This article is more than 5 years old. Information may no longer be current.
Specialized approach confers better outcomes in CABG
Click Here to Manage Email Alerts
Patients operated on by surgeons who subspecialize in CABG and are part of dedicated coronary surgery programs appear to have faster operations, fewer complications and longer survival, according to findings published in the Annals of Thoracic Surgery.
The researchers compared isolated CABG procedures between 2002 and 2013 with those performed between 2013 and 2016 to assess the effect of a subspecialized coronary surgery program on morbidity and mortality. The program was implemented at the University of Maryland Medical Center in 2013.
Specialized approach
The program included the appointment of a clinical director to review all referrals for CABG and mentor junior CABG surgeons, standardization of surgical techniques, standardization of pre- and postoperative care through dedicated nurse practitioners and trainees and intensification of quality review.
“When there are subspecialization models, the outcomes are better for aortic surgery or mitral valve surgery, but that approach is not always taken for coronary artery bypass grafting,” Bradley S. Taylor, MD, MPH, associate professor of surgery and director of coronary revascularization at the University of Maryland Medical Center, told Cardiology Today. “We felt that the more you take care of a specific problem, the better you would get at it.”
In the period before the program was adopted (general era), 3,256 CABG procedures (mean age, 64 years; 70% men) were performed by 16 surgeons, with no one doing more than 33%, whereas in the period after the program was adopted (specialized era), 1,283 procedures (mean age, 64 years; 74% men) were performed by 10 surgeons, with the clinical director performing 70% of them (P < .0001), Taylor and colleagues wrote.
Compared with the general era, procedures in the specialized era had shorter bypass (89 minutes vs. 105 minutes; P < .001) and clamp times (60 minutes vs. 70 minutes; P < .001), more use of bilateral internal mammary arteries (15% vs. 11%; P < .002), less need for blood transfusions (2.1 U vs. 2.7 U; P < .001) and lower rates of complications, according to the researchers.
Operative mortality dropped from 2.67% in the general era to 1.48% in the specialized era (P = .02), Taylor and colleagues found. Taylor said after the study period, the mortality rate dropped to less than 1%.
Collaboration key
“The findings show that collaboration among surgeons and supporting one another results in better outcomes for patients,” Taylor told Cardiology Today. “This includes evaluating patients thoroughly before you operate on them. The rush to operate is often what guides people, but medically optimizing patients, including getting them out of heart and renal failure, while taking the time to allow problems to alleviate themselves before surgery is the best strategy. We also stopped taking patients who were in cardiogenic shock to the operating room. We adopted the use of ECMO [extracorporeal membrane oxygenation] and allowed patients a recovery time for their heart muscle and end organs to recover before we performed their bypass operation.”
A key part of the program, he said, is “working very closely with our cardiologists to choose how we evaluate patients preoperatively and postoperatively to the benefit of our patients.” – by Erik Swain
For more information:
Bradley S. Taylor, MD, MPH, can be reached at 119 S. Paca St., 7th Floor, Baltimore, MD 21201; email: bradley.taylor@som.umaryland.edu.
Disclosures: The authors report no relevant financial disclosures.
Click Here to Manage Email Alerts