The current status of myocardial revascularization: changing trends and risk factor analysis.
From November 1989 to December 1994, we performed 2264 bypass procedures. Data were collected prospectively. The population was divided into three subgroups: group 1 = single internal mammary artery (IMA) +/- veins (n = 1584); group 2 = veins only (n = 503); and group 3 = two or more arterial conduits +/- veins (n = 177). Patients who received only saphenous vein conduits (group 2) were significantly older (66.7 +/- 8.9 years) than either group 1 (60.3 +/- 8.3 years) or group 3 (51.6 +/- 9.2 years). Furthermore, this cohort group had the highest percentage of females (28.6%), urgent cases (43.5%), preoperative myocardial infarction (MI) (18.5%), and redo surgery (5.4%). In contrast, patients who received two or more arterial conduits were 94.9% male, and had the lowest incidence of urgent cases (18.1%) and redo surgery (0.5%). Mortality was 1.4% in group 1 and 3.2% in group 2; there were no deaths in group 3. Furthermore, group 2 patients had the highest incidence of perioperative MI (6.6%), low output syndrome (22.1%), intra-aortic balloon pump (IABP) assist (6.2%), and stroke (2.7%). By multivariate logistic regression analysis (odds ratio in parentheses), redo surgery (7.92), preoperative IABP (5.53), poor LV function (4.01), renal impairment (3.94), and advanced age (2.12) were all predictors of operative mortality. When mortality and morbidity (death, infarction, low output syndrome, IABP assist) were combined, regression analysis revealed that in addition to the above variables, female gender and cold cardioplegia were also independent predictors of combined mortality and morbidity. Resource utilization was determined for the three patient groups. There was concern that the increased technical demands of multiple arterial grafting along with longer periods of aortic occlusion and pump times may lead to increased complications and prolonged hospital stay. However, we found that group 3 had the lowest ventilation time, intensive care unit stay, and hospital stay. The results no doubt were influenced by case selection. Whether or not this approach to revascularization will increase long-term survival and freedom from reoperation will require further study.
Del Rizzo
D F
DF
Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
Fremes
S E
SE
Christakis
G T
GT
Sever
J
J
Goldman
B S
BS
D000368:Aged; D001026:Coronary Artery Bypass / Q000401:mortality / Q000639:trends*; D003327:Coronary Disease / Q000601:surgery; D005260:Female; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications; D012086:Reoperation; D012307:Risk Factors; D012501:Saphenous Vein / Q000637:transplantation; D016896:Treatment Outcome