Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes.

Slides:

Advertisements

Similar presentations

BITA Grafting: When to do it (when to not do it ) Joseph F. Sabik, MD Chairman and Professor of Surgery Department of Thoracic and Cardiovascular Surgery.

Advertisements

Tomislav Mihaljevic, MD, Edward R

Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine

Characterization and Importance of Air Leak After Lobectomy

Residual patient, anatomic, and surgical obstacles in treating active left-sided infective endocarditis Syed T. Hussain, MD, Nabin K. Shrestha, MD, Steven.

Advising complex patients who require complex heart operations

Should lung transplantation be performed for patients on mechanical respiratory support? The US experience David P. Mason, MD, Lucy Thuita, MS, Edward.

Increased late mortality after coronary artery bypass surgery complicated by isolated new-onset atrial fibrillation: A comprehensive propensity-matched.

Morbidity of Bleeding After Cardiac Surgery: Is It Blood Transfusion, Reoperation for Bleeding, or Both? Alessandro Vivacqua, MD, Colleen G. Koch, MD,

One or Two Internal Thoracic Grafts

Effect of changes in postoperative spirometry on survival after lung transplantation David P. Mason, MD, Jeevanantham Rajeswaran, MSc, Liang Li, PhD,

Beyond the Aortic Root: Staged Open and Endovascular Repair of Arch and Descending Aorta in Patients With Connective Tissue Disorders Eric E. Roselli,

Endovascular versus open elephant trunk completion for extensive aortic disease Eric E. Roselli, MD, Sreekumar Subramanian, MD, Zhiyuan Sun, BS, Jahanzaib.

The least of 3 evils: Exposure to red blood cell transfusion, anemia, or both? Gabriel Loor, MD, Jeevanantham Rajeswaran, PhD, Liang Li, PhD, Joseph F.

Surgical treatment of pseudoaneurysm of the thoracic aorta

Joseph F. Sabik, MD, Bruce W. Lytle, MD, Eugene H

Long-term outcomes of coronary artery bypass grafting patients supported preoperatively with an intra-aortic balloon pump Eli Hemo, MD, Benjamin Medalion,

Shikhar Agarwal, MD, MPH, Aatish Garg, MD, Akhil Parashar, MD, Lars G

Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting? Khalil Masabni, MD,

Reoperation After Mitral Valve Repair for Degenerative Disease

Bruce W. Lytle, MD, Eugene H. Blackstone, MD, Joseph F

Why surgery won the SYNTAX trial and why it matters

New-Onset Postoperative Atrial Fibrillation and Long-Term Survival After Aortic Valve Replacement Surgery Giovanni Filardo, PhD, MPH, Cody Hamilton,

Clostridium difficile infection after cardiac surgery: Prevalence, morbidity, mortality, and resource utilization Suresh Keshavamurthy, MBBS, MS, Colleen.

Coronary artery bypass grafting in diabetics: A growing health care cost crisis Sajjad Raza, MD, Joseph F. Sabik, MD, Ponnuthurai Ainkaran, MS, Eugene.

Surgical Repair of Posterior Mitral Valve Prolapse: Implications for Guidelines and Percutaneous Repair Douglas R. Johnston, MD, A. Marc Gillinov, MD,

Appropriate patient selection or health care rationing

Albert S. Y. Chang, MD, Nicholas G. Smedira, MD, Catherine L

Charles M. Wojnarski, MD, Lars G. Svensson, MD, PhD, Eric E

Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine

Does a similar procedure result in similar survival for women and men undergoing isolated coronary artery bypass grafting? Tamer Attia, MD, MSc, Colleen.

Simple versus complex degenerative mitral valve disease

A. Marc Gillinov, MD, Eugene H. Blackstone, MD, Edward R

Ruben L. Osnabrugge, MS, Alan M. Speir, MD, Stuart J

Scoring system to guide decision making for the use of gentamicin-impregnated collagen sponge to prevent deep sternal wound infection Umberto Benedetto,

Gabriel Loor, MD, Liang Li, PhD, Joseph F

Atrial fibrillation complicating lung cancer resection

Long-Term Durability of Bicuspid Aortic Valve Repair

Reduced survival in women after valve surgery for aortic regurgitationEffect of aortic enlargement and late aortic rupture Monica L. McDonald, MDa, Nicholas.

A decade after the Surgical Treatment for Ischemic Heart Failure (STICH) trial: Weaving firm clinical recommendations from lessons learned Robert E.

Outcomes of less invasive J-incision approach to aortic valve surgery

One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up Raimondo Ascione, MD, Gabriele.

