Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity

DOI: https://doi.org/10.30702/ujcvs/23.31(01)/G005-1018
Keywords: high cardiac surgery risk, comorbidity, myocardial revascularization, coronary syndrome, personalized therapy, diabetes mellitus

Abstract

The aim. To analyze the effectiveness of the developed algorithms for the perioperative management of high-risk cardiac surgery patients with coronary artery disease (CAD) and polymorbidity.

Materials and methods. We analyzed perioperative management of 354 high-risk cardiac surgery patients with CAD with EuroSCORE II predicted mortality >5%, among which 194 (54.8%) underwent isolated coronary artery bypass grafting, and 160 (45.2%) had surgical myocardial revascularization with accompanying valvular pathology correction or left ventricular postinfarction aneurysm resection. All the patients were discharged after cardiac surgery performed at the Department of Surgical Treatment of CAD of the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 2009 to 2019. As part of the study, general clinical examinations, electrocardiography, echocardiography, coronary angiography, cardiosurgical treatment were provided, and perioperative patient management protocols were developed and implemented.

Results. Based on the conducted detailed analysis, it was established that the success of surgical revascularization of the myocardium depends not only on cardiac factors, but also on the compensation of concomitant diseases, the work of an experienced cardiac team consisting of a cardiologist, an interventionist, an anesthesiologist, a cardiac surgeon, and an intensivist. Treatment and prevention measures should be personalized and aimed at timely response to changes in laboratory and hemodynamic indicators of patients at all stages of their management, as well as stabilization of concomitant diseases. An important point in the preoperative preparation of cardiac surgery patients is verification of concomitant diseases with the aim of their timely compensation. The implemented algorithm for searching for comorbid conditions made it possible to improve the diagnosis of initial disorders of glucose metabolism, abnormal uric acid levels and cerebrovascular disease. Lowering the glucose level according to the developed algorithm of management of patients with impaired glucose metabolism in the perioperative period made it possible to reduce the number of postoperative wound infections by 3.4% and arrhythmological complications by 19.4%. Correction of drug therapy taking into account the glomerular filtration rate made it possible to avoid postoperative hemodialysis. Preventive prescription of therapeutic doses of proton pump inhibitors against the background of dual antiplatelet therapy, according to the developed protocol, led to a decrease in postoperative gastroduodenal complications from 5.1% to 0.3%.

Conclusions. Implementation of the system of personalized treatment and preventive management of patients in the perioperative period made it possible to reduce postoperative complications from 16.7% to 4% (p=0.0190).

