Publications (47)169.05 Total impact
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Article: Trends in aortic clamp use during coronary artery bypass surgery: Effect of aortic clamping strategies on neurologic outcomes.
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ABSTRACT: OBJECTIVE: The purpose of the present study was to determine the effect of different clamping strategies during coronary artery bypass grafting on the incidence of postoperative stroke. METHODS: In the present case-control study, all patients at Emory hospitals from 2002 to 2009 with postoperative stroke after isolated coronary artery bypass grafting (n = 141) were matched 1:4 to a contemporaneous cohort of patients without postoperative stroke (n = 565). The patients were matched according to the Society of Thoracic Surgeons' predicted risk of postoperative stroke score, which is based on 26 variables. The patients who received on-pump and off-pump coronary artery bypass grafting were matched separately. Multiple logistic regression analysis with adjusted odds ratios was performed to identify the operative variables associated with postoperative stroke. RESULTS: Among the on-pump cohort, the single crossclamp technique was associated with a decreased risk of stroke compared with the double clamp (crossclamp plus partial clamp) technique (odds ratio, 0.385; P = .044). Within the on-pump cohort, no significant difference was seen in the incidence of stroke according to clamp use. Epiaortic ultrasound of the ascending aorta increased from 45.3% in 2002 to 89.4% in 2009. From 2002 to 2009, clamp use decreased from 97.7% of cases to 72.7%. CONCLUSIONS: During on-pump coronary artery bypass grafting, the use of a single crossclamp compared with the double clamp technique decreased the risk of postoperative stroke. The use of any aortic clamp decreased and epiaortic ultrasound use increased from 2002 to 2009, indicating a change in the operative technique and surgeon awareness of the potential complications associated with manipulation of the aorta.The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor -
Article: The Impact of Specific Preoperative Organ Dysfunction in Patients Undergoing Aortic Valve Replacement.
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ABSTRACT: BACKGROUND: Optimizing treatment strategies to risk profile patients undergoing aortic valve replacement remains a priority. The role that specific and combinations of preoperative organ dysfunction (OD) plays in informing these decisions remains uncertain. This study sought to determine the relative effect that OD in particular systems has on short- and long-term outcomes. METHODS: A total of 1,759 aortic valve replacement cases with and without coronary artery bypass grafting performed from January 2002 to June 2010 at Emory University are the basis for this retrospective analysis. Patients were classified by the presence or absence of preoperative OD: (1) cardiac: congestive heart failure (ejection fraction <0.35), (2) pulmonary: forced expiratory volume in 1 second less than 50% predicted, (3) neurologic (prior stroke), and (4) renal: chronic renal failure. The impact of individual and combined OD on outcomes was evaluated. Kaplan-Meier survival estimates and Cox regression models were used to assess the relationship between OD and long-term survival. RESULTS: A total of 513 patients (29.2%) had at least one OD, including 95 patients (5.4%) with more than one OD. Organ dysfunction in each organ system was associated with poorer survival. Renal (hazard ratio, 3.90) and pulmonary (hazard ratio, 2.40) OD patients had poorer long-term survival, including 30-day mortality. Seven-year survival for OD patients is as follows: prior stroke, 48.6%; severe chronic obstructive pulmonary disease, 30.8%; congestive heart failure, 55.9%; and chronic renal failure, 11.7%. The sequential addition of OD systems was a powerful predictor of poorer long-term survival. CONCLUSIONS: The presence of chronic renal failure most profoundly decreases survival, followed by severe chronic obstructive pulmonary disease and prior stroke. Furthermore, multiple OD systems significantly decrease short- and long-term survival.The Annals of thoracic surgery 12/2012; · 3.74 Impact Factor -
Article: Ventricular Arrhythmia After Cardiac Surgery: Incidence, Predictors, and Outcomes.
