title: Improving outcomes in coronary surgery: the impact of echo-directed aortic cannulation and perioperative hemodynamic management in 500 patients.
abstract: BACKGROUND
  Stroke and death continue to occur perioperatively associated with on-pump and off-pump coronary artery bypass grafting surgery (CABG) procedures. We report on a prospectively implemented multifaceted strategy to improve short-term outcomes associated with on-pump CABG.
  
  
  METHODS
  Five hundred consecutive patients from a single teaching institution undergoing standardized on-pump nonreoperative CABG between June 1996 and July 2003 were entered into the New York State Cardiac Surgery database, a verified comprehensive clinical registry. Risk factors and outcomes were analyzed and compared with the statewide New York State CABG registry. All patients underwent intraoperative transesophageal echocardiography to guide distal aortic cannulation and high flow-high pressure cardiopulmonary bypass perfusion, arterial filtration, centrifugal pump perfusion, and membrane oxygenation. Intraoperative and early postoperative blood pressures were continuously targeted to match the patient's preoperative range.
  
  
  RESULTS
  The mean patient age was 63.5 years, 335 (67%) were male, and 320 (64%) were deemed to be of elective surgical priority. The mean ejection fraction was 0.434, with 255 (51%) having sustained a prior myocardial infarction. The mean cardiopulmonary bypass time was 95 minutes with an ischemic time of 51 minutes to accomplish a mean of 3.19 grafts/patient. The predicted group mortality was 2.28%, which was greater than the simultaneously measured 1.98% New York statewide CABG mortality during the same period for comparable patients (p < 0.05). There was no in-hospital or 30-day mortality nor were there any perioperative strokes in this group (p < 0.05). The mean postoperative hospital length of stay was 3.61 days with a 5.1% 30-day readmission rate.
  
  
  CONCLUSIONS
  A standardized approach to CABG using echocardiographic guided aortic cannulation and perioperative hemodynamic management reduces perioperative stroke and death associated with on-pump coronary surgery.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Albert Einstein College of Medicine, Bronx, New York 10467, USA. jgold@montefiore.org
authors.forename: Jeffrey P
authors.initials: JP
authors.lastname: Gold
authors.forename: Kaila E
authors.initials: KE
authors.lastname: Torres
authors.forename: William
authors.initials: W
authors.lastname: Maldarelli
authors.forename: Ilya
authors.initials: I
authors.lastname: Zhuravlev
authors.forename: Douglas
authors.initials: D
authors.lastname: Condit
authors.forename: John
authors.initials: J
authors.lastname: Wasnick
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001011:Aorta; D001018:Aortic Diseases / Q000150:complications* / Q000175:diagnosis / Q000000981:diagnostic imaging; D001161:Arteriosclerosis / Q000150:complications* / Q000175:diagnosis / Q000000981:diagnostic imaging; D002315:Cardiopulmonary Bypass / Q000379:methods*; D002404:Catheterization / Q000379:methods*; D003072:Cognition Disorders / Q000209:etiology / Q000517:prevention & control*; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data*; D016208:Databases, Factual; D017548:Echocardiography, Transesophageal; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006439:Hemodynamics; D018056:Hemorheology; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D010173:Palpation; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional
chemical_list: D000925:Anticoagulants; D006493:Heparin