References

  1. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al.; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. https://doi.org/10.1093/eurheartj/ehy394. Erratum in: Eur Heart J. 2019;40(37):3096.
  2. Dominici C, Salsano A, Nenna A, Spadaccio C, Mariscalco G, Santini F, et al. On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis. J Card Surg. 2020;35(8):1958-78. https://doi.org/10.1111/jocs.14780
  3. Writing Committee Members; Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(2):e21-e129. https://doi.org/10.1016/j.jacc.2021.09.006. Erratum in: J Am Coll Cardiol. 2022;79(15):1547.
  4. Ruel M, Kulik A. Suboptimal Medical Therapy After Coronary Revascularization: A Missed Opportunity. J Am Coll Cardiol. 2018;71(6):603-5. https://doi.org/10.1016/j.jacc.2017.12.007
  5. Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, et al.; Veterans Affairs Randomized On/ Off Bypass (ROOBY) Study Group. On-Pump versus Off- Pump Coronary-Artery Bypass Surgery. N Engl J Med. 2009;361(19):1827-37. https://doi.org/10.1056/NEJMoa0902905
  6. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Straka Z, et al.; CORONARY Investigators. Five-Year Outcomes after Off-Pump or On-Pump Coronary-Artery Bypass Grafting. N Engl J Med. 2016;375(24):2359-68. https://doi.org/10.1056/NEJMoa1601564
  7. Rogers CA, Pike K, Campbell H, Reeves BC, Angelini GD, Gray A, et al.; CRISP investigators. Coronary artery bypass grafting in high-RISk patients randomised to off- or on- Pump surgery: a randomised controlled trial (the CRISP trial). Health Technol Assess. 2014;18(44):v-xx, 1-157. https://doi.org/10.3310/hta18440
  8. Hartz AJ, Manley JC, Walker JA, Gale HH, He Z, Assa J. Trends during 25 years of coronary artery bypass operation at St. Luke’s Medical Center in Milwaukee, Wisconsin. Ann Thorac Surg. 2000;69(3):829-33. https://doi.org/10.1016/s0003-4975(99)01418-6
  9. Ferguson TB Jr, Hammill BG, Peterson ED, DeLong ER, Grover FL; STS National Database Committee. A decade of change--risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg. 2002 Feb;73(2):480-9; discussion 489-90. https://doi.org/10.1016/s0003-4975(01)03339-2
  10. Gaudino M, Glieca F, Alessandrini F, Nasso G, Pragliola C, Luciani N, et al. High risk coronary artery bypass patient: incidence, surgical strategies, and results. Ann Thorac Surg. 2004;77(2):574-9; discussion 580. https://doi.org/10.1016/S0003-4975(03)01534-0
  11. Titinger DP, Lisboa LA, Matrangolo BL, Dallan LR, Dallan LA, Trindade EM, et al. Cardiac Surgery Costs According to the Preoperative Risk in the Brazilian Public Health System. Arq Bras Cardiol. 2015;105(2):130-8. https://doi.org/10.5935/abc.20150068
  12. Hwang CW, Anderson GF, Diener-West M, Powe NR. Comorbidity and Outcomes of Coronary Artery Bypass Graft Surgery at Cardiac Specialty Hospitals Versus General Hospitals. Med Care. 2007;45(8):720-8. https://doi.org/10.1097/MLR.0b013e3180537192
  13. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross- sectional study. Lancet. 2012;380(9836):37-43. https://doi.org/10.1016/S0140-6736(12)60240-2
  14. Zhao Y, Zhang H, Liu X, Desloge A, Wang Q, Zhao S, et al. The prevalence of cardiometabolic multimorbidity and its associations with health outcomes among women in China. Front Cardiovasc Med. 2023 Feb 9;10:922932. https://doi.org/10.3389/fcvm.2023.922932
  15. Zhao Y, Zhang P, Lee JT, Oldenburg B, van Heusden A, Haregu TN, et al. The Prevalence of Metabolic Disease Multimorbidity and Its Associations With Spending and Health Outcomes in Middle-Aged and Elderly Chinese Adults. Front Public Health. 2021 May 3;9:658706. https://doi.org/10.3389/fpubh.2021.658706
  16. Arokiasamy P, Uttamacharya U, Jain K, Biritwum RB,Yawson AE, Wu F, et al. The impact of multimorbidity on adult physical and mental health in low- and middle- income countries: what does the study on global ageing and adult health (SAGE) reveal? BMC Med. 2015 Aug 3;13:178. https://doi.org/10.1186/s12916-015-0402-8
  17. Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M, et al. Review: Health Care Utilization and Costs of Elderly Persons With Multiple Chronic Conditions. Med Care Res Rev. 2011;68(4):387-420. https://doi.org/10.1177/1077558711399580
  18. Prados-Torres A, Calderón-Larrañaga A, Hancco-Saavedra J, Poblador-Plou B, van den Akker M. Multimorbidity patterns: a systematic review. J Clin Epidemiol. 2014;67(3):254-66. https://doi.org/10.1016/j.jclinepi.2013.09.021
  19. Dodel R. Multimorbidität: Konzept, Epidemiologie, Versorgung [Multimorbidity: concept, epidemiology and treatment]. Nervenarzt. 2014;85(4):401-8. German. https://doi.org/10.1007/s00115-013-3937-y
