Coronary artery bypass grafting after percutaneous coronary intervention

Following percutaneous intervention (PCI), restenosis, progression of disease and multi-vessel involvement may require further intervention in the form of surgical revascularization. Patients with coronary artery bypass grafting (CABG) done after PCI were evaluated to find out the reason for the need of surgical revascularization. Over a period of 12 months, 610 patients underwent CABG. Out of them, 34 patients had previous PCI/stenting. Coronary risk factors including hypertension in 85%, diabetes mellitus in 60%, dyslipidemia in 60%, tobacco use in 50% and a positive family history was present in 53% of the patients. All patients were symptomatic. Multi-vessel disease was present in 67% and single vessel in 4.7%. The extent of disease and stenosis of stents were responsible for reintervention. Careful selection of patients is required in presence of multiple risk factors for coronary artery disease to provide maximum benefit by either PCI or CABG

Performance of the TIMI risk score in predicting mortality after primary percutaneous coronary intervention in elderly women: Results from a developing country

Background: Despite women undergoing primary percutaneous coronary intervention (PPCI) having a higher rate of adverse outcomes than men, data evaluating prognostic risk scores, especially in elderly women, remains scarce. This study was conducted to validate the predictive value of Thrombolysis in Myocardial Infarction (TIMI) risk score in elderly female patients. Materials and Methods: This was a retrospective analysis of elderly (\u3e65 years) female patients who underwent PPCI for ST-elevated myocardial infarction (STEMI) from October 2016 to September 2018. Patients\u27 demographic details and elements of TIMI risk score including age, co-morbidities, Killip classification; weight, anterior MI and total ischemic time were extracted from hospital records. The primary outcome was in-hospital mortality and post-discharge mortality reported on telephonic follow-up. Results: A total of 404 elderly women with a median age of 70 years were included. The mean TIMI score was 5.25±1.45 with 40.3% (163) patients of TIMI score \u3e 5. In-hospital mortality rate was 6.4% (26) and was found to be associated with TIMI score (p\u3c0.001). The in-hospital mortality rate increased from 3.1% at TIMI score of 0-4 to 34.6% at the score of 8. On follow-up (16.43±7.40 months) of 211 (55.8%) patients, the overall mortality rate was 20.3%, and this was also associated with TIMI score (p\u3c0.001). The mortality rate increased from 5.6% at the score of 0-4 to 54.5% at the score of 8. The predictive values (area under the curve) of TIMI risk score for in-hospital and post-discharge mortality were 0.709 (95% CI 0.591-0.827; p \u3c0.001) and 0.689 (95% CI 0.608-0.770; p \u3c0.001), respectively. Conclusion: Increased adverse outcomes were observed with higher TIMI risk score for in hospital and post-discharge follow-up. Therefore, the prognostic TIMI risk score is a robust tool in predicting both in-hospital as well as post-discharge mortality in elderly females

Socio-Economic Variations Determine the Clinical Presentation, Aetiology and Outcome of Infective Endocarditis: a Prospective Cohort Study from the ESC-EORP EURO-ENDO (European Infective Endocarditis) Registry.

peer reviewedBACKGROUND: Infective endocarditis (IE) is a life-threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socio-economic factors might influence its epidemiology, clinical presentation, investigation and management, and outcome, in a large international multi-centre registry. METHODS: The EurObservationalProgramme (EORP) of the European Society of Cardiology (ESC) EURO-ENDO registry comprises a prospective cohort of 3113 adult patients admitted for IE in 156 hospitals in 40 countries between January 2016 and March 2018. Patients were separated in 3 groups, according to World Bank economic stratification (Group 1 - high income [75.6%]; Group 2 - upper-middle income [15.4%]; Group 3 - lower-middle income [9.1%]). RESULTS: Group 3 patients were younger (median age [IQR]: Group 1 - 66 [53-75] years; Group 2 - 57 [41-68] years; Group 3 - 33 [26-43] years; p<0.001) with a higher frequency of smokers, intravenous drug use and human immunodeficiency virus (HIV) infection (all p<0.001) and presented later (median [IQR) days since symptom onset: Group 1 - 12 [3-35]; Group 2 - 19 [6-54]; Group 3 - 31 [12-62]; p<0.001) with a higher likelihood of developing congestive heart failure (13.6%; 11.1%; and 22.6%, respectively; p<0.001) and persistent fever (9.8%; 14.2%; 27.9%; p<0.001). Among 2157 (69.3%) patients with theoretical indication for cardiac surgery, surgery was performed less frequently in Group 3 patients (75.5%, 76.8% and 51.3%, respectively p<0.001) who also demonstrated the highest mortality (15.0%, 23.0% and 23.7%, respectively; p<0.001). CONCLUSIONS: Socio-economic factors influence the clinical profile of patients presenting with IE across the world. Despite younger age, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and lower use of surgery

