09. tbl. 98. árg. 2012

Outcome of myocardial revascularisation in Iceland

Árangur kransæðahjáveituaðgerða á Íslandi 2002-2006

Introduction: In Iceland over 3500 coronary artery bypass operations have been performed, both On-Pump, using cardiopulmonary bypass  and Off-Pump, surgery on a beating heart. The aim was to study their outcome.

Material and methods: This was a retrospective study on 720 consecutive patients who underwent surgical revascularisation at Landspítali – The National University Hospital of Iceland between 2002-2006; 513 On-Pump and 207 Off-Pump patients. Complications and operative mortality (<30 days) were compared between the groups and predictors of survival identified using multivariate analysis.

Results: The number of males was significantly higher  in the On-Pump group, but other risk factors of coronary artery disease, including age and high body mass index, were comparable, as were the number of distal anastomoses and EuroSCORE. The Off-Pump procedure took 25 minutes longer on average and chest tube output was significantly increased, but  the amount of transfusions administered was similar. The rate of minor complications was higher in the On-Pump group. Of the major complications, stroke rates were similar in both groups (2%) but the rate of reoperation for bleeding was higher in the On-Pump group. Mean length of hospital stay was one day longer for On-Pump patients but operative mortality was similar for both groups (4% vs. 3%, p=0.68) as was 5 year survival (92% in both groups). In multivariate analysis both EuroSCORE and age predicted outcome of operative mortality and long term survival but type of surgery (On-Pump vs. Off-Pump) was not a predictive variant.

Conclusions: Outcome of myocardial revascularisation in Iceland is good as regards  operative mortality and long term survival. This applies to both conventional On-Pump and Off-Pump procedures.


Sigurjonsson H1,2, Helgadottir S1, Oddsson S1, Sigurdsson M1,2, Geirsson A1, Arnorsson Th1, Gudbjartsson T1,2

1Department of Cardiothoracic Surgery, Landspítali – The National University Hospital of Iceland, 2Faculty of Medicine, University of Iceland, Reykjavík, Iceland



 

Table I. Number of coronary artery revascularization procedures in Iceland 2002-2006 and ratio of Off-Pump procedures. For comparison the number of coronary angiographies in Iceland and the number of percutaneous coronary intervention (PCI) procedures during the same period is shown. Number of (%).

Year 2002 2003 2004 2005 2006 Total
Coronary angiography 1493 1630 1497 1674 1526 7820
-          Balloon angioplasty 568 (38%) 624 (38%) 556 (37%) 636 (38%) 610 (40%) 2994 (38%)
-          Stent 474 (32%) 531 (33%) 468 (31%) 570 (34%) 533 (35%) 2576 (33%)
Coronary artery bypass 153 139 133 156 139 720
-          On-Pump 117 (76%) 103 (74%) 85 (64%) 107 (69%) 101 (73%) 513 (71%)
-          Off-Pump 36 (24%) 36 (26%) 48 (36%) 49 (31%) 38 (27%) 207 (29%)

            PCI: Percutaneous coronary intervention


 

Table II. Patient demographics for OPCAB and CABG patients that underwent coronary artery bypass grafting at Landspitali University Hospital between 2002 and 2006. Number (%) if not otherwise stated.

