EDITOR'S NOTE Still considered a "hot topic" 4 years later, JIN is pleased to reprint this classic article from May/June 2015, Issue 3. Since publication, "Accepted but Unacceptable: Peripheral IV Catheter Failure" has been downloaded nearly 400 times and cited dozens of times in other related research. Based on these data, we asked the lead author to update readers on the status of catheter failure and what has been improved since 2015.

BACKGROUND:Readmissions after cardiac surgery are common and associated with increased morbidity, mortality and cost of care. Policymakers have targeted coronary artery bypass grafting to achieve value-oriented health care milestones. We explored the causes of readmission following cardiac surgery among a regional consortium of hospitals.METHODS:Using administrative data, we identified patients readmitted to the same institution within 30 days of cardiac surgery. We performed standardized review of readmitted patients' medical records to identify primary and secondary causes of readmission. We evaluated causes of readmission by procedure and tested for univariate associations between characteristics of readmitted patients and nonreadmitted patients in our clinical registry.RESULTS:Of 2218 cardiac surgery patients, 272 were readmitted to the index hospital within 30 days for a readmission rate of 12.3%. Median time to readmission was 9 days (interquartile range 4-16 days) and only 13% of patients were evaluated in-office before readmission. Readmitted patients were more likely to have had valve surgery (31.3% vs 22.7%) than patients not readmitted. Readmitted patients were also more likely to have preoperative creatinine more than or equal to 2 mg/dL (P = .015) or congestive heart failure (CHF) (P = .034), require multiple blood transfusions or sustained inotropic support (P < .001), and experience postoperative atrial fibrillation (P = .022) or renal insufficiency (P < .001). Infection (26%), pleural or pericardial effusion (19%), arrhythmia (16%), and CHF (11%) were the most common primary etiologies leading to readmission.CONCLUSIONS:Ensuring early follow-up for high-risk patient groups while improving early detection and management of the principal drivers of readmission represent promising targets for decreasing readmission rates.

Background. Of patients undergoing cardiac surgery in the United States, 15% to 20% are re-hospitalized within 30 days. Current models to predict readmission have not evaluated the association between severity of postoperative acute kidney injury (AKI) and 30-day readmissions.Methods. We collected data from 2,209 consecutive patients who underwent either coronary artery bypass or valve surgery at 7 member hospitals of the Northern New England Cardiovascular Disease Study Group Cardiac Surgery Registry between July 2008 and December 2010. Administrative data at each hospital were searched to identify all patients readmitted to the index hospital within 30 days of discharge. We defined AKI stages by the AKI Network definition of 0.3 or 50% increase (stage 1), twofold increase (stage 2), and a threefold or 0.5 increase if the baseline serum creatinine was at least 4.0 (mg/dL) or new dialysis (stage 3). We evaluate the association between stages of AKI and 30-day readmission using multivariate logistic regression.Results. There were 260 patients readmitted within 30 days (12.1%). The median time to readmission was 9 (interquartile range, 4 to 16) days. Patients not developing AKI after cardiac surgery had a 30-day readmission rate of 9.3% compared with patients developing AKI stage 1 (16.1%), AKI stage 2 (21.8%), and AKI stage 3 (28.6%, p < 0.001). Adjusted odds ratios for AKI stage 1 (1.81; 1.35, 2.44), stage 2 (2.39; 1.38, 4.14), and stage 3 (3.47; 1.85 to 6.50). Models to predict readmission were significantly improved with the addition of AKI stage (c-statistic 0.65, p = 0.001) and net reclassification rate of 14.6% (95% confidence interval: 5.05% to 24.14%, p = 0.003).Conclusions. In addition to more traditional patient characteristics, the severity of postoperative AKI should be used when assessing a patient's risk for readmission. (C) 2014 by The Society of Thoracic Surgeons