The effect of coronary artery bypass grafting on specific causes of long-term mortality in the Bypass Angioplasty Revascularization Investigation David.

A time-related parametric risk factor analysis for postoperative atrial fibrillation after heart surgery Spencer J. Melby, MD, James F. George, PhD,

Sajjad Raza, MD, Joseph F. Sabik, MD, Stephen G. Ellis, MD, Penny L

Eugene H. Blackstone, MDa,b, Bruce W. Lytle, MDb

Distal aortic interventions after repair of ascending dissection: The argument for a more aggressive approach Eric E. Roselli, MD, Gabriel Loor, MD,

A meta-analysis of adjusted hazard ratios from 20 observational studies of bilateral versus single internal thoracic artery coronary artery bypass grafting

Two internal thoracic artery grafts are better than one

Impact of the second internal thoracic artery on short- and long-term outcomes in obese patients: A propensity score matched analysis Umberto Benedetto,

Long-term effectiveness of operations for ascending aortic dissections

Decision support in surgical management of ischemic cardiomyopathy

The diabetes epidemic and its effect on cardiac surgery practice

Isolated bypass grafting of the left internal thoracic artery to the left anterior descending coronary artery Rosalyn Scott, MDa, Eugene H. Blackstone,

Mohammed A Quader, MD, Patrick M McCarthy, MD, A

Are three arteries better than two

Colleen G. Koch, MD, MS, MBA, Edward R

Late outcomes after radial artery versus saphenous vein grafting during reoperative coronary artery bypass surgery Anoar Zacharias, MD, Thomas A. Schwann,

Ventilatory dependency after cardiovascular surgery

Joseph F. Sabik, MD, Gabriel Olivares, MD, Sajjad Raza, MD, Bruce W

Douglas R. Johnston, MD, Edward G

Turki B. Albacker, MD, MSc, Eugene H. Blackstone, MD, Sarah J

Mitral valve repair with aortic valve replacement is superior to double valve replacement A.Marc Gillinov, MD, Eugene H Blackstone, MD, Delos M Cosgrove,

Siva Raja, MD, PhD, Jay J. Idrees, MD, Eugene H

Gender differences in outcomes after surgical ablation of atrial fibrillation Sonia V. Shah, BS, Jane Kruse, BSN, Adin-Cristian Andrei, PhD, Zhi Li, MS,

Guidance for the use of bilateral internal thoracic arteries according to survival benefit across age groups Umberto Benedetto, MD, PhD, Mohamed Amrani,

Off-pump bilateral skeletonized internal thoracic artery grafting in patients with chronic kidney disease Takeshi Kinoshita, MD, PhD, Tohru Asai, MD,

Pulmonary hypertension is associated with worse early and late outcomes after aortic valve replacement: Implications for transcatheter aortic valve replacement

A. Marc Gillinov, MD, Jon Sirak, MD, Eugene H

Assessment of independent predictors for long-term mortality between women and men after coronary artery bypass grafting: Are women different from men?

Presentation transcript:

Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus Sajjad Raza, MD, Joseph F. Sabik, MD, Khalil Masabni, MD, Ponnuthurai Ainkaran, MS, Bruce W. Lytle, MD, Eugene H. Blackstone, MD The Journal of Thoracic and Cardiovascular Surgery Volume 148, Issue 4, Pages 1257-1266.e9 (October 2014) DOI: 10.1016/j.jtcvs.2014.06.058 Copyright © 2014 Terms and Conditions

