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[Coronary artery bypass graft surgery in patients with diabetes]
Iradj Gandjbakhch1, Pascal Leprince, Cossimo D'Alessandro
1L'Académie Nationale de Médecine.
Insights
Strict perioperative glycemic control in diabetic patients undergoing coronary artery bypass graft (CABG) surgery significantly reduces in-hospital mortality. This aggressive protocol improved outcomes, making results comparable to non-diabetic patients.
Area of Science:
- Cardiology
- Diabetology
- Surgical Outcomes
Background:
- Diabetes mellitus is a significant risk factor for cardiovascular disease, leading to poorer prognoses in patients with coronary artery disease.
- Coronary artery bypass graft (CABG) surgery outcomes are historically worse for diabetic patients compared to non-diabetic individuals.
- Strict perioperative glycemic control is crucial for reducing morbidity and mortality in patients undergoing CABG.
Purpose of the Study:
- To evaluate the impact of an aggressive perioperative glycemic control protocol on in-hospital morbidity and mortality in diabetic patients undergoing CABG.
- To compare outcomes between diabetic patients managed with the new protocol and those treated before its implementation.
Main Methods:
- A prospective study involving 200 consecutive diabetic patients undergoing CABG with a new aggressive glycemic control protocol (Group A).
- Comparison of in-hospital morbidity and mortality data with a historical cohort of 200 diabetic patients who underwent CABG prior to the protocol (Group B).
- Analysis included preoperative data, graft details (e.g., use of internal mammary arteries), and complication rates.
Main Results:
- While the use of bilateral internal mammary arteries increased significantly in Group A (38% vs. 16% in Group B), rates of wound infection and mediastinitis remained similar (4%).
- In-hospital mortality was significantly lower in Group A (1.5%) compared to Group B (3.5%).
- The protocol did not negatively impact outcomes for diabetic patients requiring insulin, although infectious complications were higher in this subgroup.
Conclusions:
- Enhanced medical and surgical management, including aggressive perioperative glycemic control, is improving CABG outcomes in diabetic patients, approaching those of non-diabetic patients.
- The utilization of internal mammary arteries in CABG surgery is associated with improved long-term survival.
- Surgical revascularization remains the primary treatment for diabetic patients with coronary artery disease unsuitable for endovascular procedures.
Unlabelled:
Diabetes is a potent risk factor for cardiovascular disease. Whatever the treatment, the prognosis of coronary artery disease is poorer in patients with diabetes than in non diabetic patients. Strict equilibration of perioperative glycemia reduces morbidity and mortality associated with coronary artery bypass graft surgery (CABG).
Patients And Methods:
In two hundred consecutive diabetic patients who underwent CABG, perioperative glycemia was equilibrated by using a new aggressive protocol (Group A). In-hospital morbidity and mortality observed in these patients was compared to that observed in 200 diabetic patients who underwent CABG before the protocol was implemented (group B).
Results:
Preoperative data were similar in the two groups. The mean number of grafts was 2.6 per patient, and the left internal thoracic artery was used in 98% of cases. Use of the two internal mammary arteries increasedfrom 16% in group B to 38% in group A (p < 0.05). However, the rates of wound infection and mediastinitis were similar in the two groups (4%), as was the rate of other complications. In contrast, in-hospital mortality was twice as lower in group A (1.5%) than in group B (3.5%). One-quarter of the patients used insulin, and the rate of infectious complications was higher in this subgroup; however, in-hospital mortality was similar to that among diabetic patients not requiring insulin (2%). Use of the protocol did not affect the outcome of patients requiring insulin.
Conclusion:
Better medical and surgical management of diabetic patients is improving the outcome of CABG surgery, with results now similar to those obtained in non diabetic patients. The use of mammary arteries improves long-term survival. Surgical revascularization remains the most effective treatment for diabetic patients whose coronary artery lesions do not qualify for endovascular revascularization
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