Off‐pump coronary artery bypass grafting: department of veteran affairs’ use and outcomes

Background: Coronary artery bypass can be performed off pump (OPCAB) without cardiopulmonary bypass. However, trends over time for OPCAB versus on‐pump (ONCAB) use and long‐term outcome has not been reported, nor has their long‐term outcome been compared. Methods and Results: We queried the national Veterans Affairs database (2005–2019) to identify isolated coronary artery bypass procedures. Procedures were classified as OPCAB on ONCAB using the as‐treated basis. Trend analyses were performed to evaluate longitudinal changes in the preference for OPCAB. The median follow‐up period was 6.6 (3.5–10) years. An inverse probability weighted Cox model was used to compare all‐cause mortality between OPCAB and ONCAB. From 47 685 patients, 6759 (age 64±8 years) received OPCAB (14%). OPCAB usage declined from 16% (2005–2009) to 8% (2015–2019). Patients with triple vessel disease who received OPCAB received a lower mean number of grafts (2.8±0.8 versus 3.2±0.8; P<0.01). The ONCAB 5‐, 10‐, and 15‐year survival rates were 82.9% (82.5–83.3), 60.4% (59.8–61.1), and 37.2% (36.1–38.4); correspondingly, OPCAB rates were 80.7% (79.7–81.7), 57.4% (56–58.7), and 34.1% (31.7–36.6) (P<0.01). OPCAB was associated with increased risk‐adjusted all‐cause mortality (hazard ratio, 1.15 [1.13–1.18]; P<0.01) and myocardial infarction (incident rate ratio, 1.16 [1.05–1.28]; P<0.01). Conclusions: Over 15 years, OPCAB use declined considerably in Veterans Affairs medical centers. In Veterans Affairs hospitals, late all‐cause mortality and myocardial infarction rates were higher in the OPCAB cohort

Using Technology to Link Mentors and Mentees: A Data Driven Approach

Slides from a presentation given at the UNM Health Sciences Center

Improving future postoperative atrial fibrillation care: a 30,000-foot viewpoint

Aim: In the United States (US), post-operative atrial fibrillation (POAF) is the most common complication following cardiac surgery. In order to understand the opportunities to improve POAF patients’ care, this “30,000 foot” review evaluated the professional society POAF database/registry definitions and guideline recommendations.Methods: All US-based professional society organizations with an interventional cardiac database/registry and/or cardiac care guidelines were identified; from these, the POAF database definitions and guideline recommendations were evaluated using a content analysis approach.Results: The Society of Thoracic Surgeons (STS) POAF definition was the most frequently referenced definition (21% of key references). Only 50% (n = 5/10) US cardiac surgery databases/registries included any POAF definition; compared to STS, the other five definitions required substantially more detailed documentation. Across eight guidelines, three different types of POAF recommendations were found: risk assessment (n = 3); prevention (n =7); and management (n = 8). As a common feature, the risk assessment strategies tended to focus on advanced age (n = 6). Beta-blockers (n = 5) and amiodarone (n = 6) were common prevention approaches. Uniformly, anti-coagulation was the only management strategy (n = 8) recommended, barring any contraindications.Conclusion: Across ten professional societies, 50% had no POAF definition; of the remaining five, no POAF definitional consistency was found. Across the eight US-based professional society POAF-related guidelines, only anticoagulation was uniformly recommended. Given these “big picture” findings, professional societies are urged to work collaboratively to harmonize these divergent POAF definitions and consolidate their evidence-based guideline recommendations to improve future POAF patients’ quality of care

Incidence, etiology, and outcomes of pre- and post-operative atrial fibrillation in mitral valve procedures: a review

Although pre-procedural and post-procedural atrial fibrillation occur commonly in mitral valve (MV) patients, the impact on patient outcomes and resource utilization has not been well documented. A comprehensive PubMed review was performed using a combination of MeSH terms related to atrial fibrillation, MV disease, MV and atrial fibrillation procedures, and medical management. Additional publications were selected from the reference lists of studies identified in the literature search. This review found that several studies conflict with the short-term outcomes associated with pre- and post-operative atrial fibrillation in MV patients. In general, both pre- and post-operative atrial fibrillation have clear negative long-term impacts on MV patients’ mortality and risk of stroke, major bleeding and other thromboembolic events. Surgical ablation for pre-operative atrial fibrillation and transcatheter ablation for medically resistant post-operative atrial fibrillation appears to be safe and effective procedure; these percutaneous and surgical interventions have been documented to mitigate MV-related thromboembolic risk. For MV patients, evidence suggests that the first step should be to optimize the current medical therapy; for persistent symptoms not addressed medically, ablation procedures should be considered. To optimize MV patients’ quality of care, however, additional research appears warranted to prevent long-term adverse outcomes

Atrial fibrillation in mechanical circulatory support patients

Atrial fibrillation (AF) is known to be one of the most common arrhythmias noted in cardiac procedures and is frequently associated with heart failure. As frequent interventions for patients with heart failure involve implantation of mechanical circulatory assist devices (e.g., left ventricular assist devices), it is timely to review the role this arrhythmia has on adverse clinical outcomes. A comprehensive literature search was conducted for PubMed. Relevant medical subject heading (MeSH) terms used in the initial literature search include “Heart-Assist Devices”, “Extracorporeal Membrane Oxygenation”, “Atrial Fibrillation”, “Heart Failure”, “Mortality”, “Hospital Readmission”, “stroke”, “Postoperative Complications”. In this review, the relevant literature was highlighted to identify the incidence, clinical impacts, and management of AF surrounding mechanical circulatory support implantation. The incidence of AF in this mechanical circulatory support device population was similar to that of patients with other cardiac procedures (10%-40%). Moreover, in most studies, preoperative AF was not significantly associated with adverse outcomes. In contrast, however, it appears that postoperative atrial fibrillation may predispose patients to increased risk for thromboembolic events and adverse long-term outcomes

Department of veterans affairs post-coronary artery bypass graft patients’ atrial fibrillation: 10-year outcomes

Aim: This Department of Veterans Affairs’ (VA) research project evaluated the impact of postoperative atrial fibrillation (POAF) upon 10-year outcomes for coronary artery bypass grafting (CABG) patients.Methods: Veterans enrolled in the “Randomized On-/Off-pump Bypass” (ROOBY) trial with new-onset POAF post-CABG were compared to those without POAF with respect to 10-year atrial fibrillation (AF) and mortality rates. Multivariable logistic regression examined whether AF was independently associated with 10-year survival after holding other preoperative risk factors constant.Results: Of the 2203 ROOBY veterans enrolled at 18 VA medical centers from 2002 to 2008, 100 patients with preoperative AF (n = 93) or unknown post-CABG POAF status (n = 7) were excluded. The POAF rate was 26.2% (n = 551/2103). The POAF patients were older and had more co-morbidities than the non-POAF patients (n = 1552). The AF rate among 10-year ROOBY POAF survivors was 18.9% (n = 64/338) compared to 5.8% (n = 61/1048) for non-POAF patients; P < 0.001. Compared to non-POAF patients’ 10-year survival of 70%, the ROOBY POAF veterans’ 10-year survival rate was 63%. Baseline risks inversely associated with 10-year survival included age, chronic obstructive pulmonary disease, serum creatinine > 1.5, peripheral vascular disease, and smoking. Holding these factors constant, POAF was not independently associated with 10-year survival.Conclusion: Post-CABG, ROOBY POAF veterans had higher rates of 10-year AF, which was negatively associated with 10-year survival; however, this association was not significant. Given that POAF may adversely impact 10-year AF rates, additional investigation appears warranted to improve future POAF patients’ care