Prediction and Prevention of Upper Gastrointestinal Bleeding after Cardiac Surgery: A Case Control Study

BACKGROUND: Gastrointestinal (GI) complications of cardiovascular surgery, particularly bleeding, occur frequently.OBJECTIVE: To determine factors that predict upper GI bleeding (UGIB) after cardiac surgery to improve prognostication and, thus, outcomes.METHODS: The present case-control study reviewed institutional records spanning 2002 to 2005 for consecutive patients who developed in-hospital UGIB following cardiovascular surgery. Each case was matched to two to three controls for age, sex and date of hospital admission. Demographics, pharmacotherapy (including use of in-hospital acid suppression), endoscopic findings and outcomes were recorded. After adjustment for possible confounders, including Parsonnet score and demographic parameters, conditional logistic regression analysis identified independent significant predictors of the subsequent development of UGIB.RESULTS: The study population consisted of 131 cases (mean [± SD] age 68.8±10.2 years, 69.5% male, mean Parsonnet score 24.6±14.2) and 387 matched controls (mean age 68.8±10.8 years, 70.0% male, mean Parsonnet score 20.9±14.2). UGIB events occurred a mean of 10.3±7.7 days after cardiac surgery. Duration of mechanical ventilation (OR 3.01 [95% CI 1.44 to 6.28]), elevation of international normalized ratio (OR 1.91 [95% CI 1.31 to 2.78]) and occurrence ofClostridium difficilecolitis before bleeding (OR 3.15 [95% CI 1.19 to 8.36]) were independent risk factors. Use of histamine type 2 receptor antagonists (H2RAs) (OR 0.65 [95% CI 0.38 to 1.12]) or proton pump inhibitors (PPIs) (OR 0.60 [95% CI 0.27 to 1.32]) demonstrated trends toward protecting against UGIB after cardiac surgery.CONCLUSIONS: GI bleeding events occurred approximately 10 days after cardiac surgery in patients with a complicated postoperative course. Significant predictors of subsequent bleeding included increased duration of mechanical ventilation and elevation of international normalized ratio; routine acid suppression with PPIs should be considered in such patients.C difficilecolitis also significantly predicted UGIB, and H2RAs should be considered for acid suppression. Neither H2RAs nor PPIs were effective in preventing UGIB, although the small number of patients limits definitive conclusions regarding the role of acid suppression.

Assessment of the Initial and Modified Parsonnet Score in Mortality Prediction of the Patients Operated in the Sarajevo Heart Center

This study has been conducted in an effort to establish more suitable and accurate scoring model we use in everyday practice. Among the specific outcome prediction models, in 1989 Parsonnet et al elaborated a method of uniform risk stratification for evaluation of the results of cardiac surgery procedures. We have tested two forms of the Parsonnet score, Initial and Modified Parsonnet score, in our patients.In the first half of the year 2007, 145 patients were operated in Sarajevo Heart center. All operated patients in that period, have participated in this study. The overall hospital mortality was 4,13 (6 deaths). This study shows that the initial and modified Parsonnet’s scores are predictive for operative mortality in adult cardiac surgery patients.

Abstract 2471: Contemporary Results of Isolated Aortic Valve Replacement in High-Risk Patients in the Context of Emerging Percutaneous Approaches

Percutaneous aortic valve replacement (AVR) is emerging as an alternative therapeutic approach for high-risk surgical patients, but criteria for patient selection are not clearly established. We sought to evaluate the perioperative and mid-term outcomes in a contemporary cohort of high-risk patients undergoing isolated AVR. Between 1997 and 2006, 855 consecutive patients underwent isolated AVR at our institution. High-risk patients (n=162, 19%) were defined by a preoperative Parsonnet score ≥ 30 or Euroscore ≥ 9. The remaining 693 patients (81%) composed the control group for comparison of perioperative mortality and mid-term freedom from all-cause and cardiac-related mortality. Mean follow up was 2.9±2.1 years. Perioperative mortality was 8.6% in the high-risk and 2.9% in the control group (p=0.0007), lower than that predicted by both scores (p<0.05). Freedom from all-cause mortality at 1 and 5 years were 94% and 82% for the control group and 87% and 65% for high-risk patients (p<0.0001). Freedom from cardiac-related mortality was also higher in the control (96% at 1 year, 91% at 5 years) than the high-risk (89% and 82%, p=0.0003) group. When considering patients who survived the 3-month perioperative period (537 in control, 114 in high-risk group), freedom from all-cause mortality was still higher in the former group at 1 and 5 years (99% vs 99% and 85% vs 75%, respectively, p=0.005), but freedom from cardiac-related mortality was not different (99% vs 100% and 94% vs 92%, respectively, p=0.3). By multivariate analysis, chronic renal failure, emergent procedures and reoperations were identified as independent predictors of mortality in high-risk patients. Contemporary perioperative mortality for isolated AVR in high-risk patients is lower than predicted by the Parsonnet score and Euroscore. Five-year survival in these patients is acceptable, and survivors of the operation experience the same cardiac-related survival benefit as those with standard perioperative risk. The perioperative survival benefit of percutaneous approaches for high-risk patients undergoing AVR remains to be demonstrated and, if present, should be weighed against mid-term outcome benefits of conventional surgical AVR.

Coronary Artery Bypass Surgery with On-Pump Beating-Heart Technique

To evaluate the results of on-pump beating-heart coronary bypass grafting, a retrospective study was carried out on 106 patients who had this procedure between 2003 and 2006. There were 87 (82%) men and 19 (18%) women, with a mean age of 60.53 ± 11.97 years. Five (5%) patients had unstable angina, 10 (9%) had a recent myocardial infarction, and 16 (15%) had congestive heart failure. The mean ejection fraction was 40.38% ± 11.46%. The mean cardiopulmonary bypass time was 66.81 ± 31.14 min. The median number of grafts per patient was 3. The median intensive care unit stay was 47 hours, and hospital stay was 7 days. There were 4 (3.8%) deaths. The mean Parsonnet score was 12.75 ± 11.27 and the logistic EuroSCORE was 7.06 ± 8.62. This study shows that the on-pump beating-heart technique is a safe and convenient method for coronary artery bypass grafting.

Intensive Care Unit Readmission after Elective Coronary Artery Bypass Grafting

Prospective data of 3,120 consecutive patients who had elective coronary artery bypass were analyzed to identify patient profile, cost, outcome and predictors of those readmitted to the intensive care unit. Group A ( n = 3,002) had a single intensive care unit admission and group B ( n = 118) were readmitted within 30 days after surgery. Parsonnet score, EuroSCORE, age, body mass index, chronic obstructive airway disease, peripheral vascular disease, renal dysfunction, unstable angina, congestive cardiac failure, and poor left ventricular function were higher in group B. Bypass and crossclamp times were longer, and the prevalence of inotropic and balloon pump support, arrhythmias, myocardial infarction, re-exploration, blood loss and transfusion, cerebrovascular accident, wound infection, sternal dehiscence, and multisystem failure were higher in group B. Despite a 4-fold increase in cost of care, the mortality rate (32.4%) of patients readmitted to intensive care was 23-times higher than routine patients (1.4%). Crossclamp time > 80 min, Parsonnet score > 10, EuroSCORE > 9, sternal dehiscence, ventricular arrhythmias, and renal failure predicted readmission.