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The relationship of patient selection to prognosis following aortocoronary bypass
Insights
Aortocoronary bypass surgery mortality decreased over time due to better patient selection, particularly those with ventricular dysfunction. Risk stratification is crucial for managing coronary artery bypass graft outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Medical Device Technology
Background:
- Aortocoronary bypass surgery is a critical intervention for coronary artery disease.
- Early operative mortality rates for this procedure varied significantly.
- Patient selection and evolving surgical practices influence outcomes.
Purpose of the Study:
- To analyze operative mortality trends for aortocoronary bypass surgery.
- To identify factors influencing changes in mortality rates over time.
- To evaluate the impact of patient selection and disease severity on surgical outcomes.
Main Methods:
- Retrospective analysis of 787 patients undergoing aortocoronary bypass at Duke University Medical Center.
- Comparison of mortality rates before and after January 1, 1972.
- Stratification of patients based on ventricular function, left main disease, and number of diseased vessels.
Main Results:
- Overall operative mortality was 9.7%.
- Mortality decreased from 8.8% to 5.4% for elective bypass patients after 1972, linked to reduced ventricular dysfunction prevalence.
- Mortality varied by disease severity: 12.7% for left main disease, 1.0% for one/two-vessel disease, and 6.6% for three-vessel disease.
Conclusions:
- Operative mortality for aortocoronary bypass has decreased, primarily due to improved patient selection and reduced prevalence of severe ventricular dysfunction.
- Risk stratification, considering factors like left main disease and overall vessel involvement, is essential for accurate outcome prediction.
- While selected low-risk patients experience very low mortality, careful assessment of benefits versus risks is necessary for all patients considered for surgery.
Abstract:
Operative mortality for the first 787 patients who underwent aortocoronary bypass at Duke University Medical Center was 9.7%. Within 699 patients who underwent elective bypass only, operative mortality was 8.8% before January 1, 1972, and 5.4% subsequently. This apparent variation in operative mortality over time was largely a consequence of changing patterns of patient selection, i.e., a two- to three-fold decrease in the prevalence of ventricular dysfunction. Since January 1, 1972, operative mortality for 444 patients with mild or no heart failure who underwent elective bypass only was 5.0%. The 55 patients with left main disease had 12.7% operative mortality. In the 192 patients without left main disease who had one- or two-vessel disease, operative mortality was 1.0%, whereas, 197 patients with three-vessel disease had a 6.6% operative mortality. The 103 patients with three-vessel disease less than 50 years of age underwent operation with a 2.9% mortality. Although these results demonstrate that selected patients may undergo operation with a mortality approaching 1%, it is not clear that only such low risk patients should be offered surgery. Accurate estimates of benefits and risks of aortocoronary bypass surgery are necessary in the management of specific patients.
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