Validation of a New Classification Method of Postoperative Complications in Patients Undergoing Coronary Surgery

International audienceObjective The authors aimed to validate the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) classification of postoperative complications in patients undergoing coronary artery bypass grafting (CABG). Design Retrospective, observational study. Setting University hospital. Participants A total of 2,764 patients with severe coronary artery disease. Complete baseline, operative, and postoperative data were available for patients who underwent isolated CABG. Interventions Isolated CABG. Measurements and Main Results The E-CABG complication classification was used to stratify the severity and prognostic impact of adverse postoperative events. Primary outcome endpoints were 30-day, 90-day, and long-term all-cause mortality. The secondary outcome endpoints was the length of intensive care unit stay. Both the E-CABG complication grades and additive score were predictive of 30-day (area under the receiver operating characteristics curve 0.866, 95% confidence interval [CI] 0.829-0.903; and 0.876; 95% CI 0.844-0.908, respectively) and 90-day (area under the receiver operating characteristics curve 0.850, 95% CI 0.812-0.887; and 0.863, 95% CI 0.829-0.897, respectively) all-cause mortality. The complication grades were independent predictors of increased mortality at actuarial (log-rank: p<0.0001) and adjusted analysis (p<0.0001; grade 1: hazard ratio [HR] 1.757, 95% CI 1.111-2.778; grade 2: HR 2.704, 95% CI 1.664-4.394; grade 3: HR 5.081, 95% CI 3.148-8.201). When patients who died within 30 days were excluded from the analysis, this grading method still was associated with late mortality (p<0.0001). The grading method (p<0.0001) and the additive score (rho, 0.514; p<0.0001) were predictive of the length of intensive care unit stay. Conclusions The E-CABG postoperative complication classification seems to be a promising tool for stratifying the severity and prognostic impact of postoperative complications in patients undergoing cardiac surger

Utility of glycated hemoglobin screening in patients undergoing elective coronary artery surgery: Prospective, cohort study from the E-CABG registry

Background: Patients with increased glycated hemoglobin (HbA1c) seem to be at increased risk of sternal wound infection (SWI) after coronary artery bypass grafting (CABG). However, it is unclear whether increased baseline HbA1c levels may affect other postoperative outcomes.Material and methods: Data on preoperative levels of HbA1c were collected from 2606 patients undergoing elective isolated CABG from 2015 to 2016 and included in the prospective, multicenter E-CABG registry.Results: The prevalence of HbA1c ≥ 53 mmol/mol (7.0%) among non-diabetics was 5.3%, among non-insulin dependent diabetics was 53.5% and among insulin dependent diabetics was 67.1% (p  75 mmol/mol (9.0%) among non-diabetics was 0.5%, among non-insulin dependent diabetics was 5.8% and among insulin dependent diabetics was 10.6% (p Conclusions: HbA1c is increased in a significant proportion of patients undergoing elective CABG and these patients are at higher risk of SWI. Less clear is the impact of increased HbA1c on other postoperative outcomes. These results do not support screening of HbA1c in patients without history of diabetes. Preoperative screening of HbA1c is valuable only to identify diabetics at risk of SWI.</p

Glycated hemoglobin and risk of sternal wound infection after isolated coronary surgery

Background: Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG. Methods and Results: Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54\ub117 vs. 45\ub113 mmol/mol, P70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47\u201310.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24\u20133.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38\u20135.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24\u20133.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17\u20134.69). Conclusions: Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI

Utility of glycated hemoglobin screening in patients undergoing elective coronary artery surgery:prospective, cohort study from the E-CABG registry