Background— The survival of patients who undergo aortic valve replacement (AVR) for severe aortic stenosis with reduced preoperative ejection fractions (EFs) is not well described in the literature. Methods and Results— Patients undergoing AVR for severe aortic stenosis were analyzed using the Northern New England Cardiovascular Disease Study Group surgical registry. Patients were stratified by preoperative EF (≥50%, 40%–49%, and <40%) and concomitant coronary artery bypass grafting. Crude and adjusted survival across strata of EF was estimated for patients up to 8 years beyond their index admission. A total of 5277 patients underwent AVR for severe aortic stenosis between 1992 and 2008. There were 727 (14%) patients with preoperative EF <40%. Preoperative EF had minimal effect on postoperative morbidity. There was no difference in 30-day mortality across EF strata among the isolated AVR cohort. Preserved EF conferred 30-day survival benefit among the AVR+coronary artery bypass grafting population (EF≥50%, 96%; EF<40%, 91%; P =0.003). Patients with preserved EF had significantly improved 6-month and 8-year survival compared with their reduced EF counterparts. Conclusions— Survival after AVR or AVR+coronary artery bypass grafting was most favorable among patients with preoperative preserved EF. However, patients with mild to moderately depressed EF experienced a substantial survival benefit compared with the natural history of medically treated patients. Furthermore, minor reductions of EF carried equivalent increased risk to those with more compromised function suggesting patients are best served when an AVR is performed before even minor reductions in myocardial function.

Pulmonary hypertension (PH) is prevalent in patients with aortic stenosis (AS); however, previous studies have demonstrated inconsistent results regarding the association of PH with adverse outcomes after aortic valve replacement (AVR). The goal of this study was to evaluate the effects of preoperative PH on outcomes after AVR. We performed a regional prospective cohort study using the Northern New England Cardiovascular Disease Study Group database to identify 1,116 consecutive patients from 2005 to 2010 who underwent AVR +/- coronary artery bypass grafting for severe AS with a preoperative assessment of pulmonary pressures by right-sided cardiac catheterization. PH was defined as a mean pulmonary artery pressure of >= 25 mm Hg, with severity based on the pulmonary artery systolic pressure mild, 35 to 44 mm Hg; moderate, 45 to 59 mm Hg; and severe, >= 60 mm Hg. We found that PH was present in 536 patients (48%). Postoperative acute kidney injury, low-output heart failure, and in-hospital mortality increased with worsening severity of PH. In multivariate logistic regression, severe PH was independently associated with postoperative acute kidney injury (adjusted odds ratio 4.1, 95% confidence interval [CI] 1.7 to 10, p = 0.002) and in-hospital mortality (adjusted odds ratio 6.9, 95% CI 2.5 to 19.1, p <0.001). There was a significant association between PH and decreased 5-year survival (adjusted log-rank p value = 0.006), with severe PH being associated with the poorest survival (adjusted hazard ratio 2.4, 95% CI 1.3 to 4.2, p = 0.003). In conclusion, severe PH in patients with severe AS is associated with increased rates of in-hospital adverse events and decreased 5-year survival after AVR. (C) 2013 Elsevier Inc. All rights reserved.

Approximately 1 in 5 patients undergoing cardiac surgery are readmitted within 30 days of discharge. Among the primary causes of readmission are infection and disease states susceptible to the inflammatory cascade, such as diabetes, chronic obstructive pulmonary disease, and gastrointestinal complications. Currently, it is not known if a patient's baseline inflammatory statemeasured by crude white blood cell (WBC) counts could predict 30-day readmission. We collected data from 2,176 consecutive patients who underwent cardiac surgery at seven hospitals. Patient readmission data was abstracted from each hospital. The independent association with preoperativeWBC count was determined using logistic regression. There were 259 patients readmitted within 30 days, with a median time of readmission of 9 days (IQR 4-16). Patients with elevated WBC count at baseline (10,000-12,000 and > 12,000mm(3)) had higher 30-day readmission than those with lower levels ofWBC count prior to surgery (15% and 18% compared to 10%-12%, P = 0.037). Adjusted odds ratios were 1.42 (0.86, 2.34) for WBC counts 10,000-12,000 and 1.81 (1.03, 3.17) for WBC count > 12,000. We conclude that WBC count measured prior to cardiac surgery as a measure of the patient's inflammatory state could aid clinicians and continuity of caremanagement teams in identifying patients at heightened risk of 30-day readmission after discharge from cardiac surgery.

Background—Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF. Methods and Results—We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80–766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury. Conclusions—Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.

