Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures

doi:10.1016/j.athoracsur.2003.06.019

The Annals of Thoracic Surgery

Volume 77, Issue 3, March 2004, Pages 761-768

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.

https://doi.org/10.1016/j.athoracsur.2003.06.019 Get rights and content

Abstract

Background

Current practice, trends, and early outcomes in patients undergoing surgical and percutaneous coronary interventions (PCI) are changing and subject to speculation.

Methods

148,396 consecutive patients in 69 HCA, Inc hospitals who underwent either PCI or coronary artery bypass grafting (CABG) were tracked in the HCA Casemix Database from 1999 through the first quarter of 2002. Comorbid conditions, procedures, complications, and outcome variables were defined through International Classification of Diseases, Ninth Revision coding. Odds ratios (OR) for death and other procedure-related complications were estimated using logistic regression adjusting for age, sex, and 31 other patient clinical and procedural characteristics.

Results

Now 65.4% of all coronary revascularization is by PCI with a 6.8% annual rate of increase whereas CABG volume is declining by 1.9% per year. However the majority of these changes occurred between 1999 and 2000 with only small changes in the last 3 years. Coronary artery bypass grafting is still utilized primarily for multivessel disease (3.38 bypasses per patient) whereas PCI is predominately (83%) still limited to single-vessel intervention. Unadjusted mortality rates over the full 13-quarter period were 1.25% for PCI and 2.63% for CABG (p < 0.001), with PCI rates remaining constant and CABG mortality declining. Twenty-three percent of CABG is performed off pump with a lower mortality than conventional on-pump CABG (2.37% versus 2.69%, p < 0.001). Percutaneous coronary intervention patients have lower mortality (OR 0.51), and fewer acute renal failure (OR 0.39), neurologic (OR 0.12), and cardiac (OR 0.16) complications than CABG patients (p < 0.001).

Conclusions

Interventions for coronary artery disease continue to rise primarily due to an increase in PCI. The volume of PCI continues to increase relative to CABG. Although adverse outcomes are higher after CABG, the proportion of multivessel disease treated is greater. The difference in adverse outcomes between CABG and PCI remains small and continues to decline.

Section snippets

Hospital system

A nationwide for-profit healthcare system, HCA, Inc, involves 200 hospitals in 23 states [4]. A total of 76 hospitals in 17 states had cardiac surgery and interventional cardiology programs between 1999 and 2002. During the study period some hospitals (n = 7) with cardiac surgical and catheterization programs either left the hospital system, ceased performing the procedures, or began new programs. Each hospital had to perform both CABG and PCI patients in each year to be included in the

Results

During the study period from January 1, 1999 to March 31, 2002, a total of 154,701 coronary revascularization procedures were performed in all HCA hospitals. Excluded were 5,305 revascularization procedures not meeting study criteria, leaving 148,396 patients who are the subject of this analysis (Table 1). Of these patients 51,351 (34.6%) underwent CABG and 97,045 (65.4%) underwent PCI. Overall revascularization volumes increased during the study period from 42,678 in 1999 to an annualized

Comment

This study is a comprehensive review of a large population of patients that is representative of current coronary revascularization practice. The strength of this study lies in its representation of the current, real world, community-based practice.

There are, however, potential shortcomings of this study. First, it is based on an administrative rather than a clinical data; therefore particular detailed clinical data are not available which might explain differences. However, outcomes of “hard”

References (9)

Society of Thoracic Surgeons. STS National database executive summary. Available at:...
American College of Cardiology. ACC Database executive summaries. Available at:...
The State of New York heart disease data. Available at: http://health.state.ny.us/nysdoh/heart/heart_disease.htm....
HCA, Inc. Investor relations—corporate profile. Available at: http://hca.healthcare.com. Accessed on January 22,...

There are more references available in the full text version of this article.