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ABSTRACT: OBJECTIVES: This study sought to investigate the prevalence, predictors, and outcomes of patients with postoperative ventricular arrhythmia (POVA) in a large cohort of patients. BACKGROUND: New-onset POVA after cardiac surgery (CS) is uncommon and has controversial prognostic value. METHODS: A total of 14,720 consecutive patients undergoing CS at Emory University between January 2004 and July 2010 were included in the study. Data on all-cause mortality were obtained from Social Security Administration death records. Multivariable regression models were constructed to determine the risk factors for POVA and to estimate the independent impact of POVA on long-term survival after adjusting for 40 different covariates. RESULTS: POVA occurred in 248 patients (1.7%). Patients with POVA were older (63.5 vs. 61.6 years), had lower left ventricular ejection fraction (EF) (43.7 vs. 51.3), and had greater comorbidities (Society of Thoracic Surgeons mortality risk score of 7.2% vs. 3.1%, p < 0.001). Multivariable analysis showed that older age (odds ratio [OR]: 1.018 per 1-year increase, p < 0.001), emergent surgery (OR: 1.77, p = 0.019), and the presence of PVD (OR: 1.41, p = 0.049) were associated with a higher incidence of POVA, whereas higher left ventricular EF (OR: 0.97 per 1% increase, p < 0.001), mild chronic obstructive pulmonary disease (OR: 0.37, p < 0.001), and off-pump surgery (OR: O.41, p < 0.001) were associated with a lower incidence of POVA. POVA was associated with substantially increased adjusted long-term mortality (hazard rate: 2.53, p < 0.001) over 3.5 years of follow-up. CONCLUSIONS: POVA is associated with increased long-term mortality after CS. Older age, PVD, lower EF, and emergent surgery are associated with a higher risk of POVA, whereas off-pump surgery seems to be protective.Journal of the American College of Cardiology 11/2012; · 14.16 Impact Factor -
Article: Off-pump coronary artery bypass grafting attenuates morbidity and mortality for patients with low and high body mass index.
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ABSTRACT: BACKGROUND: Patients at high and low body mass index have been shown to experience higher morbidity and mortality when undergoing coronary artery bypass grafting. The purpose of this research was to compare outcomes of patients at body mass index extremes who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. METHODS: A retrospective review of 6801 patients with a body mass index <25 or >35 undergoing isolated, primary coronary artery bypass grafting from 1996 to 2009 at Emory Healthcare Hospitals was performed. Patients were compared by therapy either on-pump coronary artery bypass grafting (n = 3210) or off-pump coronary artery bypass grafting (n = 3591). Salvage patients or those with concomitant operations were excluded. Comparisons were made using multivariable regression analysis, using a propensity score covariate calculated from 41 preoperative risk factors. RESULTS: A total of 6801 patients, including 4312 with a body mass index <25 (off-pump coronary artery bypass grafting, n = 2083; on-pump coronary artery bypass grafting, n = 2229) and 2489 with a body mass index >35 (off-pump coronary artery bypass grafting, n = 1127; on-pump coronary artery bypass grafting, n = 1362) were included for analysis. Society of Thoracic Surgeons predicted risk of mortality was significantly higher for both body mass index strata in patients undergoing off-pump coronary artery bypass grafting (2.8% vs 3.1% for body mass index <25 [P = .043] and 1.7% vs 1.8% for body mass index >35 [P = .049]). For patients with a body mass index <25, multivariable analysis of outcomes showed a significant decrease in in-hospital mortality (adjusted odds ratio, 0.48; 95% confidence interval, 0.28-0.82), stroke (adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56), new-onset renal failure (adjusted odds ratio, 0.59; 95% confidence interval, 0.36-0.96), and prolonged ventilation (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.64). Long-term survival was unaffected by method of revascularization for either body mass index strata (P > .05). CONCLUSIONS: Patients with high and low body mass indices experience reduced morbidity and in-hospital mortality when undergoing off-pump coronary artery bypass grafting. Despite a higher risk profile, patients with a body mass index <25 who underwent off-pump coronary artery bypass grafting experienced a significant reduction in in-hospital mortality.The Journal of thoracic and cardiovascular surgery 10/2012; · 3.41 Impact Factor -
Article: Sternotomy Versus Nonsternotomy LIMA-LAD Grafting for Single-Vessel Disease.
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ABSTRACT: Single-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by left internal mammary artery (LIMA) grafting either through a sternotomy or a nonsternotomy approach. Nonsternotomy approaches are used in the hope of achieving a less invasive operation. It is unknown whether nonsternotomy approaches impact in-hospital or midterm outcomes. The institutional Society of Thoracic Surgeons (STS) database at a single US academic center was reviewed for 597 consecutive patients treated surgically for single-vessel LAD disease from January 1, 2002 to June 30, 2011. In-hospital adverse events and length of stay (LOS) were compared between patients who had LIMA-LAD grafting performed through a sternotomy (sternotomy patients) versus patients who had this procedure performed through a nonsternotomy approach (nonsternotomy patients), adjusted for propensity score (likelihood of receiving sternotomy, calculated on 33 variables). Midterm survival between groups was compared using Kaplan-Meier and Cox regression analysis by referencing the National Social Security Death Index. There were 597 consecutive patients who underwent single-vessel grafting by LIMA-LAD coronary artery grafting. Of these patients, 234 underwent sternotomy, whereas 363 patients had nonsternotomy procedures: 239 patients had endoscopic LIMA harvest and left anterolateral thoracotomy, 106 patients had robot LIMA harvest and left anterolateral thoracotomy, and 18 patients had minimally invasive direct coronary artery bypass. There were no strokes in the nonsternotomy group and 3 (1.3%) in the sternotomy group (p = 0.031). Thirty-day mortality, incidence of myocardial infarction, hospital LOS, and midterm survival were similar between groups. Operative time was significantly longer in the nonsternotomy group (1.8 hours, 95% confidence interval [CI], 1.5-2.1). In this propensity-adjusted comparison, sternal-sparing incisions were associated with similar 30-day adverse events and midterm survival compared with sternotomy for single-vessel LIMA-LAD artery grafting.The Annals of thoracic surgery 07/2012; 94(5):1469-77. · 3.74 Impact Factor -
Article: Bilateral internal thoracic artery grafting is associated with significantly improved long-term survival, even among diabetic patients.