Introduction: Brain injury is a common yet devastating complication of cardiac surgery. Several intra-operative practices have been identified that may reduce emboli and the systemic inflammatory response, two mediators of brain injury. Hypothesis: Practices which reduce emboli and the systemic inflammatory response will reduce brain injury Methods: We enrolled 3,994 patients undergoing coronary artery bypass grafting with or without valve surgery at eight medical centers in northern New England between 2008-2011. All procedures were performed with cardiopulmonary bypass. We studied the effect of intra-operative practices that may reduce mediators of brain injury, including: the use of: tip-to-tip coated circuits, echocardiography (transesophageal or epi-aortic), or the use of a single aortic cross-clamp. Brain injury was defined as the presence of stupor, coma, transient ischemic attack or stroke (defined as any focal neurologic deficit persisting post-operatively for more than 24 hours). Results: Brain injury was present in 7.4% (293/3994) of the patients. Adoption of practices varied, with 19.4% (765/3994) of patients receiving 1 practice, 26.0% (1024/3994) receiving 2 practices, and 34.4% (1356/3994) receiving 3 practices. Breakdown across individual practices were: 60.0% (2368/4014) coated circuits, 76.5% echocardiography (3015/4014), and 38.0% single clamp (1498/4104). Once adjusting for patient and disease characteristics and center, adoption of strategies was associated with a 15% reduced odds of brain injury (OR 0.85, ptrend 0.01). Use of a single clamp was associated with the greatest reduction in brain injury (Adj OR 0.63, p=0.02). Conclusion: While the use of any of three intra-operative practices were protective of brain injury, the use of a single clamp technique was associated with a nearly 40% reduced odds of brain injury after cardiac surgery. This analysis further confirms the benefit of a single aortic clamp approach for reducing neurologic injury.

Background. We previously reported that transfusion of 1 to 2 units of red blood cells (RBCs) confers a 16% increased hazard of late death after cardiac surgical treatment. We explored whether a similar effect existed among octogenarians.Methods. We enrolled 17,026 consecutive adult patients undergoing cardiac operations from 2001 to 2008 in northern New England. Patients receiving more than 2 units of RBCs or undergoing emergency operations were excluded. Early (to 6 months) and late (to 3 years, among those surviving longer than 6 months) survival was confirmed using the Social Security Death Index. We estimated the relationship between RBCs and survival, and any interaction by age (< 80 years versus >= 80 years) or procedure. We calculated the adjusted hazard ratio (HR), and plotted adjusted survival curves.Results. Patients receiving RBCs had more comorbidities irrespective of age. Patients 80 years of age or older underwent transfusion more often than patients younger than 80 years (51% versus 30%; p < 0.001). There was no evidence of an interaction by age or procedure (p > 0.05). Among patients younger than 80 years, RBCs significantly increased a patient's risk of early death [HR, 2.03; 95% confidence interval [CI], 1.47, 2.80] but not late death 1.21 (95% CI, 0.88, 1.67). RBCs did not increase the risk of early [HR, 1.47; 95% CI, 0.84, 2.56] or late (HR, 0.92 95% CI, 0.50, 1.69) death in patients 80 years or older.Conclusions. Octogenarians receive RBCs more often than do younger patients. Although transfusion of 1 to 2 units of RBCs increases the risk of early death in patients younger than 80 years, this effect was not present among octogenarians. There was no significant effect of RBCs in late death in either age group. (Ann Thorac Surg 2012;94:2038-45) (c) 2012 by The Society of Thoracic Surgeons

Hyperglycemia has been postulated to be cardiotoxic. We addressed the hypothesis that uncontrolled blood glucose induces myocardial damage in diabetic patients undergoing isolated coronary artery bypass graft surgery receiving continuous insulin infusion in the immediate postoperative period. Our primary aim was to assess the degree of tight glycemic control for each patient and to link the degree of glycemic control to intermediate outcome of myocardial damage. We prospectively enrolled 199 consecutive patients with diabetes undergoing isolated coronary artery bypass graft surgery from October 2003 through August 2005. Preoperative hemoglobin A1c and glucose measures were collected from the surgical admission. We measured biomarkers of myocardial damage (cardiac troponin I) and metabolic dysfunction (blood glucose and hemoglobin A1c) to identify a difference among patients under tight (90-100% of glucose measures < or = 150 mg/dL) or loose (<90%) glycemic control. All patients received continuous insulin infusion in the immediate postoperative period. We discovered 45.6% of the patients were in tight control. We found tight glycemic control resulted in no significant difference in troponin I release. Mean cardiac troponin I for tight and loose control was 4.9 and 8.5 (ng/mL), p value .3.We discovered patients varied with their degree of control, even with established protocols to maintain glucose levels within the normal range. We were unable to verify tight glycemic control compared to loose control was significantly associated with decreased cardiac troponin I release. Future studies are needed to evaluate the cardiotoxic mechanisms of hyperglycemia postulated in this study.