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Empirical findings have shown significant and non-significant effects of advanced practice nursing roles within postoperative cardiac settings. The inconsistencies of the current literature preclude the identification of a significant effect of advanced practice nursing roles on patient and organizational outcomes.
1) identify patient and organizational outcomes of advanced practice nursing roles in postoperative cardiac surgery and 2) synthesize the evidence of current roles of advanced practice nurses in postoperative cardiac surgery to provide the best quality of care for patients.
A systematic review of randomized controlled trials was conducted in six electronic databases, including Medline, CINHAL, Embase, Cochrane Database, Joanna Briggs Database and Web of Science, and the grey literature. Randomized controlled trials published after 1999 were included if they examined advanced practice nursing roles and recruited patients who underwent cardiac surgery. The study selection was performed by two independent reviewers, and consensus was achieved with a third reviewer. Data extraction was conducted by one reviewer and revised by a second reviewer. The methodological quality of the included studies was assessed with the Evidence Project risk of bias tool by two independent reviewers and revised by a third reviewer. A narrative synthesis of the available evidence was completed. No meta-analysis technique was attempted because of the high heterogeneity of the included studies.
Among 4,448 retrieved papers, ten randomized controlled trials and three secondary analyses were included in this review. The methodological quality of the included studies was moderate. All studies included a comparison group and the majority of the studies collected data using a blinded researcher. However, all studies were based on small sample sizes and failed to randomly recruit participants. Five studies implemented nurse practitioner roles and five studies implemented clinical nurse specialist roles. The advanced practice nursing care included health condition management, lifestyle promotion and coping strategies with patients. A total of 22 outcomes were identified, including 13 patient outcomes (e.g., depressive symptoms) and nine organizational outcomes (e.g., rehospitalization after discharge). Each outcome was examined in one to five studies. All of the included outcomes were associated with inconsistent findings.
The findings from existing literature remain inconsistent. The high risk of bias and the small sample sizes could potentially explain the non-significant findings. Avenues for future research should focus on the development of methodologically high-quality studies with larger sample sizes to enhance our understanding of the effectiveness of advanced practice nursing roles.
The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study
2020, Journal of Cardiothoracic and Vascular Anesthesia
The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications.
A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation.
Tertiary cardiothoracic ICU.
A total of 2,098 patients were included and analyzed.
None.
The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation.
Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.
Trends in In-hospital Coronary Artery Bypass Surgery Mortality by Gender and Race/Ethnicity –1998-2015: Why Do the Differences Remain?
2019, Journal of the National Medical Association
Between 1998 and 2015, the national coronary artery bypass graft surgery (CABG) in-hospital mortality rate fell nearly 45% to just 2.2% of CABG in-patients. By almost any standards, this large decline in the nation's in-hospital mortality for CABG inpatients has been extraordinary. Yet, over this time period, no studies have detailed these notable trends in in-hospital CABG mortality with an emphasis on the differences by gender and racial/ethnicity. The in-hospital CABG treatment period is the approximately 9 day inpatient length-of-stay the patient is completely under the care of hospital and its staff. Our research seeks to fill this research gap with analyses of 18 years of national data of over 5 million CABG inpatient discharges distinguishing gender by six categories of race/ethnicity (Asian, black, Hispanic, white, other known races/ethnicities, and unknown race/ethnicities) to evaluate three broad questions related to in-hospital CABG mortality: 1) What have been the 18-year national trends in CABG surgeries, length-of-stay, mortality, and type of discharge by gender and race/ethnicity? 2) Over time, what have been the in-hospital mortality trends by gender and race-ethnicity? 3) Using multivariate techniques to control for patient characteristics, risk factors and socioeconomic characteristics of the hospital setting and environment, what is the extent of the variations in in-hospital mortality among the 12 groupings of gender and race-ethnicity?