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ABSTRACT: This study examines if bilateral internal thoracic artery (BITA) grafting provides improved outcomes compared with single internal thoracic artery (SITA) grafting, in the modern era, in which diabetes mellitus and obesity are more prevalent. The Society of Thoracic Surgeons database at a single large academic center was reviewed for all consecutive isolated coronary artery bypass grafting patients with two or more distal anastomoses from January 1, 2002, through December 31, 2010. Propensity-adjusted logistic and Cox regression models were used to estimate the effect of BITA on short-term outcomes and long-term survival for diabetic and nondiabetic patients. A total of 3,527 coronary artery bypass grafting operations (812 BITA, 2,715 SITA) were performed. Fewer BITA than SITA patients had diabetes (28.6% vs 44.7% p<0.001). There was no significant difference in 30-day rates of death, stroke, or myocardial infarction between nondiabetic patients who had BITA vs SITA, or between diabetic patients who had BITA vs SITA. BITA grafting conferred a 35% reduction (95% confidence interval, 12% to 52%, p=0.006) in the long-term hazard of death equally for nondiabetic and diabetic patients (p=0.93). Deep sternal wound infection was more common among diabetic than among nondiabetic patients (1.5% vs 0.7%), but was similar within nondiabetic (1.0% vs 0.6%) and diabetic patients (1.7% vs 1.5%) who had BITA vs SITA. Overall, BITA and SITA patients had similar rates of deep sternal wound infection (1.2% vs 1.0%). BITA grafting confers a long-term survival advantage and should be performed whenever suitable coronary anatomy exists and patient risk factors allow an acceptable risk of deep sternal wound infection.The Annals of thoracic surgery 06/2012; 94(3):710-5; discussion 715-6. · 3.74 Impact Factor -
Article: Prediction of new onset atrial fibrillation after cardiac revascularization surgery.
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ABSTRACT: The aim of this study was to create a simple risk index to predict new-onset atrial fibrillation (AF) after coronary artery bypass grafting in patients with histories of AF. AF after coronary artery bypass grafting (referred to here as AF) is associated with increased morbidity and mortality. Identifying patients at high risk for developing AF may help identify a group of patients who might benefit from strategies to prevent postoperative AF. A cohort of 18,517 patients enrolled from January 1, 1996, to December 31, 2009, was used to derive a risk index for AF prediction. A multivariate logistic regression model determined the independent predictive impact of clinical and demographic characteristics on the occurrence of AF. A subset of these variables was used to construct a risk index to predict AF. This risk index was validated in a sequential cohort of 1,378 consecutive patients who underwent coronary artery bypass grafting from January 1, 2010, to June 30, 2011. AF occurred in 3,486 patients in the calibration cohort (18.83%) and in 269 patients in the validation cohort (19.52%). After considering patients' demographics, co-morbid conditions, and severity of illness, advanced age appeared as the most powerful predictor of AF (odds ratio 1.059/year, 95% confidence interval 1.055 to 1.063). Age, height, weight, and the presence of peripheral vascular disease contributed most to the prediction model. An AF risk index including these variables had adequate discriminatory power, with a concordance index of 0.68. In conclusion, using a large cohort of patients, a simple risk index relying only on preoperative clinical variables was developed, which will help predict AF. This risk index can be used clinically to identify patients at high risk for the development of AF.The American journal of cardiology 05/2012; 110(5):649-54. · 3.58 Impact Factor -
Article: Risk factors for conversion to cardiopulmonary bypass during off-pump coronary artery bypass surgery.