HomeCirculationVol. 124, No. 10Response to Letter Regarding Article, "Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting" Free AccessReplyPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReplyPDF/EPUBResponse to Letter Regarding Article, "Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting" Lawrence J. Dacey, MD, David J. Malenka, MD, Elaine M. Olmstead, BA, Cathy S. Ross, MS, Gerald T. O'Connor, DSc, PhD, Donald S. Likosky, PhD, John H. Braxton, MD, Robert S. Kramer, MD, Joseph D. Schmoker, MD, David C. Charlesworth, MD, Robert E. Helm, MD, Stephan R. Jones, PA-C, Carmine Frumiento, MD, Gerald L. Sardella, MD, Robert A. Clough, MD and Lawrence J. DaceyLawrence J. Dacey , David J. MalenkaDavid J. Malenka , Elaine M. OlmsteadElaine M. Olmstead , Cathy S. RossCathy S. Ross , Gerald T. O'ConnorGerald T. O'Connor , Donald S. LikoskyDonald S. Likosky , John H. BraxtonJohn H. Braxton , Robert S. KramerRobert S. Kramer , Joseph D. SchmokerJoseph D. Schmoker , David C. CharlesworthDavid C. Charlesworth , Robert E. HelmRobert E. Helm , Stephan R. JonesStephan R. Jones , Carmine FrumientoCarmine Frumiento , Gerald L. SardellaGerald L. Sardella , Robert A. CloughRobert A. Clough and and On behalf of the Northern New England Cardiovascular Disease Study Group Originally published6 Sep 2011https://doi.org/10.1161/CIRCULATIONAHA.111.032995Circulation. 2011;124:e278We appreciate the thoughtful comments of Dr Deutsch and colleagues to our article about the effect of endoscopic vein harvesting (EVH) on long-term outcomes after coronary artery bypass grafting surgery.1 Although Dr Deutsch and colleagues raise some concerns over the report from the International Society of Minimally Invasive Cardiothoracic Surgery, one must keep in mind that this report was a Consensus Statement relative to the evidence surveyed at that particular point in time, namely articles published between 1996 and 2002.2 Even though such documents are helpful in synthesizing the breadth of literature, it is paramount that they be updated as new evidence comes to light.Our regional quality improvement organization undertook a prospective observational study to understand whether everyday saphenous vein harvesting practice within northern New England was associated with poorer long-term outcomes. We focused on the time period in which EVH and its open counterpart (open vein harvesting) were both being used, as well as a time frame that was similar to that reported by Lopes and colleagues.3 We were comforted to find that regional use of EVH was not associated with harm, and in fact in many instances provided superior outcomes, such as a significant reduction in long-term mortality. Nonetheless, EVH was associated with a nonsignificant increased risk of repeat revascularization. We fully agree that efforts aimed at developing and instituting optimal EVH technique should continue. Advancements in technology should aide in these efforts.Lawrence J. Dacey, MDDavid J. Malenka, MDElaine M. Olmstead, BACathy S. Ross, MSGerald T. O'Connor, DSc, PhDDonald S. Likosky, PhD Departments of Medicine, Surgery, and Community and Family Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice Dartmouth-Hitchcock Medical Center Hanover, NHJohn H. Braxton, MDRobert S. Kramer, MD Department of Surgery Maine Medical Center Portland, MEJoseph D. Schmoker, MD Department of Surgery Fletcher Allen Health Care Burlington, VTDavid C. Charlesworth, MD Department of Surgery Catholic Medical Center Manchester, NH Robert E. Helm, MDStephan R. Jones, PA-C Department of Surgery Portsmouth Regional Hospital Portsmouth, NH Carmine Frumiento, MD Department of Surgery Central Maine Medical Center Lewiston, ME Gerald L. Sardella, MD Department of Surgery Concord Hospital Concord, NH Robert A. Clough, MD Department of Surgery Eastern Maine Medical Center Bangor, MEOn behalf of the Northern New England Cardiovascular Disease Study GroupDisclosuresNone.References1. Dacey LJ, Braxton JH, Kramer RS, Schmoker JD, Charlesworth DC, Helm RE, Frumiento C, Sardella GL, Clough RA, Jones SR, Malenka DJ, Olmstead EM, Ross CS, O'Connor GT, Likosky DS. Long-term outcomes of endoscopic vein harvesting after coronary artery bypass grafting. Circulation. 2011; 123:147–153.LinkGoogle Scholar2. Cheng D, Allen K, Cohn W, Connolly M, Edgerton J, Falk V, Martin J, Ohtsuka T, Vitali R. Endoscopic vascular harvest in coronary artery bypass grafting surgery: a meta-analysis of randomized trials and controlled trials. Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery. 2005; 1:61–74.CrossrefGoogle Scholar3. Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH, Gibson CM, Mack MJ, Kouchoukos NT, Califf RM, Alexander JH. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med. 2009; 361:235–244.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails September 6, 2011Vol 124, Issue 10 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.032995 Originally publishedSeptember 6, 2011 PDF download Advertisement

