Intermittent Aortic Cross-Clamping for Isolated CABG Can Save Lives and Money: Experience with 15 307 Patients[*]

Abstract

Background: The ideal myocardial protection during isolated CABG is still a matter of debate. Cardioplegia versus intermittent aortic cross-clamping (IACC) are the main opponents; the following article shows that IACC can be safe, efficient and might be cheaper than cardioplegia. Methods: Demographics and co-morbidities of 15 307 CABG only patients consecutively operated on between January 1993 and October 2001 in the Heart Center in Bad Oeynhausen were assessed by the German Quality Assurance data set and risk-stratified using the EuroSCORE. Outcome (30-day or in-hospital mortality) was compared to the expected EuroSCORE estimation. Results: Expected mortality was 3.25 %, observed mortality was 1.3 %, being significantly lower in the low, medium as well as high risk patients subgroup. Complication rates increased steadily with expected mortality rates. Stroke and myocardial infarction rates for patients with peripheral vessel disease were not higher than in comparable studies. More than 1 000 000 EUR were saved by lower cardioplegia bills. Conclusion: Myocardial protection with intermittent aortic cross-clamping for isolated CABG can be safe, effective, and economically advantageous when compared to cardioplegic solutions.

Key words

CABG - cross-clamping - mortality

1 Presented at the 23rd annual meeting in Leipzig, February 23 - 26, 2003

References

• 1 Roques F, Nashef S AM, Michel P. et al . Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19 030 patients.  Eur J Cardiothorac Surg. 1999;  15 816-823
• 2 Nashef S AM, Roques F, Michel P. et al . European system for cardiac operative risk evaluation (EuroSCORE).  Eur J Cardiothorac Surg. 1999;  16 9-13
• 3 Sergeant P, de Worm E, Meyns B. Single centre, single domain validation of the EuroSCORE on a consecutive sample of primary and repeat CABG.  Eur J Cardiothorac Surg. 2001;  20 1176-1182
• 4 Nashef S A, Roques F, Hammill B G. et al . Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery.  Eur J Cardiothorac Surg. 2002;  22 101-105
• 5 Geissler H J, Holzl P, Marohl S. et al . Risk stratification in heart surgery: comparison of six score systems.  Eur J Cardiothorac Surg. 2000;  17 400-406
• 6 Roques F, Michel P, Goldstone A R, Nashef S A. The logistic EuroSCORE.  Eur Heart J. 2003;  24 882-883
• 7 Pitkanen O, Niskanen M, Rehnberg S, Hippelainen M, Hynynen M. Intra-institutional prediction of outcome after cardiac surgery: comparison between a locally derived model and the EuroSCORE.  Eur J Cardiothorac Surg. 2000;  18 703-710
• 8 www.bqs-online.de/download/13. Koronarchirurgie.pdf . 
• 9 Alhan H C, Karabulut H, Tosun R. et al . Intermittent aortic cross-clamping and cold crystalloid cardioplegia for low-risk coronary patients.  Ann Thorac Surg. 1996;  61 834-839
• 10 Raman J S, Bellomo R, Hayhoe M, Tsamitros M, Buxton B F. Metabolic changes and myocardial injury during cardioplegia: a pilot study.  Ann Thorac Surg. 2001;  72 1566-1571
• 11 Liu Z, Valencia O, Treasure T, Murday A J. Cold blood cardioplegia or intermittent cross-clamping in coronary artery bypass grafting?.  Ann Thorac Surg. 1998;  66 462-465
• 12 Sunderdiek U, Feindt P, Gams E. Aortocoronary bypass grafting: a comparison of HTK cardioplegia vs. intermittent aortic cross-clamping.  Eur J Cardiothorac Surg. 2000;  18 393-399
• 13 Bucerius J, Gummert, Borger M A. et al . Stroke after cardiac surgery: a risk factor analysis of 16 184 consecutive adult patients.  Ann Thorac Surg. 2003;  75 472-478
• 14 Newman M F, Wolman R, Kanchuger M. et al . Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group.  Circulation. 1996;  94 (Suppl) II74-80
• 15 Osswald B R, Blackstone E H, Tochtermann U, Thomas G, Vahl C F, Hagl S. The meaning of early mortality after CABG.  Eur J Cardiothorac Surg. 1999;  15 401-407
• 16 www.ctsnet.org/file/STS/NationalDatabaseFall2002ExecutiveSummary.pdf . 
• 17 D'Ancona G, Saez de Ibarra J I, Baillot R, Mathieu P, Doyle D, Metras J, Desaulniers D, Dagenais F. Determinants of stroke after coronary artery bypass grafting.  Eur J Cardiothorac Surg. 2003;  24 552-556
• 18 Ovrum E, Tangen G, Tollofsrud S, Ringdal M A. Heparin-coated circuits and reduced systemic anticoagulation applied to 2500 consecutive first-time coronary artery bypass grafting procedures.  Ann Thorac Surg. 2003;  76 1144-1148
• 19 Stamou S C, Hill P C, Dangas G, Pfister A J, Boyce S W, Dullum M K, Bafi A S, Corso P J. Stroke after coronary artery bypass: incidence, predictors, and clinical outcome.  Stroke. 2001;  32 1508-1513
• 20 Loponen P, Taskinen P, Laakkonen E, Nissinen J, Luther M, Wistbacka J O. Perioperative stroke in coronary artery bypass patients.  Scand J Surg. 2003;  92 148-155
• 21 Charlesworth D C, Likosky D S, Marrin C A, Maloney C T, Quinton H B, Morton J R, Leavitt B J, Clough R A, O'Connor G T. Northern New England Cardiovascular Disease Study Group . Development and validation of a prediction model for strokes after coronary artery bypass grafting.  Ann Thorac Surg. 2003;  76 436-443

1 Presented at the 23rd annual meeting in Leipzig, February 23 - 26, 2003