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ABSTRACT: Off-pump coronary artery bypass graft (OPCAB) may be associated with improved hospital outcomes compared with on-pump coronary artery bypass graft. However, intraoperative conversion to on-pump coronary artery bypass graft has been associated with adverse outcomes. The purpose of this study was to identify preoperative risk factors for intraoperative conversion in nonemergent patients undergoing isolated OPCAB. From 2002 to 2010, 8,077 consecutive OPCAB cases were performed at a single US academic center. Of these, 200 (2.5%) required intraoperative conversion. Standard variables from The Society of Thoracic Surgeons database were analyzed. A multivariable logistic model with adjusted odds ratios (OR) and 95% confidence intervals was used to identify independent risk factors for conversion. Adjusted in-hospital and long-term survival between converted and nonconverted patients were determined using multiple logistic regression and Cox proportional hazards regression, respectively. Converted patients had a higher Society of Thoracic Surgeons predicted risk of mortality (2.8% versus 2.1%; p<0.001). Surgeon identity was the most significant multivariable predictor of conversion. After adjustment for surgeon identity, the following independent risk factors were associated with intraoperative conversion: previous coronary artery bypass graft (OR, 3.43; p=0.018), congestive heart failure (OR, 1.51), myocardial infarction (OR, 1.86), number of grafts (OR, 1.45), left main disease (OR 1.41), and urgent status (OR, 1.77; all p<0.05). Conversion to on-pump coronary artery bypass graft was associated with increased in-hospital (OR, 4.8; p<0.001) and long-term mortality (hazard ratio, 1.65; p<0.001). Conversion to cardiopulmonary bypass during OPCAB is associated with increased in-hospital and long-term mortality and may be related to surgeon experience. Recognition of the preoperative risk factors associated with an increased risk of conversion may allow for better patient selection and reduce the incidence of intraoperative conversion during OPCAB.The Annals of thoracic surgery 04/2012; 93(6):1936-41; discussion 1942. · 3.74 Impact Factor -
Article: The society of thoracic surgeons 30-day predicted risk of mortality score also predicts long-term survival.
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ABSTRACT: The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) score is a well-validated predictor of 30-day mortality after cardiac procedures. This study investigated the ability of PROM to predict longer-term survival. From January 1, 1996, to December 31, 2009, 24,222 patients with PROM scores underwent cardiac procedures at an academic center. Long-term all-cause mortality was determined from the Social Security Death Index. Logistic and Cox survival regression analyses evaluated the long-term predictive utility of the PROM. Area under the receiver operator characteristic curve measured the discrimination of PROM at 1, 3, 5, and 10 years. Kaplan-Meier curves were stratified by quartiles of PROM risk to compare long-term survival. All analyses were performed for the whole sample and for 30-day survivors. The overall 30-day mortality was 2.78% (674 of 24,222). PROM predicted 30-day mortality extremely well (area under the receiver operator characteristic, 0.794) and predicted longer-term survival almost as well. Among all patients and 30-day survivors, area under the receiver operator characteristic values for PROM at 1, 3, 5, and 10 years were remarkably similar to the 30-day end point for which PROM is calibrated. PROM was highly predictive of Kaplan-Meier survival for patients surviving beyond 30 days. Among 30-day survivors, each percent increase in PROM score was associated with a 9.6% increase (95% confidence interval, 9.3% to 10.0%) in instantaneous hazard of death (p<0.001). The PROM algorithm accurately predicts death at 30-days and during 14 years of follow-up with almost equally strong discriminatory power. This may have profound implications for informed consent and for longitudinal comparative effectiveness studies.The Annals of thoracic surgery 01/2012; 93(1):26-33; discussion 33-5. · 3.74 Impact Factor -
Article: Avoiding the clamp during off-pump coronary artery bypass reduces cerebral embolic events: results of a prospective randomized trial.
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ABSTRACT: The purpose of this study was to determine whether a clampless facilitating device (CFD) to perform proximal aortocoronary anastomoses would result in a lower incidence of cerebral embolic events compared with a partial clamping strategy during off-pump coronary artery bypass (OPCAB). After epiaortic ultrasound confirmed the mild aortic disease (Grades I and II), 57 patients were randomly assigned to have proximal anastomoses using a partial-occluding clamp (CL, n = 28) or a CFD [Heartstring (HS), n = 29] (Maquet Cardiovascular LLC, San Jose, CA). Solid and gaseous emboli in the middle cerebral arteries were detected using transcranial Doppler ultrasonography. The mean number of proximal anastomoses was similar between groups 1.93 ± 0.72 (CL) and 1.72 ± 0.70 (HS) (P = 0.28). The mean number of gaseous plus solid emboli was greater in the CL group than the HS group (90.0 ± 64.0 vs. 50.8 ± 36.6, P = 0.01). Emboli were fewest in patients undergoing HS anastomoses using the suction device. The number of intraoperative cerebral emboli was proportional to the number of proximal anastomoses in the HS groups, but independent of the number of proximal anastomoses in the CL groups. Among patients with a low burden of aortic atherosclerosis, partial clamping of the ascending aorta during OPCAB was associated with more cerebral embolic events compared with an anastomosis with a CFD.Interactive cardiovascular and thoracic surgery 11/2011; 14(1):12-6. -
Article: Short- and long-term outcomes in patients undergoing valve surgery with end-stage renal failure receiving chronic hemodialysis.
