterolaemia (63.7%) and smoking (91.1%). 128 patients (94.8%) had left internal mammary artery as conduit. The number of grafts varied between one and six with the average number of grafts being 3.3. The major morbidities were Atrial Fibrillation in 43 patients (31.8%), reexploration for bleeding in 5 (3.7%) and sternal wound breakdown in six patients (4.4%). There were four in hospital deaths (2.9%). Conclusion: Early outcome of CABG in Indigenous Australians is encouraging considering the high association of multiple comorbidities in this cohort of patients. Further analysis is required to analyse this group of patients with a propensity matched non-Indigenous population. Moreover we need to have long term follow up in this group of patients to analyse whether this initial promising result translates into a good long term outcome in terms of cardiovascular function and quality of life.
Reference doi:10.1016/j.hlc.2011.08.041 2011 Poster Presentations/Panel 3 Outcome of Coronary Artery Bypass Grafting Surgery in Indigenous Australian Population Ritwick Raj Bhuyan ∗ , Gareth Crouch, Krishanu Chaudhuri, James R.M. Edwards, Michael Worthington, Robert G. Stuklis Darcy Sutherland Cardiothoracic Surgical Unit, Royal Adelaide Hospital, Adelaide, South Australia Introduction: Cardiovascular disease is more prevalent among Indigenous Australians than non-Indigenous Australians and was the leading cause of death, accounting for 27% of all Indigenous deaths (based on data from Queensland, Western Australia, South Australia and the Northern Territory) [1]. Moreover, Indigenous Australians with cardiovascular disease are more likely to have multiple risk factors than those without cardiovascular disease and they present for Cardiac Surgery 20 years earlier, on average [2]. To date there has been several published reports pertaining to the outcome of open heart surgery in Australian Aboriginal patients. However, none of them specifically investigated the outcome of isolated Coronary Artery Bypass Grafting (CABG) surgery. The aim of this study is to analyse the risk factors, intraoperative variables and the early outcome in this complex cohort of patients undergoing isolated CABG surgery. Methods: The records of 135 consecutive aboriginal patients who underwent isolated CABG in our institution over a 10 year period (January 2001 till December 2010) were retrospectively reviewed. All the preoperative risk
[1] Elizabeth Penm, Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–2005. Canberra: Australian Institute of Health and Welfare; June 2008. [2] Lehman SJ, Baker RA, Aylward PE, Knight JL, Chew DP. Outcome of cardiac surgery in Indigenous Australians. MJA 2009;190:588–93.
doi:10.1016/j.hlc.2011.08.042 2011 Poster Presentations/Panel 4 Challenges in the Diagnosis and Management of Stanford Type A Dissection in Pregnancy Stephanie Ch’ng ∗ , Andrew Goldstein, Julian A. Smith
D.
Cochrane, Jacob
Monash Medical Centre, Melbourne, Australia Background: Stanford type A aortic dissection in pregnancy is potentially catastrophic to both mother and child. With an incidence of 0.0145/1000 pregnancies [1] it is much less common than diseases such as thrombopulmonary embolism (3–40/1000 pregnancies) [2] and pre-eclampsia (50/1000 pregnancies) [3], it is responsible for 10% of direct maternal mortality [4]. Time to diagnosis is often delayed by a low degree of suspicion, atypical presentation and difficulties associated with investigating pregnant women. Management requires early involvement of multiple medical teams and appreciation of potential complications. The ultimate goal is to save both the mother and the child. We describe a nine-year experience of Stanford type A aortic dissections occurring in pregnant women, highlighting potential pitfalls in diagnosis and propose a surgical strat-
ABSTRACTS
Heart, Lung and Circulation 2011;20:778–806