Objective To investigate the clinical characteristics, risk factors and perioperative outcome of prolonged mechanical ventilation (PMV) in elderly patients undergoing coronary artery bypass grafting (CABG). Methods The data of elderly patients receiving CABG in the Nanjing First Hospital from January 2013 to June 2019 were collected. All patients were divided into a control group and a PMV group according to whether ventilation time≥24 h.The clinical characteristics and risk factors of PMV were compared between the two groups. Variables were 1∶1 balanced through propensity score matching (PSM) and perioperative outcomes of two groups was analyzed. Results Finally 956 patients were collected, including 187 in the PMV group and 769 in the control group. There were 586 males and 370 females aged 70-94 (74.3±3.5) years. Compared with the control group, the PMV group had higher rates of smoking, preoperative renal impairment, intraoperative blood transfusion and intra-aortic balloon pump (IABP) implantation, worse cardiac function, lower glomerular filtration rate and ejection fraction, larger left atrial diameter, longer cardiopulmonary bypass time and aortic cross-clamping time (P<0.05). There was no statistical difference in other clinical data between the two groups (P>0.05). Binary multivariate logistic regression analysis showed that females, smoking, chronic obstructive pulmonary disease, left ventricular ejection fraction≤56.0%, cardiopulmonary bypass time>106.0 min, IABP implantation and intraoperative blood transfusion were independent risk factors for PMV in elderly patients. After PSM, there were 146 patients in the control group and the PMV group, respectively. The PMV group had longer ICU stay and length of hospital stay and more drainage volume compared with the control group (all P<0.05). There was no statistical difference in perioperative mortality or other complications between the two groups (all P>0.05). ConclusionThere are a lot of factors associated with PMV of the elderly patients undergoing on-pump CABG. In order to establish a complete and formal PMV prediction model, clinicians can make a further step of assessment according to perioperative elements, and improve the prognosis of such patients.
Objective To investigate the perioperative clinical effects and follow-up results of minimally invasive coronary artery bypass grafting (MICS CABG) versus conventional coronary artery bypass grafting (CABG) in thoracotomy. Methods The patients who received off-pump CABG in Beijing Anzhen Hospital from January 2017 to October 2021 were collected. Among them, the patients receiving MICS CABG performed by the same surgeon were divided into a minimally invasive group, and the patients receiving median thoracotomy were into a conventional group. By propensity score matching, preoperative data were balanced. Perioperative and postoperative follow-up data of the two groups were compared. Results A total of 890 patients were collected. There were 211 males and 28 females, aged 60.54±9.40 years in the minimally invasive group, and 487 males and 164 females, aged 62.31±8.64 years in the conventional group. After propensity score matching, there were 239 patients in each group. Compared with the conventional group, patients in the minimally invasive group had longer operation time, shorter drainage duration, less drainage volume on the first postoperative day, shorter postoperative hospital stay, and lower rate of positive inotropenic drugs use, while there was no statistical difference in the mean number of bypass grafts, ICU stay, ventilator-assisted time, blood transfusion rate or perioperative complications (P＞0.05). During the median follow-up of 2.25 years, there was no statistical difference in major adverse cardiovascular and cerebrovascular events, including all-cause death, stroke or revascularization between the two groups (P＞0.05). ConclusionReasonable clinical strategies can ensure perioperative and mid-term surgical outcomes of MICS CABG not inferior to conventional CABG. In addition, MICS CABG has the advantages in terms of postoperative hospital stay, postoperative drainage volume, and rate of positive inotropic drugs use.
Objective To evaluate the clinical efficacy of coronary artery bypass grafting in the treatment of coronary artery disease patients aged over 70 years. Methods A total of 160 patients with coronary atherosclerotic heart disease underwent off-pump coronary artery bypass grafting from January 2013 to December 2017. There were 94 males and 66 females at age of 70–85 (76.67±2.33) years. Operations were performed by using sternal median incision with the assistance of local myocardial surface fixator and shunt plug, and the saphenous vein and internal mammary arterywere used as grafted vessels. Results All the patients were received successful off-pump coronary artery bypass grafting without death, and the cardiac function improved significantly. There were 62 patients with the internal mammary artery bridge and 98 patients with the whole vein bridge. All the patients were followed-up for 1 to 4 years. All the patients had obvious relief of angina pectoris. Conclusion Off-pump coronary artery bypass grafting for the treatment of elderly patients with coronary heart disease is an effective and safe operation, especially for patients with renal insufficiency, cerebrovascular disease, respiratory disease and severe left ventricular dysfunction.