Abstract Background: Patients with increased glycated hemoglobin (HbA1c) seem to be at increased risk of sternal wound infection (SWI) after coronary artery bypass grafting (CABG). However, it is unclear whether increased baseline HbA1c levels may affect other postoperative outcomes. Material and methods: Data on preoperative levels of HbA1c were collected from 2606 patients undergoing elective isolated CABG from 2015 to 2016 and included in the prospective, multicenter E-CABG registry. Results: The prevalence of HbA1c ≥ 53 mmol/mol (7.0%) among non-diabetics was 5.3%, among non-insulin dependent diabetics was 53.5% and among insulin dependent diabetics was 67.1% (p &lt; 0.001). The prevalence of HbA1c > 75 mmol/mol (9.0%) among non-diabetics was 0.5%, among non-insulin dependent diabetics was 5.8% and among insulin dependent diabetics was 10.6% (p &lt; 0.001). Baseline levels of HbA1c ≥ 53 mmol/mol (7.0%) was a significant predictor of any SWI (10.7% vs. 3.3%, adjusted p-value: &lt;0.001), deep SWI/mediastinitis (3.8% vs. 1.3%, adjusted p-value: 0.001) and acute kidney injury (27.4% vs. 19.8%, adjusted p-value: 0.042). These findings were confirmed in multilevel mixed effect logistic regression adjusted for participating centers. Among patients with diabetes, HbA1c ≥ 53 mmol/mol (7.0%) was predictive of SWI (11.1% vs. 4.8%, p = 0.001). Conclusions: HbA1c is increased in a significant proportion of patients undergoing elective CABG and these patients are at higher risk of SWI. Less clear is the impact of increased HbA1c on other postoperative outcomes. These results do not support screening of HbA1c in patients without history of diabetes. Preoperative screening of HbA1c is valuable only to identify diabetics at risk of SWI

Variation in preoperative antithrombotic strategy, severe bleeding, and use of blood products in coronary artery bypass grafting:results from the multicentre E-CABG registry

Abstract Aims: No data exists on inter-institutional differences in terms of adherence to international guidelines regarding the discontinuation of antithrombotics and rates of severe bleeding in coronary artery bypass grafting (CABG). Methods and results: This is an analysis of 7118 patients from the prospective multicentre European CABG (E-CABG) registry who underwent isolated CABG in 15 European centres. Preoperative pause of P2Y12 receptor antagonists shorter than that suggested by the 2017 ESC guidelines (overall 11.6%) ranged from 0.7% to 24.8% between centres (adjusted P &lt; 0.0001) and increased the rate of severe-massive bleeding [E-CABG bleeding grades 2–3, OR 1.66, 95% confidence interval (CI) 1.27–2.17; Universal Definition of Perioperative Bleeding (UDPB) bleeding grades 3–4, OR 1.50, 95% CI 1.16–1.93]. The incidence of resternotomy for bleeding (overall 2.6%) ranged from 0% to 6.9% (adjusted P &lt; 0.0001), and surgical site bleeding (overall 59.6%) ranged from 0% to 84.6% (adjusted P = 0.003). The rate of the UDPB bleeding grades 3–4 (overall 8.4%) ranged from 3.7% to 22.3% (P &lt; 0.0001), and of the E-CABG bleeding grades 2–3 (overall 6.5%) ranged from 0.4% to 16.4% between centres (P &lt; 0.0001). Resternotomy for bleeding (adjusted OR 5.04, 95% CI 2.85–8.92), UDPB bleeding grades 3–4 (adjusted OR 6.61, 95% CI 4.42–9.88), and E-CABG bleeding grades 2–3 (adjusted OR 8.71, 95% CI 5.76–13.15) were associated with an increased risk of hospital/30-day mortality. Conclusions: Adherence to the current guidelines on the early discontinuation of P2Y12 receptor antagonists is of utmost importance to reduce excessive bleeding and early mortality after CABG. Inter-institutional variation should be considered for a correct interpretation of the results in multicentre studies evaluating perioperative bleeding and use of blood products

Prognostic impact of asymptomatic carotid artery stenosis in patients undergoing coronary artery bypass grafting

