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Nicholas G Smedira

Publications and source records attributed to Nicholas G Smedira.

At least 19 recordsLinked to original sources
PubMed2006

Occurrence and risk factors for reintervention after coronary artery bypass grafting.

BACKGROUND: Reintervention after coronary artery bypass grafting (CABG) is common. We sought to determine its occurrence and identify patient characteristics and operative techniques that influence the need or bias for reintervention. METHODS AND RESULTS: From 1971 to 1998, 48,758 patients underwent primary isolated CABG, and 1000 patients per year were actively followed-up every 5 years (n =26,927). A multivariable time-related analysis was performed to model freedom from first coronary reintervention (either reoperation or percutaneous coronary intervention) and identify patient and operative characteristics associated with first reintervention. A total of 3997 patients underwent coronary reintervention, percutaneous in 1638 and reoperation in 2359. Freedom from reintervention was 99%, 96%, 88%, 73%, 60%, and 46% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reintervention (hazard function) demonstrated a short, rapidly declining early phase followed by a longer, slow-rising late phase. Patient variables increasing the likelihood of coronary reintervention included younger age (P<0.0001), higher triglycerides (P=0.002), lower high-density lipoprotein (P=0.006), diabetes mellitus (P<0.0001), and more extensive coronary artery disease (P=0.0005). Increasing extent of arterial grafting performed at primary operation decreased the likelihood of coronary reintervention (P<0.0001). CONCLUSIONS: Reintervention after primary CABG is common. Risk factors for arteriosclerosis and type of bypass conduit influence the need or bias for repeat coronary therapy. Aggressive post-CABG risk factor reduction and extensive arterial grafting at primary operation should decrease coronary reinterventions.

Age Factors↗
PubMed2006

The impact of hypogammaglobulinemia on infection outcome in patients undergoing ventricular assist device implantation.

BACKGROUND: Infection is a major comorbidity after ventricular assist device (VAD) placement. Defects in cellular immunity have been reported after VAD placement. However, to our knowledge, quantitative immunoglobulin G (IgG) level determination and the impact of hypogammaglobulinemia (HGG) on infections after VAD implantation have not been evaluated before. METHODS: A total of 76 patients (mean age, 53 years) underwent VAD implantation as a bridge to transplantation and had IgG levels determined as a baseline before transplantation. Patients were divided into 2 groups according to IgG level: Control Group (n = 56, IgG > or = 700 mg/dl) and HGG Group (n = 20, IgG < 700 mg/dl). Infection outcome during the VAD course and after transplantation was analyzed in relation to the IgG level. RESULTS: Baseline characteristics were similar in both groups. The incidence of bacteremia (14/20 [70%] vs 18/56 [32%], p = 0.0032) and major infection (19/20 [95%] vs 31/56 [56%], p = 0.0009) were significantly increased in the HGG Group compared with the Control Group. After transplantation, the episodes of rejection were similar in both groups and survival was similar. The HGG Group experienced more cytomegalovirus infections compared with the Control Group (9/20 [45%] vs 9/56 [16%], p = 0.009). CONCLUSIONS: VAD patients with HGG are at increased risk of infections. After transplantation, these patients also experience increased cytomegalovirus infections. A randomized preemptive IgG replacement trial may be warranted in the future to determine if this intervention will alleviate the risk of infection.

Adult↗
PubMed2006

Ventricular assist devices and aggressive immunosuppression: looking beyond overall survival.