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ABSTRACT: The objective of this study was to evaluate the effect of chronic preoperative hemodialysis for end-stage renal failure in patients undergoing valve surgery. A retrospective review of patients undergoing primary valve with or without coronary artery bypass surgery from 1996 to 2008 at a US academic center was performed. The patients were divided into two groups: group 1 underwent valve surgery without preoperative dialysis (n = 5084) and group 2 underwent valve surgery with preoperative dialysis (n = 224). The outcomes were evaluated using multivariate regression analysis, and long-term survival was assessed with Kaplan-Meier plots. The patients in group 2 were younger (P < .001), were more likely women (P = .04), and presented with New York Heart Association class III-IV (P < .001). The ejection fraction was similar between the two groups (P = .36). The adjusted perioperative morbidity was similar between the two groups for stroke (P = .79) and myocardial infarction (P = .68). Resource use (postoperative length of stay) was greater in group 2 (P < .001), as was in-hospital mortality (group 1, 263/5084 [5.2%] vs group 2, 41/224 [18.3%]; P < .001). The 1-, 5-, and 10-year survival was less in group 2 (P < .001); the median survival was 12 or more years in group 1 and 1.8 years in group 2. Preoperative end-state renal disease, among others, show a trend as an independent predictor for short-term mortality and was a significant predictor for long-term mortality. In this large cohort of patients, preoperative dialysis conferred a high risk of perioperative morbidity and mortality and poor long-term survival after valve surgery. Risk stratification and future research efforts should focus on more precise identification of the benefits of valve surgery in this high-risk patient population.The Journal of thoracic and cardiovascular surgery 08/2011; 144(1):117-23. · 3.41 Impact Factor -
Article: Impact of preoperative renal dysfunction in patients undergoing off-pump versus on-pump coronary artery bypass.
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ABSTRACT: The impact of the degree of renal dysfunction (RD) in patients undergoing coronary artery bypass grafting (CABG) ranging from normal to dialysis-dependence is not well defined. A retrospective review of 14,199 patients undergoing isolated, primary CABG from January 1996 to May 2009 at Emory Healthcare was performed. The estimated glomerular filtration rate (eGFR) was estimated by the Modification of Diet in Renal Disease formula: mild RD (eGFR 60 to 90 mL/min/1.73 m2), moderate RD (eGFR 30 to 59), severe RD (eGFR<30). A propensity scoring was used to balance the groups with 46 preoperative covariates. Multivariable logistic and Cox regression methods were used to determine the independent association of eGFR with mortality. Adjusted odds ratios were calculated for outcomes using the normal eGFR group as the reference. Kaplan-Meier curves were created to estimate long-term survival. A total of 8,086 patients (57.0%) underwent off-pump coronary artery bypass (OPCAB) while 6,113 (43.0%) underwent on-pump CAB. Preoperative RD was common: Normal eGFR (n=3,503/14,199 [24.7%]); mild RD (7,236/14199 [51.0%]); moderate RD (2,860/14,199 [20.1%]); severe RD (283/14,199 [2.0%]); and preoperative dialysis (317/14,199 [2.2%]). Moderate to severe RD or preoperative dialysis was associated with worse adjusted in-hospital mortality: mild RD (odds ratio [OR] 1.42; 95% confidence interval [CI] 0.93 to 2.16; p=not significant); moderate RD (OR 3.55; 95% CI 2.32 to 5.43; p<0.05]; severe RD (OR 8.84; 95% CI 4.92 to 15.9; p<0.05); and dialysis-dependent (OR 9.64; 95% CI 5.45 to 17.0; p<0.05). Adjusted long-term survival was worse across levels of RD. The OPCAB patients with moderate to severe RD had worse long-term survival than on-pump CAB patients; however, the surgery types were similar among normal, mild, and dialysis patients. Preoperative RD is common in the CABG population and is associated with diminished long-term survival. Improved early outcomes in patients with RD undergoing OPCAB diminished with worsening RD.The Annals of thoracic surgery 06/2011; 92(2):595-601; discussion 602. · 3.74 Impact Factor -
Article: Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement.