Data are from the Nationwide Inpatient Sample (NIS) data from the Healthcare Utilization Project (HCUP–NIS) collected yearly. These data represent 858 hospitals, a 20% national sample representing 5,032,985 CABG patient discharges from hospitals over an 18-year period -- 1998 to 2015. Descriptive and logistic regression analyses are used to evaluate the outcomes.
The national decline in in-hospital CABG mortality trends over the 18-year period has been dramatic. These declines have substantially impacted all 12 racial/ethnic and gender groupings analyzed during this timeframe. However, over the 18-year period, both univariate and logistic regression results reveal the disadvantages females and black males have in in-hospital CABG mortality rates when compared to the comparison group, white male CABG inpatients. Female CABG inpatients consistently, regardless of their race/ethnicity, have significantly higher in-hospital mortality rates than their corresponding male counterparts even after controlling for patient characteristics and socio-economic status. For males, however, the likelihood of dying in the hospital from a CABG procedure showed wide variation across the four racial/ethnic categories. Compared with white male patients undergoing CABG surgery in the nation's hospitals, after controlling for confounding factors, Hispanic and Asian-American had significantly lower in-hospital CABG mortality rates −9.7% and −17.9% respectively. In contrast, black male CABG patients had a 35.1% higher in-hospital CABG mortality rate than white males.
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Our modified technique of combined antegrade-vein graft cardioplegia infusion versus conventional antegrade method in coronary artery bypass grafting. A randomized clinical trial
2018, International Journal of Surgery
Citation Excerpt :
As implied by the p values, the difference between the intervention and control group in terms of low output syndrome parameters is more remarkable in these two higher-risk subgroups of patients. Currently, most CABGs are performed using cardiopulmonary bypass, worldwide [16]. In spite of spectacular advances in the cardioprotection techniques, postoperative myocardial dysfunction remains by far, the most common cause of death following bypass surgery [17,18].
To determine the efficacy of antegrade cardioplegia supplemented with venous graft perfusion in patients scheduled for coronary artery bypass grafting (CABG).
223 consecutive patients scheduled for isolated CABG were randomized to receive either continuous crystalloid cardioplegia via vein grafts on completion of each distal anastomosis plus intermittent blood cardioplegia through aortic root (group 1, n = 110) or antegrade blood cardioplegia alone (group 2, n = 113). Two groups were similar in terms of preoperative patients' and procedural characteristics. The primary end-points were low output syndrome (LOS) variables.
The inotrope and intra-aortic balloon pump demand during weaning were significantly higher in the control group (31.8% vs. 20%, p = 0.043 and 7.9% vs. 1.8%, p = 0.034 respectively). Postoperative level of potassium and arterial base excess (BE), stood in the normal range in both groups, despite significant inter-group differences. Peak serum level of myocardial injury biomarkers (CK, CK-MB, and cTnI) at 12 h following operation, though markedly greater in the group 2, did not reach the cut-off point of myocardial necrosis. Postoperative arrhythmia was more commonly encountered in the control group (p = 0.045).
The duration of ventilation and hospital stay were considerably longer in the group 2. In a subgroup with LVEF<30%, the length of ICU stay was more prolonged in the control group, as well (p = 0.0145). The significant differences among groups regarding LOS parameters were more remarkable in the two high-risk subgroups (LVEF<30%, left main coronary stenosis).
Given the better postoperative cardiac performance, we recommend this method to all CABG candidates, particularly in higher-risk patients.
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Post–cardiac surgery pulmonary dysfunction may be underreported. Therefore, we evaluated associated risk factors for prolonged pulmonary support after cardiac surgery.
We conducted a retrospective, observational study of consecutive patients undergoing coronary artery bypass grafting or coronary artery bypass grafting plus valve repair/replacement between Jan 1, 2005, and Dec 31, 2010, at an academic medical center. Using multivariate logistic regression and Cox proportional hazards modeling, we identified risk factors associated with prolonged mechanical ventilation and supplemental O₂ support as well as in-hospital mortality.
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Original article: cardiovascularCurrent status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures

Abstract

Background

Methods

Results

Conclusions

Section snippets

Hospital system

Results

Comment

Original article: cardiovascular
Current status and outcomes of coronary revascularization 1999 to 2002: 148,396 surgical and percutaneous procedures