Objective To learn the predictive risk factors of acute conversion of off-pump coronary artery bypass grafting (off-pump CABG)to on-pump coronary artery bypass grafting (on-pump CABG), referring for making decision in operating. Methods During Jan. 2002 to May 2006, 546 patients underwent planned off-pump CABG were analyzed retrospectively, and cases of acute conversion of off-pump to on-pump CABG (converted group) were compared with unconverted to on-pump(off-pump group) by multivariate logistic regression. Results 24 patients of off-pump CABG were acutely converted to on-pump CABG because of ventricular fibrillation or unstable hemodynamics. The mortality in converted group was 16.7%(4/24), much higher than off-pump group ［27% (14/522) , P＜0.001］. By multivariable logistic regression, acute myocardial infarction (OR=3.142,P=0004), emergent CABG (OR=1.571,P=0.011) and right main coronary artery(RCA) stenosis less than 90% (OR=1922,P=0.024) were predictors of acute conversion of off-pump to on-pump. Conclusions The mortality in patients undergoing acute conversion of off-pump to on-pump coronary artery surgery is high. When applying off-pump CABG in patients with acute myocardial infarction, emergency CABG and right main RCA stenosis ≤90%, preventive set up of extracorporeal circulation is necessary.
Objective
To study the technical characteristics, clinical outcomes and short- and long-term results of minimally invasive multi-vessel coronary artery bypass grafting and to evaluate the feasibility and efficacy.
Methods
From April 2012 to December 2014, minimally invasive cardiac surgery for coronary artery bypass grafting (MICS CABG) in 11 patients was performed in the First Hospital of China Medical University. All patients were males and the average age was 62.7 (47.0-73.0) years. Eight patients with 3-vessel lesions and 3 patients with 2-vessel lesions. General anesthesia was performed with double lumen endotracheal intubation and single lung ventilation. The patient was positioned 15 degrees to 30 degrees in right lateral position. The left anterior and lateral incision was made at the fourth/fifth intercostal space with the length of 5-7 cm and 2/3 part of the incision located in the medial side of anterior axillary line. Left internal thoracic artery (LIMA) was harvested from the third intercostal space up to the subclavian vein and down to more than fifth intercostal space through the surgical window. Through the xiphoid and sixth intercostal space incision with the length of 1 cm, the Starfish and Octopus system were placed to fix apex and ascending aorta and target vessels were exposed. The proximal and distal anastomosis was done under the direct vision. The sequence of distal anastomosis was from posterior descending branch to obtuse/diagonal branch and left anterior descending branch. The chest and pericardial draining tubes were placed through the xiphoid and sixth intercostal space incision.
Results
The mean operation time was 4.1 (3.2–5.8) h. Five patients underwent the operation with the assist of cardiopulmonary bypass and the mean assisting time was 21.0 (17.0-38.0 ) min. The mean number of distal anastomosis was 2.8 (2.0-3.0) and LIMA was harvested and grafted in all 11 patients. The mean drainage was 425.0 (180.0-750.0) ml, mean ventilation time 7.8 (4.3-11.2) h, ICU stay 15.9 (11.0-38.0) h, and hospital time 7.7 (5.0-14.0) d. There was no operative death and re-exploration for bleeding. One patient was complicated by paroxysmal atrial fibrillation and one patient myocardial infarction. The average follow-up was 19.4 (12.0-36.0) months, and no chest pain, re-admission or re-intervention happened. Coronary artery CT angiographies demonstrated that all LIMAs were patent and 4 vein grafts were occluded and venous graft patency rate was 80.0% one year after surgery.
Conclusion
MICS CABG has the advantage of quick recovery, good cosmetic effect and low incision infection rate compared to the conventional CABG. Compared with robotic surgery, the cost of MICS CABG is low and the same as that of the conventional CABG. It is a new kind of CABG and could be performed following the learning curve under strict training of doctors and careful patient selection. With the good short- and middle-term results, MICS CABG needs to be evaluated for long-term graft patency rate, re-revascularization rate, and clinical evidence.