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ABSTRACT: The impact of the degrees of renal dysfunction (RD) after aortic valve replacement (AVR) has not been well described. The purpose of this study was to compare patients undergoing AVR with a range of renal function from normal to dialysis-dependence. A retrospective review of 2,408 patients undergoing AVR with or without coronary artery bypass graft surgery (CABG) from January 1996 to March 2009 was performed. Glomerular filtration rate (GFR) was estimated for patients using the Modification of Diet in Renal Disease formula. Multivariable logistic and Cox regression methods were used to determine the independent association of GFR with outcomes. Adjusted odds ratios were calculated for in-hospital outcomes, and Kaplan-Meier curves were created to estimate long-term survival. In all, 1,512 patients (62.8%) had isolated AVR, and 896 (37.2%) underwent AVR plus CABG. Preoperative RD was common among all patients: 1,148 of 2,408 (47.7%) with mild RD (GFR 60 to 90 mL·min(-1)·1.73 m(-2)), 644 of 2,408 (26.7%) moderate RD (GFR 30 to 59 mL·min(-1)·1.73 m(-2)), 59 of 2,408 (2.5%) severe RD (GFR 15 to 30 mL·min(-1)·1.73 m(-2)), and 114 (4.7%) with kidney failure (GFR<15) or requiring dialysis. In-hospital mortality generally rose with RD, from 2.9% for patients with no RD to 15.8% for patients with severe RD, and 17.3% for patients requiring dialysis. Patients with severe RD or preoperative dialysis were associated with significantly poorer outcomes. Adjusted long-term survival is progressively worse across levels of RD, as was postoperative length of stay (p<0.001). Preoperative RD is common among the AVR population and is associated with diminished long-term survival. The association between RD and worse outcomes after AVR surgery has significant clinical implications.The Annals of thoracic surgery 06/2011; 91(6):1798-806; discussion 1806-7. · 3.74 Impact Factor -
Article: Invited commentary.
The Annals of thoracic surgery 03/2011; 91(3):776. · 3.74 Impact Factor -
Article: The impact of body mass index on morbidity and short- and long-term mortality in cardiac valvular surgery.
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ABSTRACT: Limited data exist on patients with cardiac cachexia or morbid obesity presenting for valvular heart surgery. The objective of this study was to investigate the relationship between body mass index and morbidity and mortality after valvular surgery. A retrospective review of 4247 patients undergoing valvular surgery from 1996 to 2008 at Emory University Healthcare Hospitals was performed. Patients were divided into 3 groups: body mass index 24 or less (group 1, n = 1527), body mass index 25 to 35 (group 2, n = 2284), and body mass index 36 or more (group 3, n = 436). Data were analyzed using multivariable regression analysis, adjusted for 10 preoperative covariates. A smooth kernel regression curve was generated using body mass index and in-hospital mortality as variables. Long-term survival comparisons were made using adjusted Cox proportional hazards regression models and Kaplan-Meier product-limit estimates. Kaplan-Meier curves were generated that provide survival estimates for long-term mortality using the Social Security Death Index. Patients in group 3 were significantly younger (group 1, 61.7 ± 16.1 years; group 2, 61.9 ± 13.6; group 3, 57.5 ± 13.0; P < .001) and more likely to be female (group 1, 778/1527 [51.0%]; group 2, 912/2284 [39.9%]; group 3, 240/436 [55.0%]; P < .001). Mean ejection fractions were similar among groups (P = .51). Patients in group 2 had significantly shorter postoperative length of stay (group 1, 9.6 ± 10.3 days; group 2, 8.7 ± 8.2 days; group 3, 10.8 ± 11.0 days; P < .001). In-hospital mortality for the entire cohort was 5.8% (245/4247), and by group was 111 of 1527 (7.3%) in group 1, 110 of 2284 (4.8%) in group 2, and 24 of 436 (5.5%) in group 3 (P = .006). Actual survival at 1, 3, 5, and 10 years was significantly lower in group 1 (P < .001). A lower body mass index was a significant independent predictor for both in-hospital and long-term mortality. Patients with body mass index 24 or less are at significantly increased risk of in-hospital and long-term mortality after cardiac valvular surgery. This high-risk patient population warrants careful risk stratification and options for less-invasive valve therapies.The Journal of thoracic and cardiovascular surgery 03/2011; 142(5):1052-61. · 3.41 Impact Factor -
Article: Short- and long-term outcomes in octogenarian patients undergoing off-pump coronary artery bypass grafting compared with on-pump coronary artery bypass grafting.
