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Protocol-Driven Perioperative Management of Ischemic Cardiomyopathy in a Community Hospital Setting
Katherine Slusarz1,2, Brock Daughtry3, Jeremy London2
1Department of Cardiothoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
Insights
A defined protocol for ischemic cardiomyopathy (ICM) patients undergoing coronary artery bypass grafting (CABG) in a community hospital setting reduced morbidity and mortality compared to predictions. This practical approach improves outcomes for high-risk patients.
Area of Science:
- Cardiology
- Cardiac Surgery
Background:
- Ischemic cardiomyopathy (ICM) poses challenges for coronary artery bypass grafting (CABG).
- Community hospitals face resource limitations in managing complex cardiac cases.
Purpose of the Study:
- To evaluate a defined protocol for selecting, classifying, and treating ICM patients undergoing CABG in a nonacademic setting.
- To assess the protocol's impact on morbidity and mortality in a resource-limited environment.
Main Methods:
- A treatment algorithm was applied to 25 ICM patients (ejection fraction ≤0.44) requiring CABG.
- Patients were classified preoperatively for CABG with no device, balloon pump, or direct centrifugal pump support.
- Data collected from December 2021 to December 2023.
Main Results:
- The protocol resulted in a 4% mortality rate versus a predicted 8.455% risk.
- 30-day morbidity and mortality were 24%, lower than the predicted 27.7%.
- Subgroup analysis showed better-than-expected outcomes across different risk categories.
Conclusions:
- A defined protocol effectively manages high-risk ICM patients undergoing CABG in community hospitals.
- The protocol demonstrated reduced morbidity and mortality compared to predictions.
- This approach offers a practical solution for resource-limited settings.
Background:
We describe our experience using a defined protocol for the selection, classification, and treatment of patients with ischemic cardiomyopathy (ICM) undergoing coronary artery bypass grafting (CABG), with or without additional procedures, in a nonacademic setting with expected limited resources and support staff.
Methods:
From December 2021 to December 2023, 25 patients with an ejection fraction of ≤0.44 due to ICM requiring CABG were assigned to a treatment algorithm based on the preoperative classification for CABG with no device (n = 9), balloon pump (n = 2), or direct centrifugal pump (n = 14) placed in the operating room.
Results:
Preliminary data of all patients with surgically revascularized ICM using the defined protocol demonstrated a predicted average risk of mortality of 8.455% vs our mortality rate of 4%, whereas the average predicted risk of morbidity and mortality was 27.7%, with our 30-day morbidity and mortality of 24%. Subgroup analysis of the 3 patient categories: moderately depressed, low risk; moderately depressed, high risk; and severely depressed; shows better-than-expected outcomes when compared with predictions.
Conclusions:
In a community hospital setting, experience using a defined protocol to select and manage patients with ICM undergoing CABG reduced morbidity and mortality compared with predicted outcomes. This is a practical method of managing high-risk CABG patients with the expected limitations of a community hospital.
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