  20. Feinstein AR. The pre-therapeutic classification of co- morbidity in chronic disease. J Chronic Dis. 1970;23(7):455-68. https://doi.org/10.1016/0021-9681(70)90054-8
  21. Jakovljević M, Ostojić L. Comorbidity and multimorbidity in medicine today: challenges and opportunities for bringing separated branches of medicine closer to each other. Psychiatr Danub. 2013;25 (Suppl 1):18-28.
  22. Shawon MSR, Odutola M, Falster MO, Jorm LR. Patient and hospital factors associated with 30-day readmissions after coronary artery bypass graft (CABG) surgery: a systematic review and meta-analysis. J Cardiothorac Surg. 2021;16(1):172. https://doi.org/10.1186/s13019-021-01556-1
  23. Hannan EL, Racz MJ, Walford G, Ryan TJ, Isom OW, Bennett E, et al. Predictors of Readmission for Complications of Coronary Artery Bypass Graft Surgery. JAMA. 2003;290(6):773-80. https://doi.org/10.1001/jama.290.6.773
  24. Feng TR, White RS, Gaber-Baylis LK, Turnbull ZA, Rong LQ. Coronary artery bypass graft readmission rates and risk factors - A retrospective cohort study. Int J Surg. 2018;54(Pt A):7-17. https://doi.org/10.1016/j.ijsu.2018.04.022
  25. Lancey R, Kurlansky P, Argenziano M, Coady M, Dunton R, Greelish J, et al. Uniform standards do not apply to readmission following coronary artery bypass surgery: a multi-institutional study. J Thorac Cardiovasc Surg. 2015;149(3):850-7.e1; discussion 857. https://doi.org/10.1016/j.jtcvs.2014.08.059
  26. Scrutinio D, Giannuzzi P. Comorbidity in patients undergoing coronary artery bypass graft surgery: impact on outcome and implications for cardiac rehabilitation. Eur J Cardiovasc Prev Rehabil. 2008;15(4):379-85. https://doi.org/10.1097/HJR.0b013e3282fd5c6f
  27. Clough RA, Leavitt BJ, Morton JR, Plume SK, Hernandez F, Nugent W, et al. The Effect of Comorbid Illness on Mortality Outcomes in Cardiac Surgery. Arch Surg. 2002;137(4):428-32; discussion 432-3. https://doi.org/10.1001/archsurg.137.4.428
  28. Gogayeva OK. [Preoperative verification of comorbidity in patients with high-risk coronary heart disease on the eve of surgical myocardial revascularization]. Mizhnarodnyi medychnyi zhurnal. 2021;27(3):10-14. Ukrainian. https://doi.org/10.37436/2308-5274-2021-3-2
  29. Coyan GN, Hannah Chin, Shah A, Yisi Wang, Arman Kilic, Sultan I, et al. Charlson Comorbidity Index Predicts Longer-term Mortality and Re-admission in Isolated CABG. Circulation. 2019 Nov 19;140(Suppl 1):A11636.
  30. Gogayeva OK. [Perioperative management of patients with comorbidity and high risk in cardiac surgery of coronary artery disease] [dissertation]. Kyiv: National Amosov institute of cardiovascular surgery of the National Academy of Medical Sciences of Ukraine; 2021.
  31. Gogayeva OK. [Determination of comorbidity index for high-risk patients with coronary artery disease before cardiac surgery]. Zaporozhye medical journal. 2021;23(4):485-91. Ukrainian. https://doi.org/10.14739/2310-1210.2021.4.233643
  32. Gogayeva OK, Lebid AY, Tymoshenko DA. [Comorbidities in Patients before Surgical Myocardial Revascularization: Current State of the Problem. Part IІ]. Ukrainskyi Zhurnal Sertsevo-sudynnoi Khirurhii. 2022;30(3):22-28. Ukrainian. https://doi.org/10.30702/ujcvs/22.30(03)/GL039-2228
  33. Gogayeva OK, Rudenko AV, Lazoryshynets VV, Dzakhoieva LS. [Analysis of the endocrine status of patients with coronary artery disease in cardiac surgery]. Ukrainian Journal of Cardiology. 2021;28(1):26-33. Ukrainian. https://doi.org/10.31928/1608-635X-2021.1.2633
  34. Gogayeva O, Lazoryshynets V, Rudenko A, Dzakhoieva L, Yuvchyk O. [Perioperative evaluation of kidney function for patients with complicated forms of coronary artery disease]. Ukr J Nephr Dial. 2020;4(68):52-8. Ukrainian. https://doi.org/10.31450/ukrjnd.4(68).2020.08
  35. Gogayeva OK. [Characteristics of pharmaceutical therapy of high-risk patients with coronary artery disease after coronary artery bypass grafting]. Actual problems of modern medicine: Bulletin of Ukrainian Medical Stomatological Academy. 2021;21(1):6-11. Ukrainian. https://doi.org/10.31718/2077-1096.21.1.6
Published
2023-03-27
How to Cite
1.
Gogayeva OK. Algorithms of Perioperative Management of High-Risk Cardiac Surgery Patients with Coronary Artery Disease and Polymorbidity. ujcvs [Internet]. 2023Mar.27 [cited 2024Dec.21];31(1):10-8. Available from: https://cvs.org.ua/index.php/ujcvs/article/view/545
Issue
Ukrainian Journal of Cardiovascular Surgery Vol 31 No 1 2023
Section
ISCHEMIC HEART DISEASE

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