Surveillance of Cardio Vascular Risk Factors Among Patients Undergoing Coronary Artery Bypass Surgery

According to world health organization report 2011, coronary artery diseases are the number one cause of death globally: more people die annually from coronary artery diseases than from any other cause. For this big burden of disease we need to know the ,prevalence of cardiovascular risk factors among patients undergoing elective Coronary Artery Bypass Graft surgery (CABG) in Karachi, Pakistan

Risk stratification analysis of operative mortality in isolated coronary artery bypass graft patients in Pakistan: comparison between additive and logistic EuroSCORE models.

We compared the performances of the additive and logistic EuroSCORE in predicting mortality in Patients undergoing isolated coronary artery bypass grafting at a single institution in Pakistan. Both models were applied to 2004 Patients, operated upon at the Aga Khan University Hospital from January 2006 to July 2010. The actual mortality (3.8%) was significantly different from the additive (4.35%) and the logistic (6.41%) estimates. On the basis of degree of risk, actual mortality was 0.6% in the low-risk (additive EuroSCORE 0-4), 4.2% in the medium-risk (EuroSCORE 5-9) and 19.1% in the high-risk (EuroSCORE 10-19) group. With the low risks, both systems slightly overestimated mortality, with the logistic EuroSCORE being more accurate. At a EuroSCORE of between 10 and 19, the additive EuroSCORE underestimated and logistic EuroSCORE overestimated mortality. Both models satisfactorily discriminated outcomes (receiver operating characteristics areas of 0.866 and 0.859 for the additive and the logistic model, respectively). The Hosmer-Lemeshow test showed that calibration was good for the additive model (P=0.424) but turned out to be inadequate for the logistic model (

Towards excellence in cardiac surgery: experience from a developing country

The objective of this study is an attempt to measure the performance in terms of comparing results with a large internationally recognized database used as a benchmark.Design: Cross-sectional (prospectively collected data analysed and compared retrospectively). SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS, INTERVENTIONS AND MAIN OUTCOME MEASURES: From January 2006 to December 2010, information of the 2198 CABGs performed at Aga Khan University Hospital (AKU) was collected prospectively. This included patient characteristics and specific intra- and post-operative outcomes and compared with findings from the American Society of Thoracic Surgeons\u27 National Cardiac Database (STS-NCD).Results: There were more male patients in the AKU cohort and more diabetics. In AKU, more cases involved three or more grafts (85 vs. 78%), and in both groups, an internal mammary artery graft was used over 90% of the time. The overall 30-day mortality was 2.7% at AKU, compared with 1.5% in the STS-NCD data. AKU had a lower incidence of permanent stroke (0.5 vs. 1.2%), prolonged ventilation (10.5 vs. 11.0%), deep sternal wound infection (0.2 vs. 0.4%) and reoperation (4.0 vs. 4.7%). It had more cases of renal failure (5.4 vs. 3.6%). Readmission rates within 30 days were also less in AKU (3.9 vs. 9.1%).CONCLUSIONS: The outcomes of this study compare very favourably with the benchmark (STS). This demonstrates that high level of quality care can be achieved in this part of the world

Trends in coronary artery bypass surgery: impact on early outcomes

Background: improvements in nonsurgical revascularization have left a group of higher-risk patients presenting for operation in a later stage of coronary artery disease. We undertook this study to analyze temporal changes in demographic and clinical profiles and outcomes of cardiac surgical patients.Methods: we identified and retrieved preoperative, intraoperative, and postoperative variables for 3064 consecutive patients who underwent myocardial revascularization at the Aga Khan University Hospital between 2006 and 2011. Mortality and morbidity outcomes were compared using univariate and multivariate analyses.Results: mean age, prevalence of left ventricular systolic dysfunction, unstable angina, mean number of occluded vessels, and arrhythmias at presentation increased steadily over time. The prevalence of diabetes, chronic lung disease, peripheral vascular disease, prior stroke, prior myocardial infarction, and left main disease declined. Operative mortality did not change significantly (3.5% vs. 3.8%, p=0.512). Determinants of operative mortality included older age, female sex, renal insufficiency, left ventricular systolic dysfunction, and longer bypass and crossclamp times.CONCLUSION: coronary operations are increasingly performed in higher-risk patients with greater comorbidities. Despite this, operative mortality has not increased