Coronary artery bypass grafting in type II diabetic patients: a comparison between insulin-dependent and non-insulin-dependent patients at short- and mid-term follow-up.
BACKGROUND
Diabetes is a well-established risk factor for coronary artery disease, and it is associated with an increased rate of early and late adverse events after myocardial revascularization by coronary artery bypass grafting.


METHODS
A prospective follow-up study was done to evaluate the short-term and mid-term outcomes of type II diabetic patients who had coronary artery bypass grafting at our institution between 1996 and May 1999. A total of 200 patients, 100 insulin-dependent diabetic patients (group I) and 100 non-insulin-dependent diabetic patients (group II), met the inclusion criteria of the study and were included in the clinical follow-up study.


RESULTS
The characteristics of the patients of the two groups were similar for baseline clinical angiographic and operative characteristics. In particular, no significant differences in cardiopulmonary bypass and aortic cross-clamping times were noted between the two groups. The number grafts per patient was similar between the two groups. There were no in-hospital deaths, but postoperative complications were different among the two series. In fact, 33% of patients in group I had at least one major complication compared with 20% in group II (p = 0.037). The cumulative number of complications was 148 in group I and 69 in group II, and the mean number of complications per patient was 4.5 and 3.5 in groups I and II, respectively. The major differences in perioperative complication rates were found in the need for prolonged (> 24 hours) ventilation, occurrence of respiratory or renal insufficiency, and mediastinitis. The mean length of stay in the intensive care unit and for total hospitalization were longer in group I than group II (4.3 +/- 2.8 days versus 2.8 +/- 2.7 days [p = 0.010] and 11.1 +/- 2.2 days versus 7.2 +/- 2.4 group II [p < 0.05], respectively). At long-term follow-up, group I patients had a significantly higher mortality rate (29% versus 10%, p < 0.001). Moreover, overall late cardiac and noncardiac complication rates were significantly higher in group I than II (37% versus 22%, p = 0.02). In the multivariate analysis including several preoperative and operative variables, treatment by insulin, advanced age (> 75 years), left ventricular dysfunction (left ventricular ejection fraction < 35%), and complex lesions at coronary angiography (American Heart Association lesion classification type C lesion) were found as independent predictors of increased mortality.


CONCLUSIONS
Our data show that patients with insulin-dependent type II diabetes who had coronary artery bypass grafting have a significantly higher rate of major postoperative complications with an extremely unfavorable short- and long-term prognosis. Diabetic patients on insulin treatment should be considered high-risk candidates for coronary artery bypass grafting and require intense perioperative and long-term monitoring. Further studies will be necessary to investigate whether such conclusions may be appropriate for newer surgical strategies such as off-pump operation.
Luciani
Nicola
N
Department of Cardiology and Cardiovascular Surgery, Catholic University of the Sacred Heart, Rome, Italy. nicola.luciani@tiscalinet.it
Nasso
Giuseppe
G
Gaudino
Mario
M
Abbate
Antonio
A
Glieca
Franco
F
Alessandrini
Francesco
F
Girola
Fabiana
F
Santarelli
Filippo
F
Possati
Gianfederico
G
D000368:Aged; D002315:Cardiopulmonary Bypass; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D003922:Diabetes Mellitus, Type 1 / Q000150:complications; D003924:Diabetes Mellitus, Type 2 / Q000150:complications*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007431:Intraoperative Complications; D007902:Length of Stay; D008297:Male; D015999:Multivariate Analysis; D011379:Prognosis; D011446:Prospective Studies; D012307:Risk Factors; D016896:Treatment Outcome