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ABSTRACT: : Coronary artery bypass grafting (CAB) on elderly patients presenting with multivessel coronary artery disease has become routine in modern day operating rooms. The aim of our study was to compare short- and long-term outcomes in octogenarian patients undergoing off-pump CAB (OPCAB) versus on-pump CAB (ONCAB). : A propensity-adjusted, retrospective review of patients older than 80 years who underwent primary CAB from January 1996 to September 2008 at our institution's hospitals was performed. Nine hundred thirty-seven patients were divided into two groups: OPCAB (n = 540) or ONCAB (n = 397). A propensity score was calculated based on 29 preoperative risk factors to adjust for selection bias when comparing the groups for differences in death, stroke, myocardial infarction incidence, and their composite (major adverse cardiac events). Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index. Logistic regression analysis and Cox proportional hazards analysis were used to determine group differences in short- and long-term survival, respectively, adjusted for the propensity score. Kaplan-Meier curves were fit to estimate 10-year survival. : The mean age (OPCAB: 82.9 ± 2.8 years vs ONCAB: 82.3 ± 2.4, P = 0.003) and male sex (OPCAB: 292/540, 54.1% vs ONCAB: 220/397, 55.4%, P = 0.68) were clinically similar between groups. Although the ejection fraction (OPCAB: 52.1 ± 12.5% vs ONCAB: 50.6 ± 13.1, P = 0.10) were similar between groups, the mean number of distal anastomoses [OPCAB: 2.7 ± 1.0 (median 3) vs ONCAB: 3.4 ± 0.9 (median 3), P < 0.001] were less in the OPCAB group. The median postoperative length of stay was 7 days for OPCAB group and 6 for the ONCAB group (P = 0.31). The Society of Thoracic Surgery predicted risk of in-hospital mortality was similar for OPCAB (5.4%) and ONCAB (5.3%) patients (P = 0.81). However, observed in-hospital mortality was improved for patients in the OPCAB group (OPCAB: 15/540, 2.8% vs ONCAB: 37/397, 9.3%, P = 0.007). Ten-year survival was similar between groups (OPCAB: 28.8% vs ONCAB: 26.3%, P = 0.22). : In this series, OPCAB reduced the incidence of in-hospital mortality compared with ONCAB. Long-term mortality was similar between groups.Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 03/2011; 6(2):110-5. -
Article: Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.
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ABSTRACT: The objective of this study was to assess short-term and long-term outcomes after valve replacement with biologic or mechanical prostheses in patients with preoperative end-stage renal disease on chronic dialysis. A retrospective review of patients with end-stage renal disease undergoing valve replacement from January 1996 through March 2008 at Emory Healthcare Hospitals was performed. Outcomes were compared using χ(2) tests and 2-sample t tests. Adjusted long-term survival up to 10 years was assessed with Kaplan-Meier plots and compared between biologic and mechanical replacements using the Cox proportional hazards model. A total of 202 patients underwent 211 valve replacement operations. Patient age was 20 to 83 years (mean age, 54.8 ± 14.0); 115 of 211 (54.5%) were male. Operations included the following: 100 of 211 (47.4%) isolated aortic; 49 of 211 (23.2%) isolated mitral; 4 of 211 (1.9%) isolated tricuspid; and 58 of 211 (27.5%) combined replacements. Thirteen (6.2%) patients underwent reoperative valve replacements. Most patients received bioprosthetic valves (143 of 211, 67.8%), while 68 of 211 (32.2%) received mechanical valves. Concomitant coronary artery bypass was performed in 53 of 211 (25.1%) patients. Thirty-day mortality was in 42 of 211 patients (19.9%) and was not different between bioprosthetic and mechanical replacements. Overall 10-year survival was 18.1% for all patients and was not influenced by valve type implanted. For patients with end-stage renal disease treated with dialysis, valve replacement carries acceptable operative mortality. Long-term survival is similar among patients receiving bioprosthetic versus mechanical valve replacement. Careful risk assessment and choice of valve prosthesis should be performed prior to surgical intervention in this high-risk patient population.The Annals of thoracic surgery 02/2011; 91(4):1127-34. · 3.74 Impact Factor -
Article: Impact of off-pump coronary artery bypass graft surgery on postoperative pulmonary complications in patients with chronic lung disease.
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ABSTRACT: Off-pump coronary artery bypass graft surgery (OPCAB) has proven to be beneficial in many high-risk subgroups. This study aims to determine whether OPCAB lowers the incidence of pulmonary complications among patients with chronic lung disease (CLD) when compared with on-pump coronary artery bypass graft surgery (ONCAB). From 2002 to 2007, 7,060 patients underwent isolated coronary artery bypass graft surgery in an academic center. Patients were classified according to surgery type (ONCAB or OPCAB) and presence or absence of CLD. A propensity score was produced to estimate each patient's likelihood of being assigned to OPCAB on the basis of 39 preoperative risk factors. Multiple logistic regression models and adjusted odds ratios with 95% confidence intervals were used to evaluate the effect of surgery type, CLD, and their interaction on pulmonary-related complications and mortality. Among OPCAB patients, 15.3% (720 of 4,693) had CLD compared with 11.2% (264 of 2,367) for ONCAB. Off-pump coronary artery bypass graft surgery was performed in 73.2% of CLD patients compared with 66.5% in those without CLD (p<0.0001). Chronic lung disease was associated with a greater incidence of prolonged ventilation, reintubation, pneumonia, intensive care unit hours, and non-home discharge. After propensity score adjustment, OPCAB was associated with a significantly reduced incidence of prolonged ventilation, pneumonia, intensive care unit stay, and mortality. No significant interactions existed between surgery type and CLD status, suggesting that OPCAB was equally beneficial to patients with and without CLD. In this series, patients with CLD were more likely to undergo OPCAB. Patients with CLD are at significantly greater risk of pulmonary-related complications than patients without CLD. Off-pump coronary artery bypass graft surgery reduced the incidence of pulmonary complications and mortality in all patients. Importantly, this benefit was seen similarly for patients with and without CLD.The Annals of thoracic surgery 01/2011; 91(1):8-15. · 3.74 Impact Factor -
Article: Outcomes of off-pump aortic valve bypass surgery for the relief of aortic stenosis in adults.