ObjectiveTo evaluate the safety and efficacy of total arterial off-pump coronary artery bypass grafting (OPCABG) using a left internal thoracic artery (LITA) combined with bilateral radial arteries (RAs). MethodsWe retrospectively analyzed the clinical data of patients with severe multi-vessel coronary artery disease who underwent total arterial OPCABG with a LITA and bilateral RAs at Sichuan Provincial People’s Hospital from November 2020 to April 2023. Results A total of 24 patients were included, comprising 23 males and 1 female, with a mean age of (53.63±4.33) years. The New York Heart Association (NYHA) functional class was Ⅱ to Ⅲ. The mean number of distal anastomoses was 3.17±0.38. A Y-graft was constructed in 12 patients and sequential grafting was performed in 4 patients. Concomitant procedures included coronary endarterectomy in 1 patient, intra-aortic balloon pump (IABP) implantation in 10 patients, and thymoma resection in 1 patient. The mean operative time was (308.13±30.39) min, mechanical ventilation time was (15.42±7.42) h, ICU stay was (46.08±27.32) h, and postoperative hospital stay was (11.71±1.90) d. There were no in-hospital deaths. Postoperative complications included one patient of acute renal failure and one patient of cerebral infarction. Pre-discharge color Doppler echocardiography revealed that the left ventricular end-diastolic diameter was significantly smaller than before surgery (P<0.05), while the left ventricular ejection fraction and fractional shortening were significantly higher (P<0.05). Coronary computed tomography angiography (CTA) showed that all arterial grafts were patent. During a mean follow-up of (14.58±8.75) months, no patients experienced angina recurrence or mortality. Repeat coronary CTA or angiography in 16 patients one year postoperatively confirmed that all arterial grafts remained patent. Conclusion Total arterial OPCABG using a LITA and bilateral RAs is a safe and effective treatment for patients with severe multi-vessel coronary artery disease. For high-risk patients, intraoperative IABP support is recommended.
ObjectiveTo analyze the safety and follow-up results of on-pump coronary artery bypass grafting (CABG) for the treatment of multivessel diseases via left anterolateral minithoracotomy.MethodsFrom January 2018 to March 2020, a total of 30 patients including 18 males and 12 females with an average age of 61.3±7.5 years having multivessel coronary heart diseases were treated in our hospital with on-pump CABG via left anterolateral minithoracotomy. Among them, 14 patients had three-vessel diseases and 16 patients had two-vessel diseases.ResultsThere were 29 internal mammary artery-to-left anterior descending bypass grafts harvested in total while the rest were saphenous-vein bypass grafts. The average number of bypass vessels was 2.3±0.5. There was no perioperative death in the whole group, one patient underwent rethoracotomy due to hemorrhage, and one patient suffered acute renal insufficiency. The average time of postoperative tracheal intubation was 16.0±5.8 hours, and the postoperative ICU stay was 30.1±11.5 hours. Twenty five patients were followed up, including coronary CT angiography examinations at 6 months and 1 year after operation. Proximal anastomotic stenosis in one patient and distal anastomosis occlusion in one patient occurred.ConclusionOn-pump CABG via left anterolateral minithoracotomy is safe for appropriately selected patients.
Objective To investigate the influence of prior percutaneous coronary intervention (PCI) on the outcome of coronary artery bypass grafting (CABG). Methods Clinical data of 5 216 patients from Jiangsu Province CABG registry who underwent primary isolated CABG from 2016 to 2019 were retrospectively analyzed. Patients were divided into a PCI group (n=673) and a non-PCI group (n=4 543) according to whether they had received PCI treatment. The PCI group included 491 males and 182 females, aged 62.6±8.2 years, and the non-PCI group included 3 335 males and 1 208 females, aged 63.7±8.7 years. Multivariable logistic regression and propensity score matching (PSM) were used to compare 30-day mortality, incidence of major complications and 1-year follow-up outcomes between the two groups. Results Both in original cohort and matched cohort, there was no statistical difference in the 30-day mortality [14 (2.1%) vs. 77 (1.7%), P=0.579; 14 (2.1%) vs. 11 (1.6%), P=0.686], or the incidence of major complications (myocardial infarction, stroke, mechanical ventilation≥24 h, dialysis for new-onset renal failure, deep sternal wound infection and atrial fibrillation) (all P>0.05). The rate of reoperation for bleeding in the PCI group was higher than that in the non-PCI group [19 (2.8%) vs. 67 (1.5%), P=0.016; 19 (2.8%) vs. 7 (1.0%), P=0.029]. Both in original cohort and matched cohort, there was no statistical difference in 1-year survival rate between the two groups [613 (93.1%) vs. 4225 (94.6%), P=0.119; 613 (93.1%) vs. 630 (95.2%), P=0.124], while the re-admission rate in the PCI group was significantly higher than that in the non-PCI group [32 (4.9%) vs. 113 (2.5%), P=0.001; 32 (4.9%) vs. 17 (2.6%), P=0.040]. Conclusion This study shows that a history of PCI treatment does not significantly increase the perioperative mortality and major complications of CABG, but increases the rate of cardiogenic re-admission 1 year postoperatively.