Background: Post-operative low output failure (LOF) is an important contributor to morbidity and mortality during coronary artery bypass grafting (CABG) surgery, and may result from poor myocardial protection. We hypothesized that rates of LOF would vary across surgeons, in part attributed to their myocardial protective strategy. Methods: We identified 11,838 patients undergoing non-emergent, isolated CABG surgery utilizing cardiopulmonary bypass (CPB) at 8 centers in northern New England from 2001-2009. Our cohort included patients with preoperative ejection fractions 40+% and patients operated on by surgeons who performed 80+ CABG procedures during the time period. Patients with preoperative balloon pumps were excluded. LOF was defined as the need for an intra- or post-operative balloon pump, or return to CPB or 2+ inotropes at 48 hours. Predicted rates of LOF were estimated using logistic regression. Results: Case volume varied across surgeons (range: 80-766, median: 344). Overall rate of LOF was 5.3% (return to CPB: 3.2%, balloon pump: 1.8%, inotrope usage: 1.3%). While predicted risk of LOF did not differ across surgeons, p=0.381, observed rates varied from 1.1% to 15.6%, p=0.003 (Figure). Post-operative outcomes, including death (ptrend=0.03) or stroke (ptrend =0.02), significantly increased across surgical LOF strata (low: <2%, medium: 3-9%, high: 10+%). Conclusions There was a 14-fold variability in rates of LOF across surgeons among patients with ejection fractions 40+%. This variability could not be explained by patient case mix. Future work should focus on understanding the relationship between myocardial protective strategy and risk of LOF.

Background— Use of endoscopic saphenous vein harvesting has developed into a routine surgical approach at many cardiothoracic surgical centers. The association between this technique and long-term morbidity and mortality has recently been called into question. The present report describes the use of open versus endoscopic vein harvesting and risk of mortality and repeat revascularization in northern New England during a time period (2001 to 2004) in which both techniques were being performed. Methods and Results— From 2001 to 2004, 8542 patients underwent isolated coronary artery bypass grafting procedures, 52.5% with endoscopic vein harvesting. Surgical discretion dictated the vein harvest approach. The main outcomes were death and repeat revascularization (percutaneous coronary intervention or coronary artery bypass grafting) within 4 years of the index admission. The use of endoscopic vein harvesting increased from 34% in 2001 to 75% in 2004. In general, patients undergoing endoscopic vein harvesting had greater disease burden. Endoscopic vein harvesting was associated with an increased adjusted risk of bleeding requiring a return to the operating room (2.4 versus 1.7; P =0.03) but a decreased risk of leg wound infections (0.2 versus 1.1; P <0.001). Use of endoscopic vein harvesting was associated with a significant reduction in long-term mortality (adjusted hazard ratio, 0.74; 95% confidence interval, 0.60 to 0.92) but a nonsignificant increased risk of repeat revascularization (adjusted hazard ratio, 1.29; 95% confidence interval, 0.96 to 1.74). Similar results were obtained in propensity-stratified analysis. Conclusions— During 2001 to 2004 in northern New England, the use of endoscopic vein harvesting was not associated with harm. There was a nonsignificant increase in repeat revascularization, and survival was not decreased.

Background. There is a high rate of readmission within 30 days following discharge from a hospitalization for cardiac surgery. This is associated with increased morbidity, mortality, and cost of ca...