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ABSTRACT: Elderly patients with aortic stenosis presenting for an aortic valve replacement with a hostile ascending aorta remain a challenging patient cohort. The purpose of this study was to assess outcomes after the use of an aortic valve bypass performed without cardiopulmonary bypass. A retrospective review was performed on 21 high-risk patients who underwent primary, isolated aortic valve bypass from September 2004 to June 2009 at Emory Healthcare Hospitals. Aortic valve bypass was used for a porcelain aorta alone in 6 (28.6%) patients, previous coronary artery bypass grafting in 4 (19.0%), or both in 10 (47.6%). One patient (4.8%) was thought not to be a candidate for cardiopulmonary bypass secondary to a severe cirrhosis. Mean age was 73.9±7.0 years (median, 75.0 years), and 15 patients (71.4%) were male. Mean New York Heart Association classification was 3.0±1.0 (median, 3.0), and preoperative ejection fraction was 0.460±0.163 (median, 0.500). Preoperative comorbidities included peripheral vascular disease (n=10; 47.6%), chronic lung disease (n=16; 76.2%), diabetes mellitus (n=10; 47.6%), and dialysis-dependence (n=2; 9.5%). Either an 18-mm (n=11; 52.4%) or 20-mm (n=10; 47.6%) conduit was used, with an interposed Freestyle 21 porcine root in all patients. All operations were performed without cardiopulmonary bypass. There were no intraoperative mortalities. The mean intensive care unit stay was 133.7±161.3 hours (median, 80.2 hours), and overall postoperative length of stay was 12.9±10.8 days (median, 9.0 days). In-hospital mortality occurred in 3 patients (14.3%). Mid-term follow-up shows an additional 4 patients died at a median follow-up of 1.3 years. Aortic valve bypass without cardiopulmonary bypass is a feasible alternative for the treatment of severe aortic stenosis with acceptable short-term morbidity and minimal mortality in this extremely high-risk surgical population.The Annals of thoracic surgery 01/2011; 91(1):131-6. · 3.74 Impact Factor -
Article: The effect of diabetes mellitus on in-hospital and long-term outcomes after heart valve operations.
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ABSTRACT: Diabetes mellitus (DM) is associated with adverse in-hospital and long-term outcomes in patients undergoing coronary artery bypass grafting. This study evaluated outcomes in patients with DM undergoing isolated heart valve operations. From January 1, 1996, to March 31, 2008, 2964 consecutive patients underwent primary, isolated heart valve operations at Emory University Hospitals. Patients undergoing concomitant coronary bypass grafting were excluded. Of the heart valve patients, 424 (14.3%) had a diagnosis of DM, and 126 (29.7%) received insulin therapy. Long-term survival status was determined using the Social Security Death Index. Odds ratios and proportional hazards regression analysis (hazard ratio) were used to identify risk factors for in-hospital and long-term mortality, respectively. Thirty-four DM patients (8.0%) died in-hospital compared with 99 (3.9%) without DM (p < 0.001). In-hospital mortality was higher in DM patients who received insulin (12.7%) than in those without insulin therapy (6.0%, p = 0.021). DM patients had significantly reduced 10-year survival of 41.5% vs 70.5% for those without DM (p < 0.001). After risk adjustment, DM remained a strong risk factor for reduced 10-year survival (hazard ratio, 1.30; 95% confidence interval, 1.05 to 1.61; p = 0.018); other risk factors include advanced age, stroke, female gender, peripheral vascular disease, advanced heart failure, and renal failure. DM is associated with significantly worse outcomes after valve operations. Given the reduced long-term survival observed in these patients, this information should be used when making operative decisions regarding surgical techniques and types of prosthesis in these complex patients.The Annals of thoracic surgery 07/2010; 90(1):124-30. · 3.74 Impact Factor
Top co-authors
Top Journals
Institutions
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2003–2013
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Emory University
- • Division of Cardiothoracic Surgery
- • Division of Cardiology
Atlanta, GA, USA
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2012
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University of Louisville
- Division of Thoracic and Cardiovascular Surgery
Louisville, KY, USA
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2008
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Emory Hospitals
Atlanta, GA, USA
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