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SHOULD WE ABLATE ATRIAL FIBRILLATION DURING CORONARY ARTERY BYPASS GRAFTING AND AORTIC VALVE REPLACEMENT?
S170
Canadian Journal of Cardiology Volume 31 2015
BACKGROUND:
Single stage hybrid aortic arch repair is a novel technique advocated for management of diffuse thoracic aortic pathology. Type II hybrid aortic repair involves surgical replacement of the ascending aorta with a Dacron graft, proximalization of arch vessels by debranching and Zone 0 stent graft deployment into the Dacron ascending aortic graft. We describe our completed experience with this technique, lessons learnt and reasons for evolution to a Zone 2 arch replacement technique. METHODS: This single centre retrospective study includes 23 consecutive patients (65% male) who underwent type II hybrid arch replacement with a 4 branch Bavaria graft and Zone 0 endovascular stent graft placement, from November 2008 to July 2014. Follow up imaging was performed as per a pre-determined protocol. Imaging was reviewed by a dedicated cardiovascular radiologist to evaluate early and late outcomes and complications. RESULTS: Indications included aortic dissection (n¼13), aortic aneurysm (n¼9),and penetrating atherosclerotic ulcer (n¼1), all involving the ascending aorta, arch and descending thoracic aorta. There was 1 intra-operative death. One patient was lost to follow up after 12 months. Mean imaging follow-up was 33 months (Range 4 to 72 months). One third of patients had mean follow up greater than 4.5 years. Three patients required 4 re-interventions for proximal landing zone complications -stent graft buckling (n¼1), graft migration (n¼1) and persistent Type 1a endoleak (n¼2). There was no stent graft fracture. Proximal stent graft bird beaking within Zone 0 was seen along the lesser curve of the Dacron graft in 15 patients, 4 of which caused greater than 2 cm non-apposition. At 6 year clinical follow up there was no aortic rupture or late mortality. CONCLUSIONS: Perioperative and midterm survival with Hybrid Type II technique appears to be favourable. However, current generation of endografts deployed in Zone 0 have limitations in their ability to conform to the double curve of the ascending aorta, arch and descending thoracic aorta. Based on proximal landing zone complications and non-ideal apposition in the ascending aortic graft, we have moved towards extension of the surgical graft into Zone 2 of the arch with creation of an idealized Dacron landing zone for the stent graft that does not involve a double curve.
323 SHOULD WE ABLATE ATRIAL FIBRILLATION DURING CORONARY ARTERY BYPASS GRAFTING AND AORTIC VALVE REPLACEMENT? D Kimmaliardjuk, T Al-Atassi, C Dagenais, M Bourke, B Lam, F Rubens Ottawa, Ontario BACKGROUND: Atrial fibrillation (AF) is associated with significant morbidity and mortality. Whether adding AF ablation to coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) raises the operative risk remains unclear. Herein we evaluate the safety and efficacy of concomitant AF ablation during CABG and/or AVR in contemporary patients. METHODS: This is a single-center retrospective study of prospectively collected data. All patients with preoperative AF presenting for CABG and/or AVR between 2009 and 2013 were included. These patients were divided into an intervention group that underwent concomitant AF ablation and a control group that did not. Preoperative, operative, and postoperative data was obtained on all patients. RESULTS: Patients with preoperative AF (n¼375) presenting for CABG (44%), AVR (27%), or combined CABG/AVR (29%), were divided into an intervention (n¼129) and control (n¼246) groups. Both groups had similar baseline characteristics except for a younger intervention group (711 vs. 741 years, p¼0.048) with higher male proportion (80% vs. 70%, p¼0.031). The intervention group had less redo (4% vs. 11%, p¼0.015) and AVR cases (19% vs. 31%, p¼0.017) balanced by more CABG (50% vs. 41%, p¼0.113) and combined cases (31% vs. 28%, p¼0.549), with a similar urgency profile. The intervention significantly lengthened surgery, cardiopulmonary bypass, and cross-clamp times, adding a mean of 325, 313, and 223 minutes,
Abstracts
respectively. Both groups had similar unadjusted rates of inhospital mortality, myocardial infarction, stroke, reopening, acute renal failure, and prolonged ventilation. The intensive care and hospital length of stays were similar. Postoperative AF was significantly lower in the intervention group (27% vs. 78%, p<0.0001). After adjusting for clinical and operative characteristics, the intervention group showed a trend towards lower odds of mortality (p¼0.058) and prolonged ventilation (p¼0.078), and significantly lower odds of postoperative AF (OR 0.07; p<0.001) compared to controls. CONCLUSIONS: To date, this represents the largest contemporary data demonstrating that patients with preoperative AF undergoing CABG and/or AVR can safely undergo concomitant AF ablation without increased surgical risk. Moreover, surgical AF ablation in this patient population is effective at reducing the burden of postoperative AF.