BACKGROUND: Patients bridged to heart transplantation with a ventricular assist device (VAD) developed coronary vasculopathy at the same rate as non-bridged patients despite having higher levels of pre-formed antibodies. We hypothesized that allosensitized VAD patients have higher levels of immunosuppression and thus different morbidity and causes of mortality. METHODS: Patients who received a transplant between January 1996 and May 2002 were separated into 2 groups based on the need for VAD support as a bridge to transplantation. Transplant and Inpatient Pharmacy Databases and charts were queried for date of transplantation, degree of allosensitization, use of desensitization therapy, immunosuppressive strategies, number of treated rejection episodes, and specific causes of death. RESULTS: This study investigated 238 patients (125 VAD patients, 113 non-VAD patients). VAD patients were more likely to be allosensitized than non-VAD patients (20% vs 5%, p < 0.01). OKT3 was given to 22% of VAD patients as anti-rejection prophylaxis and 14% received pre-transplant plasmapheresis. Non-VAD patients rarely were desensitized (2.6% of non-VAD patients). After transplantation, 68 VAD patients (54%) and 44 non-VAD patients (39%) had episodes of severe rejection requiring therapy. Episodes of rejection in VAD patients were commonly treated with steroids (90%), plasmapheresis (10%), and OKT3 (7%), and episodes of rejection in non-VAD patients were treated with steroids (76%) and OKT3 (8%). The 5-year survival for both groups was similar (90% and 86% respectively, p = 0.31). VAD patients commonly died of sepsis (75%), and non-VAD patients died of rejection (39%) and ischemic transplant cardiomyopathy (30%). CONCLUSION: When short-term outcomes between bridged and non-bridged heart transplant recipients were compared, overall survival was similar but causes of death differed. Findings in this study might aid in the post-operative management of patients bridged to transplantation with a VAD.

Aged↗
PubMed2006

Anticoagulation with bivalirudin for off-pump coronary artery bypass grafting: the results of the EVOLUTION-OFF study.

OBJECTIVES: Unfractionated heparin has many shortcomings, including indirect and partial inhibition of thrombin, antibody formation, and platelet activation. Bivalirudin, a short-acting direct thrombin inhibitor, avoids these limitations and has superior outcomes during percutaneous revascularization. This trial was performed to evaluate the safety and efficacy of bivalirudin in off-pump coronary artery bypass grafting. METHODS: An open-label, multicenter randomized trial compared heparin with protamine reversal to bivalirudin in patients undergoing off-pump coronary artery bypass. The primary objective was safety as demonstrated by similar rates of procedural success defined as freedom from a composite of death, myocardial infarction, stroke, and repeat revascularization. Twenty-one institutions randomized 105 patients to receive bivalirudin and 52 patients to receive heparin. RESULTS: The mean age was 65 years for both groups. The bivalirudin group had more grafts: 3.0 +/- 1 versus 2.5 +/- 1. Procedural success rates at 30 days were identical in bivalirudin- and heparin-treated patients (93%). Operative times, total blood loss, reoperations for bleeding, and major adverse events were not significantly different. Strokes were more frequent in the heparin group: 5.5% versus 0; P = .05. Mortality was 2% in each group. Repeat revascularization was required in 3% of bivalirudin- and 2% of the heparin-treated patients. CONCLUSIONS: For patients undergoing off-pump coronary artery bypass grafting, bivalirudin was an effective anticoagulant, without excessive bleeding and with a safety profile similar to that of heparin. Further trials are warranted to assess whether anticoagulation with bivalirudin improves clinical outcomes.

Aged↗
PubMed2006

Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation.

