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Clinical and angiographic predictors of operative mortality from the collaborative study in coronary artery surgery
Insights
Coronary artery bypass surgery has a 2.3% operative mortality, with higher risks for women, older patients, and those with severe left main coronary artery stenosis or heart failure. Patient selection is crucial for improving outcomes in coronary artery disease treatment.
Area of Science:
- Cardiovascular Surgery
- Clinical Outcomes Research
- Epidemiology of Cardiovascular Disease
Background:
- Coronary artery bypass grafting (CABG) is a common surgical intervention for coronary artery disease (CAD).
- Understanding operative mortality (OM) and its associated risk factors is essential for patient management and surgical decision-making.
- The Collaborative Study in Coronary Artery Surgery (CASS) provides a large dataset for analyzing CABG outcomes.
Purpose of the Study:
- To analyze the operative mortality (OM) associated with isolated coronary artery bypass surgery.
- To identify patient-specific and disease-specific factors influencing OM in a large cohort.
- To inform patient selection criteria for coronary artery surgery.
Main Methods:
- Analysis of data from 6630 patients undergoing isolated CABG across 15 institutions in the CASS registry.
- Stratification of operative mortality by age, sex, disease severity (number of diseased vessels, left main coronary artery stenosis), left ventricular function (ejection fraction, wall motion score), and surgical urgency.
- Statistical analysis to determine the association between various factors and operative mortality.
Main Results:
- Overall operative mortality was 2.3%, with significant increases in mortality associated with advanced age, female sex, congestive heart failure symptoms, left main coronary artery (LMCA) stenosis (especially severe stenosis with left dominance), impaired left ventricular function, and nonelective surgery.
- Mortality ranged from 0% in the 20-29 age group to 7.9% in the 70+ age group.
- For LMCA stenosis, OM varied from 1.6% to 25% based on severity and dominance. Emergency revascularization for severe LMCA stenosis had a 40% mortality rate.
- Women consistently experienced higher OM than men across age groups.
Conclusions:
- Advanced age, female sex, heart failure symptoms, LMCA stenosis, reduced left ventricular function, and nonelective surgical status are significant predictors of increased operative mortality after CABG.
- These identified risk factors are critical considerations for optimizing patient selection and improving outcomes in coronary artery bypass surgery.
- The findings underscore the importance of individualized risk assessment in the surgical management of coronary artery disease.
Abstract:
Fifteen institutions participating in the Collaborative Study in Coronary Artery Surgery (CASS) have performed isolated coronary artery bypass surgery upon 6630 patients (1061 women and 5569 men) for coronary artery disease. The overall operative mortality (OM) was 2.3% (range 0.3-6.4%). Mortality increased with age, from 0 in the group 20-29 years old to 7.9% in the group 70 years and older. OM was higher for women in each group, ranging from 2.8% for ages 30-39 years to 12.3% for age 70 years and older (0.8% and 5.8% for men). Clinical manifestations of congestive heart failure were associated with increased OM. Mortality was 1.4% in one-vessel, 2.1% in two-vessel and 2.8% in three-vessel disease (diameter narrowing greater than or equal to 70%). Among 1019 patients with left main coronary artery (LMCA) stenosis, OM ranged from 1.6% in patients with mild stenosis and a right-dominant system to 25% in patients with severe (greater than or equal to 90%) stenosis and left dominance. OM varied with ejection fraction (EF) (1.9% for EF greater than or equal to 50% to 6.7% for EF less than 19%) and left ventricular wall motion score (1.7% for least abnormal to 9.1% for most abnormal). For elective surgery, OM was 1.7%, for urgent surgery 3.5%, and for emergency surgery 10.8%. Mortality was 40.0% among 30 patients with severe LMCA stenosis who underwent emergency revascularization. Advanced age, female sex, symptoms of heart failure, LMCA stenosis, impaired left ventricular function and nonelective surgery are associated with a higher OM. These factors should be considered in the selection of patients for coronary artery surgery.