Figure 1 Comparative risk of developing complications after coronary artery bypass grafting in diabetic patients. An odds ratio of 1.0 indicates equal risk; odds ratios >1.0 indicate greater risk and those <1.0, lower risk. Symbols represent point estimates and horizontal bars, 68% confidence limits equivalent to ±1 standard error. A and B, Bilateral (BITA) versus single (SITA) internal thoracic artery grafting. C and D, Incomplete versus complete revascularization. E and F, Off- versus on-pump surgery. Reop, Reoperation; Postop, postoperative; LOS, length of stay; SWI, sternal wound infection. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure 2 Effect of risk factors on probability of deep sternal wound infection (DSWI) across a range of body mass indexes. Simulations were based on the logistic regression model (Table 1) for a patient undergoing coronary artery bypass grafting with cardiopulmonary bypass, in the past decade, with complete revascularization. Other factors are listed for the individual depictions. A, Effect of female sex after bilateral (BITA) and single (SITA) internal thoracic artery grafting. Simulations are based on an insulin-treated patient with no history of peripheral arterial disease (PAD) or myocardial infarction (MI). B, Effect of PAD and MI after BITA grafting. Simulations are based on an insulin-treated woman. C, Effect of diet-controlled versus medically treated diabetes. Simulations are based on a man with no history of PAD or MI undergoing CABG with BITA grafting. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure 3 Unadjusted survival after coronary artery bypass grafting. Each symbol represents a death at selected points (1, 3, 5, 10, 15, and 20 years after surgery) from Kaplan-Meier estimation; vertical bars are confidence limits equivalent to ±1 standard error (SE). Solid lines are parametric estimates enclosed within dashed confidence bands equivalent to ±1 SE. A, Stratified by bilateral and single internal thoracic artery grafting and saphenous vein grafting only. B, Stratified by incomplete versus complete revascularization. C, Stratified by off- versus on-pump coronary artery bypass grafting. BITA, Bilateral internal thoracic artery; SITA, single internal thoracic artery; SVG, saphenous vein grafting. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure 4 Risk-adjusted effect of bilateral (BITA) versus single (SITA) internal thoracic artery grafting and incomplete (IR) versus complete (CR) revascularization on predicted survival after coronary artery bypass grafting (CABG) in diabetic patients. Simulations were based on the multivariable model (Table 2), with the following variables held constant: 62-year-old non–insulin-treated diabetic man, New York Heart Association functional class II, preoperative cholesterol 200 mg/dL, bilirubin 0.6 mg/dL, creatinine 0.8 mg/dL, no carotid disease, heart failure, previous myocardial infarction, peripheral arterial disease, previous stroke, and on-pump coronary artery bypass grafting. SVG, Saphenous vein grafting. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure E1 Probability of developing a deep sternal wound infection (DSWI). Solid line represents parametric estimate enclosed within a 68% confidence limit band. This graph represents a nomogram of the logistic regression equation for DSWI (Table 1). A, Effect of body mass index. Simulation was based on pharmacologically treated (non–insulin-treated) diabetic woman with no previous myocardial infarction or history of peripheral arterial disease undergoing coronary artery bypass grafting with cardiopulmonary bypass and bilateral internal thoracic artery grafts, receiving complete revascularization, and treated in 2007. B, Effect of date of operation. Simulation was based on pharmacologically treated (non–insulin-treated) diabetic woman with no previous myocardial infarction or history of peripheral arterial disease, body mass index of 29 kg/m2, undergoing coronary artery bypass grafting with cardiopulmonary bypass, grafting with bilateral internal thoracic artery grafts, and complete revascularization. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure E2 Survival of diabetic patients who underwent coronary artery bypass grafting estimated using the Kaplan-Meier method. A, Stratified by deep sternal wound infection (DSWI) and bilateral (BITA) and single (SITA) internal thoracic artery grafting. B, Stratified by BITA and SITA grafting and showing the effect of DSWI on survival. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure E3 Cumulative distribution of predicted 10-year survival. A, For a combination of surgical techniques. The increasing order of these cumulative distributions of 10-year survival from left to right is shown in the table underneath the graph. B, For the number of ITA grafts used. C, For complete versus incomplete revascularization. D, For off-pump versus on-pump coronary artery bypass grafting. ITA, Internal thoracic artery; BITA, bilateral ITA graft; SITA, single ITA graft; SVG, saphenous vein graft. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions

Figure E4 Patient factors associated with maximum survival benefit from best combination of surgical techniques (ie, bilateral internal thoracic artery grafting, complete revascularization, and off-pump surgery). Solid line represents parametric estimate enclosed within a 68% confidence limit band. This graph represents a nomogram of the logistic regression equation for maximum survival benefit (Table 3). A, Older age. Simulation is based on pharmacologically (non-insulin) treated diabetic woman presenting with mild symptoms of heart failure (New York Heart Association class II), cholesterol level 230 mg/dL, bilirubin 0.63 mg/dL, no history of heart failure or peripheral arterial disease, undergoing nonemergency surgery. B, Lower cholesterol. Simulation is based on a 60-year-old pharmacologically (non-insulin) treated diabetic woman presenting with mild symptoms of heart failure (New York Heart Association class II), bilirubin 0.63 mg/dL, no history of heart failure or peripheral arterial disease, undergoing nonemergency surgery. C, Lower bilirubin. Simulation is based on a 60-year-old pharmacologically (non-insulin) treated diabetic woman presenting with mild symptoms of heart failure (New York Heart Association class II), cholesterol level 230 mg/dL, no history of heart failure or peripheral arterial disease, undergoing nonemergency surgery. The Journal of Thoracic and Cardiovascular Surgery 2014 148, 1257-1266.e9DOI: (10.1016/j.jtcvs.2014.06.058) Copyright © 2014 Terms and Conditions