BACKGROUND: Left ventricular (LV) thrombus is a frequent and potentially dangerous complication of ischemic heart disease (IHD). We evaluated the clinical, imaging, and pathology characteristics of confirmed LV thrombus and compared the diagnostic value of contrast-enhanced magnetic resonance imaging (MRI) with transthoracic (TTE) and transesophageal echocardiography (TEE) for the diagnosis of LV thrombi. METHODS: Between November 1997 and December 2003, 361 patients with IHD had surgical and/or pathological confirmation of presence or absence of LV thrombus. Clinical information and preoperative imaging study reports were retrospectively reviewed regarding detection of thrombus. Comparisons were made between clinical and imaging characteristics of patients with and without confirmed thrombus. RESULTS: Left ventricular thrombus was present in 106 (29%) of 361 patients in this study. Patients with thrombus had a higher incidence of recent embolic events (6.1% vs 0.8%, P < .005). In 160 patients with all 3 imaging modalities performed within 30 days of surgical or pathological confirmation, contrast-enhanced MRI showed the highest sensitivity and specificity (88% +/- 9% and 99% +/- 2%, respectively) compared with TTE (23% +/- 12% and 96% +/- 3.6%, respectively) and TEE (40% +/- 14% and 96% +/- 3.6%, respectively) for thrombus detection. CONCLUSIONS: Left ventricular thrombus occurs frequently in patients with IHD and is associated with risk of systemic embolization. Contrast-enhanced MRI provided the highest sensitivity and specificity for LV thrombus when compared to TTE and TEE, and should be considered in the care of patients at high risk of LV thrombus formation.

Aged↗
PubMed2006

Surgery for permanent atrial fibrillation: impact of patient factors and lesion set.

BACKGROUND: Whether a complete Cox-maze procedure is needed to ablate permanent atrial fibrillation in patients undergoing concomitant cardiac surgery is unknown. Our objective was to assess the effectiveness of different lesion sets in such patients. METHODS: From November 1991 to January 2004, 575 patients underwent surgical treatment of permanent atrial fibrillation (duration > 6 months); mitral valve disease was the primary indication for surgery in 74%. Procedures included pulmonary vein isolation alone (n = 68, 12%), pulmonary vein isolation with left atrial connecting lesions (n = 265, 46%), and Cox-maze (n = 242, 42%). Rhythm documented on 5,120 postoperative electrocardiograms was used to estimate time-related prevalence of, and risk factors for, atrial fibrillation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 46% two weeks after operation, declining to 24% at one year. Patient-related risk factors for increased prevalence included older age (p < 0.0001), larger left atrium (p < 0.0001), and longer duration of preoperative atrial fibrillation (p = 0.0008). The Cox-maze procedure and lesion sets resembling it created with alternative energy sources had a similarly low prevalence of late postoperative atrial fibrillation; in contrast, pulmonary vein isolation and lesion sets that did not include a lesion to the mitral anulus were less effective. CONCLUSIONS: This study suggests that in cardiac surgical patients with permanent atrial fibrillation the left atrial lesion set should include wide pulmonary vein isolation, at least one connection between right and left pulmonary veins, and a connection to the mitral anulus. Availability of alternative energy sources to create lesions sets has virtually eliminated the need for the cut-and-sew Cox-maze procedure.

Adult↗
PubMed2006

Asymmetry of systolic anterior motion of the mitral valve in patients with hypertrophic obstructive cardiomyopathy: a real-time three-dimensional echocardiographic study.

By geometric analysis of real-time 3-dimensional echocardiography performed in 39 patients with hypertrophic obstructive cardiomyopathy and definite systolic anterior motion of the mitral valve, we found that the angle between the mitral annular plane and basal portion of the anterior mitral valve leaflet, and the angle between the basal portion of the anterior leaflet and its tip portion measured in the medial and central anteroposterior planes, were significantly smaller than those in the lateral plane. The distance between the interventricular septum and the anterior mitral valve tip in the medial and central plane was also significantly smaller than that in the lateral plane. The lateral distance between the interventricular septum and the anterior mitral valve tip was the only independent determinant of left ventricular outflow tract pressure gradient by multiple stepwise regression analysis. In conclusion, systolic anterior motion of the mitral valve develops predominantly in the medial side, resulting in laterally located narrow left ventricular outflow tract opening in patients with hypertrophic obstructive cardiomyopathy.

Adult↗
PubMed2006

Are allografts the biologic valve of choice for aortic valve replacement in nonelderly patients? Comparison of explantation for structural valve deterioration of allograft and pericardial prostheses.

