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Effects of Concomitant CABG on Outcomes in Veterans Who Require Surgery for Endocarditis
John Duggan1, Alex Peters2, Sarah A Halbert3
1Division of Cardiothoracic Surgery, Veterans Affairs Medical Center, Washington, D.C. 20422, USA; Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA. duggan.johnp@gmail.com.
Insights
Concomitant coronary artery bypass grafting (CABG) during infective endocarditis (IE) surgery increased myocardial infarction (MI) risk in US veterans. However, it did not raise stroke or mortality risks, suggesting careful consideration for combined procedures.
Area of Science:
- Cardiovascular Surgery
- Infectious Diseases
- Health Services Research
Background:
- Infective Endocarditis (IE) often co-occurs with Coronary Artery Disease (CAD), but guidelines for combined surgical treatment are lacking.
- Data on the impact of combined surgery in the US Veteran population is scarce.
- This study examines the effects of concurrent Coronary Artery Bypass Grafting (CABG) on morbidity and mortality in US Veterans undergoing IE surgery.
Purpose of the Study:
- To investigate the impact of concomitant CABG on morbidity and mortality in US Veterans with IE requiring valve surgery.
- To analyze the risks of myocardial infarction (MI), stroke, and death associated with combined procedures.
Main Methods:
- A retrospective analysis of 489 US Veterans undergoing IE surgery between 2010-2020.
- Patients were stratified into groups with and without concomitant CABG.
- Cox proportional-hazard models were used to assess primary outcomes: postoperative MI, stroke, and mortality.
Main Results:
- 12.5% of patients (61/489) underwent concomitant CABG.
- CABG was associated with a higher risk of 30-day (aHR 2.34) and long-term MI (aHR 2.37).
- No significant association was found between concomitant CABG and stroke or mortality at 30 days or long-term.
Conclusions:
- Concomitant CABG during IE surgery increases MI risk in US Veterans, despite often involving a low number of grafts.
- Combined procedures did not increase stroke or mortality risks.
- Optimal management strategies for concurrent CAD in veterans undergoing IE surgery require further investigation.
Background:
Infective Endocarditis (IE) is a complicated disease frequently accompanied by coronary artery disease (CAD) though no clear guidelines exist for when concomitant revascularization should be undertaken once valve surgery is indicated. Data on this topic within the United States (US) Veteran population, who have unique healthcare needs when compared to the civilian population, is sparse. We investigated the impact of concomitant coronary artery bypass grafting (CABG) on morbidity and mortality in US Veterans requiring surgical management of IE.
Methods:
We identified 489 patients who underwent surgical management of IE between January 1 2010 and December 31 2020 at any of 43 Veterans Affairs (VA) cardiac surgery centers in the US. Patients were stratified based on who underwent concomitant CABG at the time of operation. Primary outcomes included the occurrence of postoperative myocardial infarction (MI), stroke, or mortality. Continuous variables were compared using independent t-tests or Mann Whitney U tests, and categorical variables were compared using the Chi square test. Cox proportional-hazard models were used to calculate risk for primary outcomes based on group.
Results:
61 patients (12.5%) underwent concomitant CABG for CAD. After adjusting for significant covariates, patients who underwent CABG had a higher long-term risk of MI (adjusted hazard ratios (aHR) 2.37, 95% CI: 1.29-4.35, p = 0.005) and higher risk of MI at 30-days (aHR 2.34, 95% CI: 1.06-5.19, p = 0.035). Concomitant CABG was not associated with long-term stroke or death, 30-day stroke or death, or perioperative complications. On sub-analysis of patients with moderate to severe CAD, rates of MI were higher in the CABG group at 30 days (25.9 vs. 3.4%, p = 0.016) and 1 year (33.3 vs. 3.4%, p = 0.004), though not long-term. The mean number of grafts was 1.51 ± 0.76, with only one graft performed in 65.6% (40/61) of patients.
Conclusions:
Concomitant CABG at the time of operation for IE was associated with increased risk of MI at 30-day and long-term, though most CABGs involved a low number of grafts. It was not associated with 30-day stroke or death, long term stroke or death, or perioperative complications. The optimal treatment of CAD noted during preoperative evaluation for veterans undergoing surgery for IE remains unclear.
