To assess the prevalence and clinical significance of incidental findings identified during computed tomography imaging of coronary artery bypass grafts.This prospective study includes 144 patients undergoing coronary graft patency assessment using computed tomography. Incidental findings were classified as significant if they were considered to need an immediate action or treatment, short-term work-up or follow-up, or minor. A total of 211 incidental findings were present in 109 (75.7%) patients. Seventy-one incidental findings (33.6%) were cardiac and 140 (66.4%) were extracardiac. Most common cardiac incidental findings were atrial dilatation [39 patients, 48 incidental findings (67.6%)] and aortic valve calcifications (7 patients, 9.9%). Among the 140 extracardiac incidental findings, the most common were lung nodules (51 patients, 54 nodules, 38.6%), and emphysema (21 patients, 15%). Thirty-six (25.7%) extracardiac incidental findings were significant and notably, 23 (63.9%) were lung nodules. Follow-up was recommended in 37 cases, among which all patients with significant lung nodules (23 patients, 62.2%). In conclusion, most common computed tomography incidental findings in patients with coronary grafts were lung nodules and emphysema.
PURPOSE: To assess if the addition of cardiac resynchronization therapy (CRT) and/or ablation of AF improves the outcome of patients undergoing mitral repair for functional mitral regurgitation (MR...
ObjectiveCoronary artery bypass graft (CABG) surgery with arterial conduits is considered optimal. A deterrent to bilateral internal thoracic artery (BITA) grafting is the risk of deep sternal wound infection (DSWI). We introduced infection prevention measures sequentially, attempting to reduce DSWIs. The aim was to determine (1) if the absence of DSWIs in the last 469 of 1001 consecutive operations was significant; (2) which measures explained the change; and (3) the impact of diabetes.MethodsThe measures included internal thoracic artery (ITA) skeletonization, no bone wax, wound irrigation, 1 observer per case, harmonic scalpel harvest of ITAs, vancomycin paste on sternal marrow, iodine-impregnated skin drapes, chlorhexidine-alcohol skin preparation, no BITA grafts in obese, diabetic women, more off-pump procedures, aseptic wound care, and marrow irrigation before sternal approximation.ResultsMean age was 65 ± 10.4 years, 78% were male, 34% had diabetes, and 34% were obese. The first 532 patients had 16 DSWIs (3%) and the subsequent 469 had none (P < .001). Analysis of the data suggested that the first 11 measures likely contributed to the absence of DSWI and less likely, the twelfth. Key measures were likely chlorhexidine-alcohol use and avoidance of BITAs in obese diabetic women who had a 10-fold higher DSWI rate than the other patients (21.4% vs 2.0%). Other diabetics, including obese men, had no increased risk of DSWI.ConclusionsThe measures applied caused a substantial reduction in DSWIs. Key measures included the use of chlorhexidine-alcohol and avoidance of BITA grafting in obese diabetic females. These measures reduced DSWIs after BITA grafting in most diabetics.
C oronary artery bypass grafting (CABG) is a common procedure for the treatment of coronary artery disease.Over a five-year period, 774,881 isolated CABG procedures were recorded in the Society of Thoracic Surgeons National Audit Cardiac Surgery Database in the United States (1).Sternal wound dehiscence following mid-line sternotomy approach for CABG can result in significant morbidity and mortality (5% to 20%) (2).Despite significant sequelae from developing wound dehiscence, this complication is relatively uncommon, with incidence commonly reported to be between 0.4% and 4% (1,(3)(4)(5)(6)(7)(8)(9)(10)(11)(12).As described by Pairolero and Arnold (13), sternal wound dehiscence can be classified as type I (postoperative days 1 to 3), type II (within the first two to three weeks postoperatively) and type III (one year to several years postoperatively).Type I infections are generally superficial in nature, with the possibility of progressing to type II infections.Type II infections generally require irrigation and debridement, serial dressing changes, and local or regional flap closure.It is inferred that additional procedures such as these result in prolonged length of stay, increase risk to the patient and increased use of hospital resources.Understanding the incidence of sternal wound dehiscence in a given patient population is important for quality control and resource planning.The patient population undergoing CABG appears to be changing, as evidenced by long-term studies demonstrating that CABG benefits individuals with certain comorbid conditions (such as diabetes and renal failure) compared with angioplasty (14-17).It is believed this has an impact on management protocols -and, therefore, the incidence of sternal wound dehiscence -because individuals undergoing CABG today have proportionately more comorbid conditions than previously studied cohorts.original arTicle
Acute kidney injury after cardiac surgery is associated with adverse in-hospital and long-term outcomes. Novel risk factors for acute kidney injury have been identified, but it is unknown whether their incorporation into risk models substantially improves prediction of postoperative acute kidney injury requiring renal replacement therapy.