OBJECTIVE: To compare explantation for structural valve deterioration in nonelderly patients after aortic valve replacement with stented bovine pericardial and cryopreserved allograft valves. METHODS: From 1981 to 1985, 478 patients received pericardial prostheses during premarket approval; from 1987 to 2000, 744 patients received cryopreserved allografts. Mean age of patients receiving allografts was 49 +/- 12 years, and that of those receiving pericardial prostheses was 65 +/- 11 years; pericardial valves were used in 138 patients younger than age 60. Mean follow-up was 15 +/- 5.1 years for pericardial valves (4674 patient-years of follow-up) and 5.6 +/- 3.1 years for allografts (3892 patient years of follow-up). Multivariable hazard function methodology, age-group stratification, and propensity matching were used to compare age-specific explantation for structural valve deterioration. RESULTS: Ninety-five pericardial valves and 46 allografts were explanted, and structural valve deterioration was the mechanism of failure in 74% and 59%, respectively. The risk of structural valve deterioration increased with younger age at implantation for both allografts (P = .07) and pericardial valves (P < .0001), with a similar magnitude of effect in patients age 50 years or younger (P = .5), 50 to 60 years (P = .7), and greater than 60 years (P = .9) and in propensity-matched pairs (P = .2). Thus, pericardial valves were as durable as allografts at all adult ages. CONCLUSIONS: Structural valve deterioration is the most frequent cause of valve-related reoperation after both pericardial and allograft aortic valve replacement and is similarly age dependent, suggesting that pericardial valves may be appropriate for nonelderly as well as older persons.

Adult↗
PubMed2006

Duration of inotropic support after left ventricular assist device implantation: risk factors and impact on outcome.

OBJECTIVES: Because duration of inotropic support after left ventricular assist device implantation has been recognized as a surrogate for right ventricular dysfunction, we sought to (1) identify its preimplantation risk factors, particularly its association with preimplantation right ventricular dysfunction, and (2) assess its impact on clinical outcomes. METHODS: Between 1991 and 2002, left ventricular assist devices were implanted in 207 patients, exclusive of those receiving preoperative mechanical circulatory support, which precluded measuring right ventricular stroke work. Duration of inotropic support was analyzed as a continuous variable, truncated by death or transplantation, and in turn as a risk factor for these 2 events. RESULTS: Inotropic support decreased from 100% on the day of implantation to 57%, 33%, and 22% by days 7, 14, and 21. Its duration was strongly associated with lower preimplantation right ventricular stroke work index, older age, and nonischemic cardiomyopathy and was associated (P < .04) with higher mortality before transplantation but not with transition to transplantation. We identified no preimplantation risk factors for right ventricular assist device use because of its relatively infrequent use in this population (18 patients, only 4 of whom survived to transplantation). CONCLUSION: Duration of inotropic support after left ventricular assist device insertion is strongly correlated with low preimplantation right ventricular stroke work index. In turn, it was associated with reduced survival to transplantation. Thus, right ventricular stroke work measured before implantation might be useful in decision making for biventricular support, destination therapy, or total artificial heart.

Cardiomyopathies↗
PubMed2006

A comparison of bivalirudin to heparin with protamine reversal in patients undergoing cardiac surgery with cardiopulmonary bypass: the EVOLUTION-ON study.