S171
CABG+valve procedures. Following surgery, patients with greater obesity were more likely to experience in-hospital mortality (Table 1). Furthermore, they were more likely to experience greater initial ventilation times, initial and overall ICU hours and rates of readmission to ICU (Table 1). Following adjustment for differences in baseline characteristics and surgery type, increasing obesity was associated with greater likelihood of ICU LOS > 48 hours. [A: OR 1.00 (ref); B: OR 1.00 (95% CI 0.73-1.35); C: OR 1.10 (95% CI 0.771.56); D: OR 2.45 (95% CI 1.58-3.78); E: OR 4.40 (95% CI 2.53-7.66)]. CONCLUSION: In patients undergoing cardiac surgery, increasing obesity was associated with a significant increase in ICU resource utilization. Further study is required to determine how this deleterious effect of obesity may be reduced in order to optimize heath care efficiency following cardiac surgery.
324 IMPACT OF OBESITY ON INTENSIVE CARE UNIT RESOURCE UTILIZATION IN PATIENTS POST CARDIAC SURGERY BR Rosvall, JB MacLeod, AM Yip, S Lutchmedial, CD Brown, R Forgie, MP Pelletier, A Hassan Saint John, New Brunswick BACKGROUND:
An increasing number of patients undergoing cardiac surgery are obese. While much has been published about the effect of obesity on post-operative morbidity and mortality, little is known regarding the impact of obesity on intensive care unit (ICU) resource utilization in these patients. The purpose of this study is to examine the impact of obesity on ICU resource utilization following cardiac surgery at a single institution. METHODS: All patients who underwent cardiac surgery via a median sternotomy between January 2006 and December 2013 were considered. Those with a BMI < 18.5 were excluded, as well as those having undergone an emergent procedure or who experienced an intra-operative death. The remaining patients were stratified into one of the following weight categories as defined by the World Health Organization - A: Normal (BMI 18.5-24.99); B: Pre-Obese (BMI 2529.99); C: Obese Class I (BMI 30-34.99); D: Obese Class II (BMI 35-39.99); E: Obese Class III (BMI 40). Comparisons between weight categories were carried out on the basis of baseline and intra-operative characteristics as well as inhospital outcomes. The risk-adjusted effect of weight category on ICU LOS > 48 hours was determined using multivariable logistic regression modeling. RESULTS: A total of 5365 patients were included in the final analysis [A: n¼1178 (22%); B: n¼2240 (42%); C: n¼1362 (25%); D: n¼441 (8%); E: n¼144 (3%)]. Pre-operatively, increasing obesity was associated with greater co-morbid disease. Intra-operatively, patients with a BMI 40 were more likely to undergo isolated valve procedures, while patients with a BMI < 35 were more likely to undergo combined
325 WHAT IS THE MOST COST EFFECTIVE PHARMACOLOGICAL METHOD TO PREVENT DELIRIUM POST-CARDIAC SURGERY? Y Jung, J Witt, RC Arora, RA Manji Winnipeg, Manitoba BACKGROUND:
Delirious patients are at increased risk of falls, and increased risk of self-extubation with their associated complications. Delirious patients are also at increased risk of dementia over a 10 year period. Drug classes used to treat delirium include narcotics/benzodiazepines, typical antipsychotics (i.e. haloperidol), atypical antipsychotics (i.e. risperiodone) and alpha2-adrenergic agonists (dexmedetomidine (dex)). OBJECTIVE: To determine the most cost effective (C/E) pharmacological method from 4 drug classes outlined to prevent delirium post cardiac surgery taking into account the potential “costs” associated with having delirium (risks of falls, self-extubation and dementia) and the “costs” of the drugs. METHODS: Decision analysis and Markov modeling was used to evaluate the cost and effectiveness of four prophylactic strategies to prevent delirium in cardiac surgery patients. Values for probabilities of events, costs, and quality adjusted life years (QALYs) were obtained from the literature, local pharmacy and extrapolation. The Markov cycle is 10 years to allow effects of dementia to manifest. A discount rate of 5% was used. Sensitivity analysis was done to test the robustness of the model.