ObjectiveTo investigate the factors associated with unplanned readmission within 30 days after discharge in adult patients who underwent coronary artery bypass grafting (CABG) and to develop and validate a risk prediction model. MethodsA retrospective analysis was conducted on the clinical data of patients who underwent isolated CABG at the Nanjing First Hospital between January 2020 and June 2024. Data from January 2020 to August 2023 were used as a training set, and data from September 2023 to June 2024 were used as a validation set. In the training set, patients were divided into a readmission group and a non-readmission group based on whether they had unplanned readmission within 30 days post-discharge. Clinical data between the two groups were compared, and logistic regression was performed to identify independent risk factors for unplanned readmission. A risk prediction model and a nomogram were constructed, and internal validation was performed to assess the model’s performance. The validation set was used for validation. ResultsA total of 2 460 patients were included, comprising 1 787 males and 673 females, with a median age of 70 (34, 89) years. The training set included 1 932 patients, and the validation set included 528 patients. In the training set, there were statistically significant differences between the readmission group (79 patients) and the non-readmission group (1 853 patients) in terms of gender, age, carotid artery stenosis, history of myocardial infarction, preoperative anemia, and heart failure classification (P<0.05). The main causes of readmission were poor wound healing, postoperative pulmonary infections, and new-onset atrial fibrillation. Multivariable logistic regression analysis revealed that females [OR=1.659, 95%CI (1.022, 2.692), P=0.041], age [OR=1.042, 95%CI (1.011, 1.075), P=0.008], carotid artery stenosis [OR=1.680, 95%CI (1.130, 2.496), P=0.010], duration of first ICU stay [OR=1.359, 95%CI (1.195, 1.545), P<0.001], and the second ICU admission [OR=4.142, 95%CI (1.507, 11.383), P=0.006] were independent risk factors for unplanned readmission. In the internal validation, the area under the curve (AUC) was 0.806, and the net benefit rate of the clinical decision curve analysis (DCA) was >3%. In the validation set, the AUC was 0.732, and the DCA net benefit rate ranged from 3% to 48%. ConclusionFemales, age, carotid artery stenosis, duration of first ICU stay, and second ICU admission are independent risk factors for unplanned readmission within 30 days after isolated CABG. The constructed nomogram demonstrates good predictive power.
ObjectiveTo study the learning curve of minimal invasive coronary artery bypass grafting (MICS CABG) and the influence on the perioperative clinical effects by analyzing operation time.MethodsFrom March 2012 to November 2020, 212 patients underwent MICS CABG by the same surgeon. Among them, 59 patients (52 males and average age of 62.89±8.27 years) with single vessel bypass grafting were as a single-vessel group and 153 patients (138 males, average age of 59.80±9.22 years) with multi-vessel bypass grafting were as a multi-vessel group. Two sets of operation time-operation sequence scatter plots were made and learning curve was analyzed by cumulative summation (CUSUM) and regression method of operation time. The surgical data of each group before and after the inflection point of the learning curve were compared with the main clinical outcome events within 30 days after surgery.ResultsThere was no death, perioperative myocardial infarction and stroke in 212 MICS CABG patients and no transfer to cardiopulmonary bypass or redo thoracotomy. The learning curve conformed to the cubic fitting formula. In the single-vessel group, CUSUM (x operation number)=–1.93+93.45×x–2.33×x2+0.01×x3, P=0.000, R2=0.986, the tipping point was 27 patients. In the multi-vessel group, CUSUM (x)=y=2.87+1.15×x–1.29× x2+3.463×x3, P=0.000, R2=0.993, and the tipping point was 59 patients. The two sets of case data were compared before and after the learning curve and there was no statistical difference in main clinical outcomes within 30 days (mortality, acute myocardial infarction, stroke, perioperative blood transfusion rate), ventilator tube, and intensive care unit retention.ConclusionThe learning curve of MICS CABG conforms to the cubic formula, and the process transitions from single to multiple vessels bypass. To enter the mature stage of the learning phase, a certain number of patients need to be done. Reasonable surgical procedures and quality control measures can ensure the safety during the learning phase.