OBJECTIVES: Unfractionated heparin and its antidote, protamine sulfate, allow for rapid and reversible anticoagulation during cardiac surgery with cardiopulmonary bypass, yet limitations exist, including a variable dose-response, dependence on a cofactor for anticoagulant effect, and antigenic potential. This trial was performed to evaluate the safety and efficacy of bivalirudin as an alternative to heparin with protamine reversal in on-pump cardiac surgery. METHODS: We conducted a randomized, open-label, multicenter trial comparing heparin with protamine reversal to bivalirudin in patients undergoing cardiac surgery with cardiopulmonary bypass. The primary objective was to demonstrate comparable rates of in-hospital procedural success defined as freedom from death, Q-wave myocardial infarction, stroke, or repeat revascularization. Twenty-one institutions enrolled 101 patients randomized to bivalirudin and 49 patients to heparin treatment. RESULTS: The primary end point of procedural success was not significantly different between the bivalirudin arm and the heparin/protamine arms at 7 days, 30 days, or 12 weeks' follow-up. Adequate anticoagulation was achieved in all patients. Secondary end points including mortality, 24-hour blood loss, overall incidence of transfusions, and duration of surgery were similar between the two arms. CONCLUSIONS: Bivalirudin is a safe and effective anticoagulant for patients undergoing a wide range of cardiac surgical procedures with cardiopulmonary bypass. Procedural success rates with bivalirudin were similar to rates in patients receiving heparin anticoagulation, with no difference in mortality. Avoidance of blood stasis and attention to the intraoperative medical management of patients is critical for successful use of bivalirudin during cardiopulmonary bypass.

Aged↗
PubMed2006

Allocating hearts.

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Heart Diseases↗
PubMed2006

Extended use of extracorporeal membrane oxygenation after lung transplantation.

OBJECTIVES: Extracorporeal membrane oxygenation (ECMO) for severe graft failure after lung transplantation is accepted immediately postoperatively; extending its use is controversial. We evaluated our post-lung transplant ECMO experience, which included extended indication, to (1) determine its prevalence, risk factors, indications, and timing, (2) compare complications and outcomes of these patients with those not requiring it, and (3) identify risk factors, including indications, for mortality. METHODS: From February 1990 to October 2005, 474 patients underwent lung transplantation; postoperative ECMO support was instituted for severe graft failure 23 times in 22 patients (4.0%). Indications for ECMO and its timing were obtained by reviewing medical records and survival by systematic follow-up. RESULTS: No factor evaluated predicted severe graft failure leading to ECMO. The most common indication for ECMO was early graft failure (13 patients); however, it was also used for pneumonia or sepsis (6) and acute rejection (4). ECMO was initiated at a median arterial oxygen tension/inspired oxygen fraction of 59 at a median of 2 days postoperatively and was maintained for a median of 4 days. The most common complications were renal failure (57%) and bleeding (43%). ECMO was effective in salvaging patients with rejection and early graft failure (survival at 1, 3, 6, and 12 months: 62%, 54%, 49%, and 41%), but ineffective for pneumonia or sepsis (survival at these intervals: 9%, 4%, 4%, and 3%). CONCLUSIONS: ECMO can be extended beyond early severe graft failure to acute rejection and can be considered after the immediate postoperative period. Survival after ECMO in patients with pneumonia or sepsis is poor.

Extracorporeal Membrane Oxygenation↗
PubMed2006

Determinants of ischemic mitral regurgitation in patients with chronic anterior wall myocardial infarction: a real time three-dimensional echocardiography study.

OBJECTIVE: We sought to elucidate the geometric determinants of ischemic mitral regurgitation (IMR) in patients with chronic anterior myocardial infarction (MI). MATERIALS AND METHODS: In 16 patients with anterior MI only (Group A) and 18 patients with both anterior and inferoposterior MI (Group B), three parallel equidistant anteroposterior (AP) planes (medial, central, lateral) perpendicular to the mitral valvular commissure-commissure plane were generated. The systolic tenting area of the mitral valve (MVTa) and the angles between the annular plane and leaflets (anterior, Aalpha; posterior, Palpha) on the AP planes were measured. The left ventricular end-systolic and end-diastolic volumes, and end-diastolic and end-systolic mitral annular area (MAAs) were obtained. RESULT: The regurgitant orifice area (ROA) was significantly smaller in Group A than Group B (0.08 +/- 0.09 vs 0.20 +/- 0.18 cm(2), P < 0.05). In the total of 34 patients, the medial MVTa (P < 0.001), MAAs (P < 0.05) and the spherical index (P < 0.05) were three independent determinants of ROA while the left ventricular volumes were not. MAAs was the only independent determinant of ROA in Group A, while the medial MVTa was in Group B. Palpha (P < 0.05) and MVTa (P = 0.06) tended to be larger in the medial than the lateral side in Group B, while no differences were found in Group A. CONCLUSION: The geometry of the mitral valve apparatus was more important than the left ventricular volumes in determining the severity of IMR in patients with anterior MI. The posteromedial side tenting could play a critical role in causing significant IMR when the inferoposterior MI coexists with anterior MI.