Canadian Journal of Cardiology Volume 31 2015
BACKGROUND:
Single stage hybrid aortic arch repair is a novel technique advocated for management of diffuse thoracic aortic pathology. Type II hybrid aortic repair involves surgical replacement of the ascending aorta with a Dacron graft, proximalization of arch vessels by debranching and Zone 0 stent graft deployment into the Dacron ascending aortic graft. We describe our completed experience with this technique, lessons learnt and reasons for evolution to a Zone 2 arch replacement technique. METHODS: This single centre retrospective study includes 23 consecutive patients (65% male) who underwent type II hybrid arch replacement with a 4 branch Bavaria graft and Zone 0 endovascular stent graft placement, from November 2008 to July 2014. Follow up imaging was performed as per a pre-determined protocol. Imaging was reviewed by a dedicated cardiovascular radiologist to evaluate early and late outcomes and complications. RESULTS: Indications included aortic dissection (n¼13), aortic aneurysm (n¼9),and penetrating atherosclerotic ulcer (n¼1), all involving the ascending aorta, arch and descending thoracic aorta. There was 1 intra-operative death. One patient was lost to follow up after 12 months. Mean imaging follow-up was 33 months (Range 4 to 72 months). One third of patients had mean follow up greater than 4.5 years. Three patients required 4 re-interventions for proximal landing zone complications -stent graft buckling (n¼1), graft migration (n¼1) and persistent Type 1a endoleak (n¼2). There was no stent graft fracture. Proximal stent graft bird beaking within Zone 0 was seen along the lesser curve of the Dacron graft in 15 patients, 4 of which caused greater than 2 cm non-apposition. At 6 year clinical follow up there was no aortic rupture or late mortality. CONCLUSIONS: Perioperative and midterm survival with Hybrid Type II technique appears to be favourable. However, current generation of endografts deployed in Zone 0 have limitations in their ability to conform to the double curve of the ascending aorta, arch and descending thoracic aorta. Based on proximal landing zone complications and non-ideal apposition in the ascending aortic graft, we have moved towards extension of the surgical graft into Zone 2 of the arch with creation of an idealized Dacron landing zone for the stent graft that does not involve a double curve.
323 SHOULD WE ABLATE ATRIAL FIBRILLATION DURING CORONARY ARTERY BYPASS GRAFTING AND AORTIC VALVE REPLACEMENT? D Kimmaliardjuk, T Al-Atassi, C Dagenais, M Bourke, B Lam, F Rubens Ottawa, Ontario BACKGROUND: Atrial fibrillation (AF) is associated with significant morbidity and mortality. Whether adding AF ablation to coronary artery bypass grafting (CABG) and/or aortic valve replacement (AVR) raises the operative risk remains unclear. Herein we evaluate the safety and efficacy of concomitant AF ablation during CABG and/or AVR in contemporary patients. METHODS: This is a single-center retrospective study of prospectively collected data. All patients with preoperative AF presenting for CABG and/or AVR between 2009 and 2013 were included. These patients were divided into an intervention group that underwent concomitant AF ablation and a control group that did not. Preoperative, operative, and postoperative data was obtained on all patients. RESULTS: Patients with preoperative AF (n¼375) presenting for CABG (44%), AVR (27%), or combined CABG/AVR (29%), were divided into an intervention (n¼129) and control (n¼246) groups. Both groups had similar baseline characteristics except for a younger intervention group (711 vs. 741 years, p¼0.048) with higher male proportion (80% vs. 70%, p¼0.031). The intervention group had less redo (4% vs. 11%, p¼0.015) and AVR cases (19% vs. 31%, p¼0.017) balanced by more CABG (50% vs. 41%, p¼0.113) and combined cases (31% vs. 28%, p¼0.549), with a similar urgency profile. The intervention significantly lengthened surgery, cardiopulmonary bypass, and cross-clamp times, adding a mean of 325, 313, and 223 minutes,
Abstracts
respectively. Both groups had similar unadjusted rates of inhospital mortality, myocardial infarction, stroke, reopening, acute renal failure, and prolonged ventilation. The intensive care and hospital length of stays were similar. Postoperative AF was significantly lower in the intervention group (27% vs. 78%, p<0.0001). After adjusting for clinical and operative characteristics, the intervention group showed a trend towards lower odds of mortality (p¼0.058) and prolonged ventilation (p¼0.078), and significantly lower odds of postoperative AF (OR 0.07; p<0.001) compared to controls. CONCLUSIONS: To date, this represents the largest contemporary data demonstrating that patients with preoperative AF undergoing CABG and/or AVR can safely undergo concomitant AF ablation without increased surgical risk. Moreover, surgical AF ablation in this patient population is effective at reducing the burden of postoperative AF.