Background. We examined a recent regional experience to determine the effect of a prior cardiac operation on short-term and midterm outcomes after coronary artery bypass grafting (CABG).Methods. We identified 20,703 patients who underwent nonemergent CABG at 8 centers in northern New England from 2000 to 2008, of whom 818 (3.8%) had undergone prior cardiac operations. Prior CABG using a minimal or full sternotomy was considered a prior sternotomy. Survival data out to 4 years were obtained from a link with the Social Security Administration Death Index. Hazard ratios were estimated using a Cox proportional hazards regression model, and adjusted survival curves were estimated using inverse probability weighting. In a separate analysis, 1,182 patients were matched 1: 1 by a patient's propensity for having undergone prior CABG.Results. Patients with prior sternotomies had a greater burden of comorbid diseases and increased acuity and had a greater likelihood of returning to the operating room for bleeding and low cardiac output failure. Prior sternotomy was associated with an increased risk of death out to 4 years for patients undergoing CABG, with an unmatched hazard ratio of 1.34 (95% confidence interval, 1.10 to 1.64) and a matched hazard ratio of 1.36 (95% confidence interval, 1.01 to 1.81).Conclusions. Analyses of our recent regional experience with nonemergent CABG showed that a prior cardiac operation was associated with a nearly twofold increased hazard of death at up to 4 years of follow-up. (Ann Thorac Surg 2011;92:1260-8) (C) 2011 by The Society of Thoracic Surgeons

Background: We examined a recent regional experience to determine the impact of a prior cardiac surgery on short and long-term outcomes following coronary artery bypass grafting (CABG) surgery. Methods: We identified 20,504 patients undergoing non-emergent CABG surgery at 8 centers in northern New England from 2000-2008, of whom 818 (4.0%) had undergone prior cardiac surgery. Prior CABG and/or valve surgery utilizing a mini- or full sternotomy was considered a prior sternotomy. Survival data was obtained by linkage to the Social Security Administration Death Index. Hazard ratios were estimated using a Cox Proportional Hazards regression model while adjusted survival curves were estimated using inverse probability weighting. Models were adjusted for age, sex, ejection fraction, acuity, vascular disease, diabetes, prior myocardial infarction, renal failure or creatinine >2 mg/dl, left main disease, chronic obstructive pulmonary disease, body mass index, medical center and year. We conducted a nearest-neighbor propensity matched analysis among a subset of 1,568 patients who were matched 1:1 having a prior cardiac procedure based on their history of a cardiac surgical procedure and aforementioned patient and disease characteristics. Results: In both instances, prior sternotomy was associated with increased risk of mortality for patients undergoing CABG: [adjusted unmatched HR: 1.68, (CI 95% 1.46, 1.93)]; [propensity matched HR: 1.44, (CI 95% 1.12, 1.86)]. Conclusions In our recent regional experience with non-emergent CABG, a prior cardiac surgery was associated with a nearly two-fold increased hazard of mortality at up to 4 years of follow-up.

Lawrence J. Dacey, MD; John H. Braxton, Jr, MD; Robert S. Kramer, MD; Joseph D. Schmoker, MD; David C. Charlesworth, MD; Robert E. Helm, MD; Carmine Frumiento, MD; Gerald L. Sardella, MD; Robert A. Clough, MD; Stephan R. Jones, PA-C; David J. Malenka, MD; Elaine M. Olmstead, BA; Cathy S. Ross, MS; Gerald T. O’Connor, DSc, PhD; Donald S. Likosky, PhD; for the Northern New England Cardiovascular Disease Study Group