Aged↗
PubMed2006

Effects of surgical ventricular restoration on left ventricular function: dynamic MR imaging.

PURPOSE: To retrospectively evaluate with dynamic magnetic resonance (MR) imaging the changes in global and regional left ventricular (LV) function after surgical ventricular restoration (SVR) performed in chronic ischemic heart disease patients with large nonaneurysmal or aneurysmal postmyocardial infarction zones. MATERIALS AND METHODS: The study was performed with institutional review board approval, and a waiver of individual informed consent was obtained. The study was HIPAA compliant. Patients (83 men, 22 women; mean age, 61 years +/- 9 [standard deviation]) were evaluated with MR imaging before and after SVR as follows: pre-SVR examination (n = 105; 25 days +/- 39 before SVR; median, 7 days; range, 1-189 days), early post-SVR examination (n = 95, 7 days +/- 3 after SVR), and late post-SVR (n = 35, 313 days +/- 158 after SVR). Cine MR imaging allowed calculation of ejection fraction and rate-corrected velocity of circumferential fiber shortening (Vcf(C)) for global LV functional evaluation, whereas tagged MR imaging (spatial modulation of magnetization with harmonic phase analysis) permitted assessment of regional circumferential strain (E(C)) with coronary distribution. Vcf(C) and E(C) were computed at both LV base- and mid-LV short-axis levels remote from the site of anteroapical SVR. RESULTS: Prior to SVR, LV dilatation and diminished global and regional LV function were observed. At early post-SVR examination, Vcf(C) had improved significantly but E(C) showed a worsening trend overall, although only E(C )of the right coronary artery at the mid-LV level worsened significantly. At late post-SVR examination, Vcf(C) values were improved when compared with pre-SVR values, although E(C) showed no statistically significant improvement. When compared with that at early post-SVR examination, however, E(C) showed significant improvement in two segments: left anterior descending artery and right coronary artery at mid-LV level. CONCLUSION: Although volume-based indexes of global LV function improve significantly after SVR, regional LV function did not improve significantly; there was evidence of continued LV remodeling after SVR.

Cardiac Surgical Procedures↗
PubMed2006

Bivalirudin provides rapid, effective, and reliable anticoagulation during off-pump coronary revascularization: results of the "EVOLUTION OFF" trial.

In the EVOLUTION OFF trial, we evaluated the safety and efficacy of bivalirudin during off-pump coronary artery bypass grafting as compared with heparin-protamine. In this subanalysis of EVOLUTION OFF data of bivalirudin-treated patients, we assessed the pharmacokinetics (PK) and effectiveness of bivalirudin anticoagulation to achieve target activated clotting time (ACT)+ values. Data from 101 patients were assessed. A bolus of 0.75 mg/kg of bivalirudin was followed by a continuous infusion of 1.75 mg x kg(-1) x h(-1) during the grafting procedure. An ACT+ value of >300 s was the target. In four patients, PK data for bivalirudin were obtained. Only in exceptional cases were repeat fractional boluses or an increase of the infusion rate required. Assessment of the PK data showed a mean concentration of bivalirudin after the initial bolus of 11.0 +/- 0.53 microg/mL and a mean concentration during infusion of 11.2 +/- 2.32 microg/mL. Pearson's correlation between bivalirudin concentrations and ACT+ values was 0.92. Bivalirudin PK data consistently exceeded concentrations of 6.5 microg/mL, which have been evaluated as effective during percutaneous coronary intervention. The correlation between bivalirudin levels and ACT+ values was good, and the target ACT+ values were almost always achieved. These results suggest that bivalirudin, given according to the current protocol, provides reliable and effective anticoagulation during off-pump coronary artery bypass graft surgery.