Abstract Objectives: The aim of this study was to evaluate the prognostic impact of untreated asymptomatic carotid artery stenosis (CS) in patients undergoing isolated coronary artery bypass grafting (CABG). Methods: This was a post hoc analysis of data from a prospective multicentre observational study. Patients without history of stroke or transient ischaemic attack from the multicentre E-CABG registry who were screened for CS before isolated CABG were included. Results: Among 2813 patients screened by duplex ultrasound and who did not undergo carotid intervention for asymptomatic CS, 11.1% had a stenosis of 50–59%, 6.0% of 60–69%, 3.1% of 70–79%, 1.4% of 80–89%, 0.5% of 90–99%, and 1.1% had carotid occlusion. In the screened population post-operative stroke occurred in 25 patients (0.9%), with an incidence of 1.5% among patients with CS ≥ 50% (n = 649). Pre-operative screening had not found a relevant CS in 15 of 25 patients suffering stroke after CABG. Brain imaging identified cerebral ischaemic injury in 20 patients, which was bilateral in five patients (25%), ipsilateral to a CS ≥ 50% in six (30%), and ipsilateral to a CS ≥ 70% in three (15%). In univariable analysis, the severity of CS was associated with a significantly increased risk of stroke (CS &lt; 50%, 0.7%; 50–59%, 1.0%; 60–69%, 0.6%; 70–79%, 1.2%; 80–89%, 5.1%; 90–99%, 7.7%; occluded, 6.7%, p &lt; .001). In multivariable analysis, a CS of 90–99% (OR 12.03, 95% CI 1.34–108.23) and the presence of an occluded internal carotid artery (OR 8.783, 95% CI 1.820–42.40) were independent predictors of stroke along with urgency of the procedure, severe massive bleeding according to the E-CABG classification, and the presence of a porcelain ascending aorta. Conclusions: Among screened patients with untreated asymptomatic patients, CS ≥ 90% was an independent predictor of post-operative stroke. As this condition has a low prevalence and when left untreated is associated with a relatively low rate of stroke, pre-operative screening of asymptomatic CS before CABG may not be justified. Clinical Trial registration: https://clinicaltrials.gov. Unique identifier: NCT02319083

Clinical frailty scale and outcome after coronary artery bypass grafting

Abstract OBJECTIVES: The aim of this study was to assess the impact of frailty on the outcome after coronary artery bypass grafting (CABG) and whether it may improve the predictive ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE II). METHODS: The Clinical Frailty Scale (CFS) was assessed preoperatively in patients undergoing isolated CABG from the multicentre E-CABG registry, and patients were stratified into 3 classes: scores 1–2, scores 3–4 and scores 5–7. RESULTS: Of the 6156 patients enrolled, 39.2% had CFS scores 1–2, 57.6% scores 3–4, and 3.2% scores 5–7. Logistic regression adjusted for multiple covariates showed that the CFS was an independent predictor of hospital/30-day mortality [CFS scores 3–4, odds ratio (OR) 3.95, 95% confidence interval (CI) 2.19–7.14; CFS scores 5–7, OR 5.90, 95% CI 2.67–13.05] and resulted in an Integrated Improvement Index of 1.3 (P < 0.001) and a Net Reclassification Index of 55.6 (P < 0.001) for prediction of hospital/30-day mortality. Adding the CFS classes to EuroSCORE II resulted in an Integrated Improvement Index of 0.9 (P < 0.001) and Net Reclassification Index of 59.6 (P < 0.001) for prediction of hospital/30-day mortality with a significantly larger area under the receiver operating characteristics curve (0.809 vs 0.781, P = 0.028). The CFS was an independent predictor of mid-term mortality [CFS scores 3–4, hazard ratio (HR) 2.05, 95% CI 1.43–2.85; CFS scores 5–7, HR 3.05, 95% CI 1.83–5.06]. CONCLUSIONS: The CFS predicted early- and mid-term mortality in patients undergoing isolated CABG. Further studies are needed to evaluate whether frailty may improve the estimation of the operative risk of patients undergoing adult cardiac surgery

Infectious complications in patients receiving ticagrelor or clopidogrel before coronary artery bypass grafting.