Una mujer de 62 años con obesidad, hipertensión arterial y diabetes mellitus tipo 2 es remitida a una unidad de riesgo vascular del servicio de medicina interna porque su HbA1c está elevada (8,1%) a pesar de tomar regularmente metformina (850 mg/12 h) y glipizida (10 mg/12 h). Trata de hacer ejercicio cada día (caminar 30 min) y ha adelgazado (de 5 a 12 kg) en varias ocasiones, pero siempre ha vuelto a ganar lo perdido. Además se controla su glucemia en ayunas cada dos semanas y suele tener entre 120 y 160 mg/dl. Su hipertensión arterial está siendo tratada con enalapril/hidroclorotiazida y además toma aspirina (100 mg/día) y simvastatina (20 mg/día). En su historia familiar se recoge que un hermano falleció súbitamente a los 50 años. En la exploración física presenta un IMC de 32,4 kg/m2 y no tiene edemas en los miembros inferiores. Su PA es de 154/82 mmHg y la creatinina de 0,9 mg/dl. No presenta microalbuminuria y su función hepática es normal.¿Qué tratamiento le parece a Vd. más indicado?1. Añadir glitazonas.2. Añadir incretín miméticos (glucagon like peptide 1 [GLP1]/inhibidores de la dipeptidilpeptidasa 4 [DPP-4]).3. Añadir insulina de acción lenta.A 62-year old woman with obesity, high blood pressure and type 2 diabetes mellitus (DM2) was referred to a Vascular Risk Unit of the Internal Medicine Department due to elevated HbA1C (8.1%) in spite of having taken metformin (850 mg/12 h) and glipizide (10 mg/12 h) regularly. She tries to exercise daily (walking 30 min) and has lost weight (from 5 to 12 kg) several times, but always regains what she has lost. Furthermore, she monitors her glucose levels in fasting every two weeks and generally has between 120 and 160 mg/dL. Her high blood pressure is being treated with enalapril/HCTZ and she also takes aspirin 100 mg/day and simvastatin 20 mg/day. It is seen in her family background that one brother died suddenly at 50 years of age. Her physical examination shows a BMI of 32.4 Kg/m2, and she has no edemas in the lower limbs. Her BP is 154/82 mmHg and creatinine 0.9 mg/dL. She has no microalbuminuria and her liver function is normal.What treatment do you think would be the more appropriate?1 - Add glitazones.2 - Add incretin mimetics (GLP 1/ DPP-4).3 - Slow acting insulin.

BACKGROUND:Cardiac surgery-related acute kidney injury has short- and long-term impact on patients' risk for further morbidity and mortality. Consensus statements have yielded criteria--such as the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) criteria, and the Acute Kidney Injury Network (AKIN) criteria--to define the type and consequence of acute kidney injury. We sought to estimate the ability of both the RIFLE and and AKIN criteria to predict the risk of in-hospital mortality in the setting of cardiac surgery. METHODS:Data were collected on 25,086 patients undergoing cardiac surgery in Northern New England from January 2001 to December 2007, excluding 339 patients on preoperative dialysis. The AKIN and RIFLE criteria were used to classify patients postoperatively, using the last preoperative and the highest postoperative serum creatinine. We compared the diagnostic properties of both criteria, and calculated the areas under the receiver operating characteristic curve. RESULTS:Acute kidney injury occurred in 30% of patients using the AKIN criteria and in 31% of patients using the RIFLE criteria. The areas under the receiver operating characteristic curve for in-hospital mortality estimated by AKIN and RIFLE criteria were 0.79 (95% confidence interval: 0.77 to 0.80) and 0.78 (95% confidence interval: 0.76 to 0.80), respectively (p = 0.369). CONCLUSIONS:The AKIN and RIFLE criteria are accurate early predictors of mortality. The high incidence of cardiac surgery postoperative acute kidney injury should prompt the use of either AKIN or RIFLE criteria to identify patients at risk and to stimulate institutional measures that target acute kidney injury as a quality improvement initiative.

The current risk prediction models for mortality following coronary artery bypass graft (CABG) surgery have been developed on patient and disease characteristics alone. Improvements to these models potentially may be made through the analysis of biomarkers of unmeasured risk. We hypothesize that preoperative biomarkers reflecting myocardial damage, inflammation, and metabolic dysfunction are associated with an increased risk of mortality following CABG surgery and the use of biomarkers associated with these injuries will improve the Northern New England (NNE) CABG mortality risk prediction model. We prospectively followed 1731 isolated CABG patients with preoperative blood collection at eight medical centers in Northern New England for a nested case-control study from 2003-2007. Preoperative blood samples were drawn at the center and then stored at a central facility. Frozen serum was analyzed at a central laboratory on an Elecsys 2010, at the same time for Cardiac Troponin T, N-Terminal pro-Brain Natriuretic Peptide, high sensitivity C-Reactive Protein, and blood glucose. We compared the strength of the prediction model for mortality using multivariable logistic regression, goodness of fit and tested the equality of the receiving operating characteristic curve (ROC) area. There were 33 cases (dead at discharge) and 66 randomly matched controls (alive at discharge).The ROC for the preoperative mortality model was improved from .83 (95% confidence interval: .74-.92) to .87 (95% confidence interval: .80-.94) with biomarkers (p-value for equality of ROC areas .09). The addition of biomarkers to the NNE preoperative risk prediction model did not significantly improve the prediction of mortality over patient and disease characteristics alone. The added measurement of multiple biomarkers outside of preoperative risk factors may be an unnecessary use of health care resources with little added benefit for predicting in-hospital mortality.