Original Article
Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(3) 276–281 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314545620 aan.sagepub.com
Maryam Rahim Sheikh, Muhammad Shahjahan Khan, Zeb Saeed, Shumaila Furnaz and Hasanat Sharif
Abstract Background: Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease. Methods: Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed. Results: Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (52 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively. Conclusion: Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.
Keywords Coronary artery bypass, coronary disease, diabetes mellitus, hypertension, Pakistan, treatment outcome
Introduction Coronary artery stenosis represents an increasingly worrisome disease burden on society, with stenosis of the left main coronary artery (LMCA) and multivessel disease being the most significant threats. Angiographically significant LMCA lesions (stenosis >50%) are seen in approximately 4% of the population referred for diagnostic evaluation of chest pain.1 Such lesions compromise approximately two-thirds of the myocardial and left ventricular blood supply, giving left main stenosis critical prognostic importance.2 This is further complicated by the fact that more than 80% of individuals with LMCA disease have significant stenosis (>50%) in other epicardial coronary arteries. Additionally, there is a high incidence of bifurcation
stenosis which favors restenosis.3 Globally, 25%–30% of patients who undergo coronary artery bypass grafting (CABG) or a percutaneous coronary intervention (PCI) have both multivessel coronary artery disease (CAD) as well as diabetes mellitus (DM).4 Given the much higher prevalence DM in our region, it is becoming increasingly important to determine the best region-specific treatment.5 European and USA studies
Department of Cardiothoracic Surgery, Aga Khan University, Karachi, Pakistan Corresponding author: Hasanat Sharif, Department of Cardiothoracic Surgery, Aga Khan University, Stadium Road, Karachi, Pakistan. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF CONNECTICUT on May 21, 2015
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conducted in the 1970s and 1980s reported very high mortality rates in cases of unprotected LMCA disease.6–11 CABG has been the mainstay of management of left main stenosis and multivessel disease since the 1960s. Currently, the American and European guidelines assign CABG as a class 1 A indication for most patients with 1 -, 2 - or 3-vessel disease with any SYNTAX score.12 The widespread use of drug-eluting stents has rekindled interest in percutaneous techniques for LMCA and multivessel disease. The SYNTAX trial examined 1800 patients with CAD over a 5-year period, and concluded that CABG delivers better outcomes than PCI for intermediate- and high-risk patients.13 The FREEDOM trial, a multicenter open-label prospective randomized superiority trial of PCI versus CABG on 1900 diabetic patients in whom revascularization was indicated, concluded that CABG significantly reduced the risk of postoperative adverse outcomes compared to PCI in the diabetic population.14 Advocates of PCI consider it to be less invasive than CABG and thus safer in the periprocedural period. However, when postoperative morbidity and mortality rates for CABG are low, it seems reasonable to opt for bypass surgery in a high-risk patient group. In this study, we analyzed the early morbidity and mortality after CABG for LMCA and multivessel disease in a tertiary-care hospital. These institutional results are essential for the evaluation of CABG as a modality for the treatment of CAD in this region, and to compare our results with international data.
Patients and methods An observational retrospective study was carried out on patients who underwent CABG in the Aga Khan University Hospital from July 2006 to July 2013. Data collection was started after receiving approval from the institutional ethical review committee. Patients were identified by their medical record numbers. Data were collected on a preformed questionnaire from files and computer records by 2 individuals, and cross-checked to ensure consistency. Additional information with regards to follow-up conducted elsewhere and recurrence of symptoms was sought by getting in touch with the patients by telephone. Patients undergoing redo surgery or having undergone another intervention, any concomitant surgery on the heart valves or other vessels, or any other major general surgery, and any patient with incomplete data at the end of the review were excluded from the study. The surgeries were carried out by 5 different surgeons in the Aga Khan University Hospital. To ensure consistency of data, a comprehensive questionnaire was constructed and divided into 5 sections. The first section consisted of patient demographics, the 2nd
section focused on the preoperative characteristics, the 3rd section was intraoperative data, the 4th section was data regarding postoperative characteristics, and the last section was follow-up data including mortality, recurrence of symptoms, and need for revascularization. Early mortality was defined as death during the hospital stay or within 30 days after surgery. Follow-up was carried out for 1 year, with mortality outcomes noted. Multivessel disease was defined as significant stenosis (>50%) in the 3 main vessels and/or their branches. Data were entered and analyzed using SPSS version 20.0 software (SPSS, Inc., Chicago, IL, USA). Data were evaluated for mean with standard deviation and frequencies with percentages. Student’s t test was used to evaluate means and compare continuous variables, and the Pearson chi-square test was used for proportions to compare discrete variables. These tests were used to find any meaningful associations between patient demographic and clinical characteristics and adverse postoperative outcomes. A p-value
Outcome of coronary artery bypass grafting in a tertiary-care center in Pakistan
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(3) 276–281 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314545620 aan.sagepub.com
Maryam Rahim Sheikh, Muhammad Shahjahan Khan, Zeb Saeed, Shumaila Furnaz and Hasanat Sharif
Abstract Background: Coronary artery bypass grafting and percutaneous coronary intervention are revascularization options for significant coronary artery disease. While international data support the use of coronary artery bypass in high-risk groups, regional data on outcomes in these groups are rare. We conducted a retrospective study to determine the outcomes of patients undergoing coronary artery bypass for left main and multivessel disease. Methods: Two thousand eight hundred and fifty-one patients undergoing coronary artery bypass at the Aga Khan University Hospital from 2006 to 2013 were included; patients undergoing redo surgery were excluded. Demographic data, comorbidities, angiography findings, in-hospital complications, one-month and one-year follow-up were analyzed. Results: Of the 2851 patients, 568 had left main disease (group 1) and 2283 (group 2) had multivessel disease (52 vessels excluding the left main). Group 1 had significantly more chronic lung disease, cardiogenic shock, and congestive heart failure than group 2 (p < 0.001); 50.6% of patients were diabetic and 71.8% were hypertensive. Mortality was 5.1% and 2.2% during hospital stay, 6.5% and 2.6% at 30 days, and 6.7% and 2.7% at 1 year in groups 1 and 2, respectively. Conclusion: Our comparable results and international data advocate revision of the current practice of using percutaneous coronary intervention over coronary artery bypass in the developing world. Institutional results are essential to determine the outcome of coronary artery bypass in high-risk populations with a high burden of diabetes and hypertension. We noted increased complications and mortality in patients with left main rather than multivessel disease.