Methods:
We developed and validated a risk prediction model for acute kidney injury requiring renal replacement therapy within 14 days after cardiac surgery. We used demographic, and preoperative clinical and laboratory data from 2 independent cohorts of adults who underwent cardiac surgery (excluding transplantation) between Jan. 1, 2004, and Mar. 31, 2009. We developed the risk prediction model using multivariable logistic regression and compared it with existing models based on the C statistic, Hosmer–Lemeshow goodness-of-fit test and Net Reclassification Improvement index.
Results:
We identified 8 independent predictors of acute kidney injury requiring renal replacement therapy in the derivation model (adjusted odds ratio, 95% confidence interval [CI]): congestive heart failure (3.03, 2.00–4.58), Canadian Cardiovascular Society angina class III or higher (1.66, 1.15–2.40), diabetes mellitus (1.61, 1.12–2.31), baseline estimated glomerular filtration rate (0.96, 0.95–0.97), increasing hemoglobin concentration (0.85, 0.77–0.93), proteinuria (1.65, 1.07–2.54), coronary artery bypass graft (CABG) plus valve surgery (v. CABG only, 1.25, 0.64–2.43), other cardiac procedure (v. CABG only, 3.11, 2.12–4.58) and emergent status for surgery booking (4.63, 2.61–8.21). The 8-variable risk prediction model had excellent performance characteristics in the validation cohort (C statistic 0.83, 95% CI 0.79–0.86). The net reclassification improvement with the prediction model was 13.9% (p < 0.001) compared with the best existing risk prediction model (Cleveland Clinic Score).
Interpretation:
We have developed and validated a practical and accurate risk prediction model for acute kidney injury requiring renal replacement therapy after cardiac surgery based on routinely available preoperative clinical and laboratory data. The prediction model can be easily applied at the bedside and provides a simple and interpretable estimation of risk.
Transit time flow measurement (TTFM) allows quality control in coronary artery bypass grafting but remains largely underused, probably because of limited information and the lack of standardization. We performed a systematic review of the evidence on TTFM and other methods for quality control in coronary artery bypass grafting following PRISMA standards and elaborated expert recommendations by using a structured process. A panel of 19 experts took part in the consensus process using a 3-step modified Delphi method that consisted of 2 rounds of electronic voting and a final face-to-face virtual meeting. Eighty percent agreement was required for acceptance of the statements. A 2-level scale (strong, moderate) was used to grade the statements based on the perceived likelihood of a clinical benefit. The existing evidence supports an association between TTFM readings and graft patency and postoperative clinical outcomes, although there is high methodological heterogeneity among the published series. The evidence is more robust for arterial, rather than venous, grafts and for grafts to the left anterior descending artery. Although TTFM use increases the duration and the cost of surgery, there are no data to quantify this effect. Based on the systematic review, 10 expert statements for TTFM use in clinical practice were formulated. Six were approved at the first round of voting, 3 at the second round, and 1 at the virtual meeting. In conclusion, although TTFM use may increase the costs and duration of the procedure and requires a learning curve, its cost/benefit ratio seems largely favorable, in view of the potential clinical consequences of graft dysfunction. These consensus statements will help to standardize the use of TTFM in clinical practice and provide guidance in clinical decision-making.