Variable

All patients

n = 720

Off-Pump

n = 207, %

On-Pump

n = 513, %

p-value
Age, mean, years . ± stdv. 66.4 66.4±9.2 66.4±9.3 0.95
Male sex, 591 (82) 160 (77) 431 (84) 0.04
Risk factors for coronary artery disease        
   Hypertension 443 (60) 130 (61) 313 (63) 0.73
   Diabetes 109 (15) 29 (14) 80 (16) 0.67
   Dyslipidemia 421 (58) 120 (58) 301 (58) 0.93
   Smoker, current 174 (24) 45 (22) 129 (25) 0.37
   Body mass index (kg/m2 ) 28,0 28.2 ± 4.2 27.9 ± 4.1 0.37
Preoperative medication(< 5 days from surgery)        
    ASA 513 (71) 150 (72) 363 (71) 0.71
    Cholesterol lowering statins 529 (73) 148 (71) 381 (74) 0.50
    Betablockers 482 (67) 141 (68) 341 (66) 0.74
Coronary artery disease 3-vessel 628 (87) 176 (85) 452 (88) 0.32
Left main stenosis 152 (21) 44 (21) 108 (21) 0.97
Left ventricular ejection fraction <35% 59 (8) 17 (8) 42 (8) 0.89
Chronic obstructive pulmonary disease 55 (8) 14 (7) 41 (8) 0.70
NYHA class III and IV 499 (69) 160 (77) 339 (66) 0.004
EuroSCORE standard 4.9 5.2±3.5 4.8±3.2 0.23

NYHA = New York Heart Association, ASA = Acetylsalicylacid.

 

 

Table III. Operation characteristics, length of stay and mortality for OPCAB and CABG patients in Iceland between 2002 and 2006.  

Variable

All patients

n = 720

Off-Pump

n = 207, %

On-Pump

n = 513, %

p-value
Acute operation, n (%) 25 (4) 10 (5) 15 (2) 0.30
Operation time*, min. ± stdv. (range) 204 

223 ± 59

(85-460)

197 ± 47

(90-555)

<0.001
Number of distal anastomoses, ± stdv. (range) 3.4 3.5 ± 0.9 (1-6) 3.3 ± 0.8 (1-5) 0.06
Postoperative bleeding <24hours, ml± stdv.,(range) 1037

1230 ± 740

(230-5620)

960 ± 1530

(100-31820)

<0.001
RBC transfusions, units ± stdv., (range) 2.5

2.4 ± 3.7

(0-31)

2.5 ± 5.5

(0-88)

0.84
Reoperation for bleeding, % 42 (5,8) 9 (4,3) 33 (6,4) 0.02
Intensive care unit stay – days, ±stdv. 2.0 1.9 ± 2.7 2.1 ± 3.7 0.47
Length of hospital stay – days, ±stdv. 12.1 11.3 ± 4.9 12.5 ± 6.9 0.04
Operative mortality (< 30 days) , n (%) 23 (3.2) 8 (3.9) 15 (2.9) 0.68

*skin-to-skin time, PRC = packed red cells



 

Table IV.  Comparison of minor and major complications in patients undergoing Off-Pump or On-Pump coronary revascularization at Landspitali University Hospital between 2002 and 2006.

Variable

All patients

n = 720, %

Off-Pump

n = 207, %

On-Pump

n = 513, %

p-value
Major complications 118  16) 33 (16) 85(17) 0.44
   Stroke 16 (2) 5 (2) 11 (2) 0.79
   Deep sternal wound infection 6 (0.8) 1 (0.5) 5 (1.0) 0.84
   Renal injury requiring dialysis 12 (2) 3 (1) 9 (2) 0.97
   Perioperative myocardial infarction 95 (13) 23 (11) 72 (14) 0.35
   Multi organ failure 23 (3) 5 (2) 18 (4) 0.60
   Sternal insufficience 19 (3) 3 (1) 16 (3) 0.31
Minor complications 391 (54) 100 (48) 291 (58) 0.05
   Atrial fibrillation/flutter 294 (41) 80 (39) 214 (42) 0.50
   Superficial wound infection 65 (9) 16 (9) 49 (10) 0.53
   Pneumonia 45 (6) 10 (5) 35 (7) 0.41
   Urinary tract infection 27 (4) 12 (6) 15 (3) 0.11

 

 


Fig. 1. Flow chart of patients included in the study.

 

Fig. 2a and b. Cox survival graphs. Total- (a) and disease specific survival (b) of patients undergoing coronary artery bypass in Iceland, CABG and OPCAB patients combined, but survival for these groups was comparable. (95% confidence interval shown).

 

 

 

 

 

 

 

 

 

 

 

Sigurjonsson_CardSurv_Eng

b)

 

 









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