Aged↗
PubMed2006

Failure modes of the Carpentier-Edwards pericardial bioprosthesis in the aortic position.

BACKGROUND AND AIM OF THE STUDY: Modes of failure of the Perimount bioprostheses have not been characterized. Thus, the study aim was to classify their failure modes, to compare their rates of occurrence, and to relate these to patient age. METHODS: Between September 1981 and July 1985, a total of 478 patients received Carpentier-Edwards Perimount aortic valve prostheses as part of a premarket approval cohort. During yearly follow up over 19 years, 95 prostheses were explanted, 70 (74%) for reasons of structural valve deterioration (SVD). Preoperative diagnostic studies, echocardiograms, operative notes and pathology reports were reviewed to classify the primary modes of failure. Hazard function methodology established mode-specific occurrence rates and how these were modulated by patient age at implant. RESULTS: The pathophysiology of SVD was pure regurgitation in 23 cases, pure stenosis in 18, mixed in 20, and uncertain in nine. Primary modes of failure were calcification (n = 27; 39%), non-calcific degeneration (n = 21; 30%), fibrosis (n = 5; 7.1%), dehiscence (n = 4; 5.7%), a combination of these (n = 10; 14%), or unknown (n = 3; 4.3%). The failure rate for each mode accelerated with time, was highest and almost equal for calcification and degeneration, and was slower and almost equal for fibrosis and dehiscence. Except for dehiscence, failure modes were age-dependent (p < 0.05), and this was most prominent for degeneration and calcification. CONCLUSION: Perimount bioprostheses rarely fail from design-related causes; rather, they fail at almost equal rates from calcific and non-calcific degeneration, both of which occur late and are age-dependent. Further investigation into improved methods for fixation and anti-calcification in preparing these valves is warranted.

Adult↗
PubMed2005

Influence of patient characteristics and arterial grafts on freedom from coronary reoperation.

OBJECTIVE: Arteriosclerosis is a progressive disease, and many patients require repeat coronary intervention after coronary artery bypass grafting. We sought to identify patient characteristics and operative factors that predict the need for or bias toward reoperative coronary artery bypass grafting. METHODS: From 1971 to 1998, 48,758 patients underwent primary isolated coronary artery bypass grafting, and 1000 per year were followed every 5 years (n = 26,927). A multivariable time-related analysis was performed to model freedom from coronary reoperation and to identify patient and operative variables associated with occurrence of coronary reoperation. RESULTS: Freedoms from reoperative coronary artery bypass grafting were 99.6%, 98.4%, 93%, 82%, 72%, and 65% at 1, 5, 10, 15, 20, and 25 years, respectively. Risk of reoperation (hazard function) demonstrated a short, rapidly declining early phase, followed by a long, slow-rising late phase. Patient variables that increased the likelihood of coronary reoperation included younger age (P < .0001), higher total cholesterol (P = .0004) and triglyceride levels (P = .0005), lower high-density lipoprotein (P = .0002) level, diabetes mellitus (P < .0001), and more extensive coronary artery disease (P = .01). Increasing extent of arterial grafting performed at primary coronary artery bypass grafting decreased occurrence of coronary reoperation (P < .0001). CONCLUSION: Patient factors associated with arteriosclerosis progression and type of bypass conduit influence the need for or bias toward repeat coronary artery bypass grafting. Aggressive patient risk-factor reduction and extensive arterial coronary revascularization at primary coronary artery bypass grafting should result in fewer coronary reoperations.

Coronary Artery Bypass↗