The antiplatelet agent ticagrelor has recently been found to have bactericidal activity, demonstrated in vitro and in an in vivo mouse model, which warrants further clinical investigations. The aim of this study was to evaluate infectious complications after coronary artery bypass grafting in patients pre-operatively treated with ticagrelor or clopidogrel. In a multi-centre trial, all adult patients who were pre-operatively treated with ticagrelor or clopidogrel prior to isolated primary coronary artery bypass grafting were eligible. Propensity score matching was used. Outcome measures were any sternal wound infection, deep sternal wound infection, and any in-hospital use of postoperative antibiotics. Of 2311 patients who were included, 1293 (55.9%) received clopidogrel and 1018 (44.1%) ticagrelor pre-operatively. In both overall and propensity score matched analyses, ticagrelor was associated with a similar incidence of infectious complications compared to clopidogrel. Our findings do not support a clinically relevant bactericidal effect of ticagrelor in patients undergoing coronary artery bypass grafting

Impact of preoperative thrombocytopenia on the outcome after coronary artery bypass grafting

Abstract The impact of thrombocytopenia on postoperative bleeding and other major adverse events after cardiac surgery is unclear. This issue was investigated in a series of patients who underwent isolated coronary artery bypass grafting (CABG) from the prospective, multicenter E-CABG registry. Preoperative thrombocytopenia was defined as preoperative platelet count &lt;150 × 10⁹/L and it was considered moderate-severe when preoperative platelet count was &lt;100 × 10⁹/L. Multilevel mixed-effects regression analysis was performed to adjust the effect of thrombocytopenia on outcomes for baseline and operative covariates as well as for interinstitutional differences in patient-blood management. Among 7189 patients included in this analysis, 599 (8.3%) had preoperative thrombocytopenia. Patient with preoperative thrombocytopenia had an increased chest drainage output at 12 h (mean, 519 vs. 456 mL, adjusted coeff. 39, 95%CI 18–60) and rates of severe-massive bleeding (Universal Definition of Perioperative Bleeding (UDPB) severity grades 3–4: 12.7% vs. 8.1%, adjusted OR 1.47, 95%CI 1.11–1.93; E-CABG bleeding severity grades 2–3: 10.4% vs. 6.1%, adjusted OR 1.78, 95%CI 1.30–2.43). Thrombocytopenia was associated with an increased risk of hospital/30-day death (3.2% vs. 1.9%, adjusted OR 2.02, 95%CI 1.20–3.42), 1-year death (5.7% vs. 3.4%, adjusted HR 1.68, 95%CI 1.16–2.44), deep sternal wound infection (3.5% vs. 2.4%, adjusted OR 1.65, 95%CI 1.02–2.66), acute kidney injury (28.1% vs. 22.2%, OR 1.45, 1.18–1.78), and prolonged stay in the intensive care unit (mean, 3.6 vs 2.8 days, adjusted coeff. 0.74, 95%CI 0.40–1.09). Similar results were observed in a subset of patients with moderate-severe thrombocytopenia (51 patients, 0.7%). In particular, these patients had a markedly higher rate of acute kidney injury (40%, adjusted OR, 1.94, 95%CI 1.05–3.57), resternotomy for bleeding (7.8%, adjusted OR 3.49, 95%CI 1.20–10.21), and severe-massive bleeding (UDPB severity grades 3–4: 23.5%, adjusted OR 3.08, 95%CI 1.52–6.22; E-CABG bleeding severity grades 2–3: 23.5%, adjusted OR 4.43, 95%CI 2.15–9.15) compared to patients with normal preoperative platelet count. Mild preoperative thrombocytopenia is associated with increased risk of severe-massive bleeding, mortality, and other major adverse events after CABG. Such risks are markedly increased in patients with moderate-severe preoperative thrombocytopenia