Cirrhosis as a Moderator of Outcomes in Coronary Artery Bypass Grafting and Off-Pump Coronary Artery Bypass Operations: A 12-Year Population-Based Study

University of Missouri, Columbia, Missouri, United States
The Annals of thoracic surgery (Impact Factor: 3.85). 07/2013; 96(4). DOI: 10.1016/j.athoracsur.2013.04.103
Source: PubMed


Cirrhosis substantially affects morbidity and mortality in patients who undergo complex surgical procedures. However, cirrhosis is not included as a parameter in standardized perioperative cardiac risk assessment models. We sought to identify the impact of cirrhosis on coronary artery bypass grafting (CABG) and off-pump CABG (OPCAB) outcomes.
Using the 1998 to 2009 Nationwide Inpatient Sample databases, we identified 3,046,709 patients who underwent CABG procedures, 744,636 (24.4%) of which were OPCAB; 6,448 (0.3%) had cirrhosis. Using hierarchical multivariable regression models, we analyzed the impact of cirrhosis on in-hospital outcomes: mortality, morbidity, length of stay, hospital charges, and disposition. Severity of liver dysfunction was assessed by the Deyo-Charlson comorbidity index.
In the overall CABG group, cirrhosis was independently associated with increased mortality (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI] 2.8 to 17), morbidity (AOR 1.6, 95% CI 1.3 to 2.0), length of stay (+1.2 days; p < 0.001), and hospital charges (+$22,491; p < 0.001). The prevalence of cirrhosis in the OPCAB group was 0.3% (n = 2,246); the OPCAB subgroup analysis revealed that the presence of cirrhosis did not affect mortality or morbidity unless there was severe liver dysfunction (mortality AOR 5.1, 95% CI 3.7 to 6.9; morbidity AOR 2.1, 95% CI 1.6 to 2.4). However, in the on-pump CABG patients, cirrhosis was associated with increased mortality and morbidity regardless of the severity of liver dysfunction.
The impact of cirrhosis on perioperative outcomes and health care costs is significant; CABG should be performed on carefully selected cirrhotic patients and, whenever possible, without the use of cardiopulmonary bypass.

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    ABSTRACT: Objectives: Recent national trends in off-pump versus on-pump coronary artery bypass grafting have not been reported. Methods: We analyzed data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database regarding isolated primary coronary artery bypass grafting operations (N = 2,137,841; 1997-2012). The off-pump percentages were calculated in aggregate, by center, and by surgeon. On the basis of the 2007/2008 yearly off-pump volume, the analysis subgroups were "high" (center n > 200, surgeon n > 100), "intermediate" (center n = 50-200, surgeon n = 20-100), and "low" (center n = 1-49, surgeon n = 1-19). Results: The use of off-pump procedures peaked in 2002 (23%) and again in 2008 (21%), followed by a progressive decline in off-pump frequency to 17% by 2012. After 2008, off-pump rates declined among both high-volume and intermediate-volume centers and surgeons; little change was observed for low-volume centers or surgeons (off-pump rates = 10% since 2008). By the end of the study period, 84% of centers performed fewer than 50 off-pump cases per year, 34% of surgeons performed no off-pump operations, and 86% of surgeons performed fewer than 20 off-pump cases per year. Except for a higher (7.8%) conversion rate in 2003, the rate for conversions fluctuated approximately 6%. Conclusions: Enthusiasm for off-pump coronary artery bypass grafting has been tempered. The percentage of coronary artery bypass grafting operations performed off-pump has steadily declined over the last 5 years, and currently this technique is used in fewer than 1 in 5 patients who undergo surgical coronary revascularization. A minority of surgeons and centers continue to perform off-pump coronary artery bypass grafting in most of their patients.
    Journal of Thoracic and Cardiovascular Surgery 01/2014; 148(3). DOI:10.1016/j.jtcvs.2013.12.047 · 4.17 Impact Factor

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