Keywords Coronary artery bypass, coronary disease, diabetes mellitus, hypertension, Pakistan, treatment outcome
Introduction Coronary artery stenosis represents an increasingly worrisome disease burden on society, with stenosis of the left main coronary artery (LMCA) and multivessel disease being the most significant threats. Angiographically significant LMCA lesions (stenosis >50%) are seen in approximately 4% of the population referred for diagnostic evaluation of chest pain.1 Such lesions compromise approximately two-thirds of the myocardial and left ventricular blood supply, giving left main stenosis critical prognostic importance.2 This is further complicated by the fact that more than 80% of individuals with LMCA disease have significant stenosis (>50%) in other epicardial coronary arteries. Additionally, there is a high incidence of bifurcation
stenosis which favors restenosis.3 Globally, 25%–30% of patients who undergo coronary artery bypass grafting (CABG) or a percutaneous coronary intervention (PCI) have both multivessel coronary artery disease (CAD) as well as diabetes mellitus (DM).4 Given the much higher prevalence DM in our region, it is becoming increasingly important to determine the best region-specific treatment.5 European and USA studies
Department of Cardiothoracic Surgery, Aga Khan University, Karachi, Pakistan Corresponding author: Hasanat Sharif, Department of Cardiothoracic Surgery, Aga Khan University, Stadium Road, Karachi, Pakistan. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF CONNECTICUT on May 21, 2015
Sheikh et al.
277
conducted in the 1970s and 1980s reported very high mortality rates in cases of unprotected LMCA disease.6–11 CABG has been the mainstay of management of left main stenosis and multivessel disease since the 1960s. Currently, the American and European guidelines assign CABG as a class 1 A indication for most patients with 1 -, 2 - or 3-vessel disease with any SYNTAX score.12 The widespread use of drug-eluting stents has rekindled interest in percutaneous techniques for LMCA and multivessel disease. The SYNTAX trial examined 1800 patients with CAD over a 5-year period, and concluded that CABG delivers better outcomes than PCI for intermediate- and high-risk patients.13 The FREEDOM trial, a multicenter open-label prospective randomized superiority trial of PCI versus CABG on 1900 diabetic patients in whom revascularization was indicated, concluded that CABG significantly reduced the risk of postoperative adverse outcomes compared to PCI in the diabetic population.14 Advocates of PCI consider it to be less invasive than CABG and thus safer in the periprocedural period. However, when postoperative morbidity and mortality rates for CABG are low, it seems reasonable to opt for bypass surgery in a high-risk patient group. In this study, we analyzed the early morbidity and mortality after CABG for LMCA and multivessel disease in a tertiary-care hospital. These institutional results are essential for the evaluation of CABG as a modality for the treatment of CAD in this region, and to compare our results with international data.
Patients and methods An observational retrospective study was carried out on patients who underwent CABG in the Aga Khan University Hospital from July 2006 to July 2013. Data collection was started after receiving approval from the institutional ethical review committee. Patients were identified by their medical record numbers. Data were collected on a preformed questionnaire from files and computer records by 2 individuals, and cross-checked to ensure consistency. Additional information with regards to follow-up conducted elsewhere and recurrence of symptoms was sought by getting in touch with the patients by telephone. Patients undergoing redo surgery or having undergone another intervention, any concomitant surgery on the heart valves or other vessels, or any other major general surgery, and any patient with incomplete data at the end of the review were excluded from the study. The surgeries were carried out by 5 different surgeons in the Aga Khan University Hospital. To ensure consistency of data, a comprehensive questionnaire was constructed and divided into 5 sections. The first section consisted of patient demographics, the 2nd
section focused on the preoperative characteristics, the 3rd section was intraoperative data, the 4th section was data regarding postoperative characteristics, and the last section was follow-up data including mortality, recurrence of symptoms, and need for revascularization. Early mortality was defined as death during the hospital stay or within 30 days after surgery. Follow-up was carried out for 1 year, with mortality outcomes noted. Multivessel disease was defined as significant stenosis (>50%) in the 3 main vessels and/or their branches. Data were entered and analyzed using SPSS version 20.0 software (SPSS, Inc., Chicago, IL, USA). Data were evaluated for mean with standard deviation and frequencies with percentages. Student’s t test was used to evaluate means and compare continuous variables, and the Pearson chi-square test was used for proportions to compare discrete variables. These tests were used to find any meaningful associations between patient demographic and clinical characteristics and adverse postoperative outcomes. A p-value