S171
CABG+valve procedures. Following surgery, patients with greater obesity were more likely to experience in-hospital mortality (Table 1). Furthermore, they were more likely to experience greater initial ventilation times, initial and overall ICU hours and rates of readmission to ICU (Table 1). Following adjustment for differences in baseline characteristics and surgery type, increasing obesity was associated with greater likelihood of ICU LOS > 48 hours. [A: OR 1.00 (ref); B: OR 1.00 (95% CI 0.73-1.35); C: OR 1.10 (95% CI 0.771.56); D: OR 2.45 (95% CI 1.58-3.78); E: OR 4.40 (95% CI 2.53-7.66)]. CONCLUSION: In patients undergoing cardiac surgery, increasing obesity was associated with a significant increase in ICU resource utilization. Further study is required to determine how this deleterious effect of obesity may be reduced in order to optimize heath care efficiency following cardiac surgery.
324 IMPACT OF OBESITY ON INTENSIVE CARE UNIT RESOURCE UTILIZATION IN PATIENTS POST CARDIAC SURGERY BR Rosvall, JB MacLeod, AM Yip, S Lutchmedial, CD Brown, R Forgie, MP Pelletier, A Hassan Saint John, New Brunswick BACKGROUND:
An increasing number of patients undergoing cardiac surgery are obese. While much has been published about the effect of obesity on post-operative morbidity and mortality, little is known regarding the impact of obesity on intensive care unit (ICU) resource utilization in these patients. The purpose of this study is to examine the impact of obesity on ICU resource utilization following cardiac surgery at a single institution. METHODS: All patients who underwent cardiac surgery via a median sternotomy between January 2006 and December 2013 were considered. Those with a BMI < 18.5 were excluded, as well as those having undergone an emergent procedure or who experienced an intra-operative death. The remaining patients were stratified into one of the following weight categories as defined by the World Health Organization - A: Normal (BMI 18.5-24.99); B: Pre-Obese (BMI 2529.99); C: Obese Class I (BMI 30-34.99); D: Obese Class II (BMI 35-39.99); E: Obese Class III (BMI 40). Comparisons between weight categories were carried out on the basis of baseline and intra-operative characteristics as well as inhospital outcomes. The risk-adjusted effect of weight category on ICU LOS > 48 hours was determined using multivariable logistic regression modeling. RESULTS: A total of 5365 patients were included in the final analysis [A: n¼1178 (22%); B: n¼2240 (42%); C: n¼1362 (25%); D: n¼441 (8%); E: n¼144 (3%)]. Pre-operatively, increasing obesity was associated with greater co-morbid disease. Intra-operatively, patients with a BMI 40 were more likely to undergo isolated valve procedures, while patients with a BMI < 35 were more likely to undergo combined
325 WHAT IS THE MOST COST EFFECTIVE PHARMACOLOGICAL METHOD TO PREVENT DELIRIUM POST-CARDIAC SURGERY? Y Jung, J Witt, RC Arora, RA Manji Winnipeg, Manitoba BACKGROUND:
Delirious patients are at increased risk of falls, and increased risk of self-extubation with their associated complications. Delirious patients are also at increased risk of dementia over a 10 year period. Drug classes used to treat delirium include narcotics/benzodiazepines, typical antipsychotics (i.e. haloperidol), atypical antipsychotics (i.e. risperiodone) and alpha2-adrenergic agonists (dexmedetomidine (dex)). OBJECTIVE: To determine the most cost effective (C/E) pharmacological method from 4 drug classes outlined to prevent delirium post cardiac surgery taking into account the potential “costs” associated with having delirium (risks of falls, self-extubation and dementia) and the “costs” of the drugs. METHODS: Decision analysis and Markov modeling was used to evaluate the cost and effectiveness of four prophylactic strategies to prevent delirium in cardiac surgery patients. Values for probabilities of events, costs, and quality adjusted life years (QALYs) were obtained from the literature, local pharmacy and extrapolation. The Markov cycle is 10 years to allow effects of dementia to manifest. A discount rate of 5% was used. Sensitivity analysis was done to test the robustness of the model.