Key result
Higher ASA-PS, NYHA class, and inotrope use linked to ~13% in-hospital cardiac surgery mortality.
Why the study?
Predicting outcome after cardiac surgery remains difficult despite numerous existing models, and risk factors from all three perioperative phases (pre-, intra-, and post-operative) should ideally be identified to predict mortality, morbidity, and length of stay.
Do pre-, intra-, and post-operative risk factors and severity scoring systems predict in-hospital mortality and length of stay in adults undergoing elective open cardiac surgery under cardiopulmonary bypass?
Cohort (n=88)
No
Do pre-, intra-, and post-operative risk factors and severity scoring systems predict in-hospital mortality and length of stay in adults undergoing elective open cardiac surgery under cardiopulmonary bypass?
Simple preoperative cardiac risk indices (ASA-PS, CARE, NYHA), prolonged cardiopulmonary bypass, and perioperative inotrope requirements predict mortality after open heart surgery, whereas general ICU scores like APACHE II are hindered by postoperative sedation and add no extra prognostic value.
Answers are grounded in this paper and cite their sources.
Perioperative risk associations support preoperative stratification in cardiac surgery; confirms prior models but leaves open need for prospective validation before practice change.
BACKGROUND: Prediction of outcome after cardiac surgery is difficult despite a number of models using pre-, intra- and post-operative factors. Ideally, risk factors operating in all three phases of the patients' stay in the hospital should be incorporated into any outcome prediction model. The aim of the present study was to identify the perioperative risk factors associated with morbidity, mortality and length of stay in the recovery room (LOSR) and length of stay in the hospital (LOSH). METHODS: Eighty-eight adults of either sex, patients undergoing elective open cardiac surgery were studied prospectively. The ability of a number of pre-, intra- and post-operative factors to predict outcome in the form of mortality, immediate morbidity (LOSR) and intermediate morbidity (LOSH) was assessed. RESULTS: Factors associated with higher mortality were preoperative prothrombin index (PTI), American Society of Anesthesiology-Physical Status (ASA-PS) grade, Cardiac Anaesthesia Risk Evaluation (CARE) score and New York Heart Association (NYHA) class, intraoperative duration of cardiopulmonary bypass (DCPB), number of inotropes used while coming off cardiopulmonary bypass and postoperatively, Acute Physiology and Chronic Health Evaluation (APACHE) II excluding the Glassgow Comma Scale (GCS) component and the number of inotropes used. Immediate morbidity was associated with preoperative PTI, inotrope usage intra- and post-operatively and the APACHE score. Intermediate morbidity was associated with DCPB and intra- and post-operative inotrope usage. Individual surgeon influenced the LOSR and the LOSH. CONCLUSION: APACHE score, a general purpose severity of illness score, was relatively ineffective in the postoperative period because of sedation, neuromuscular blockade and elective ventilation used in a number of these patients. The preoperative and intraoperative factors like CARE, ASA-PS grade, NYHA, DCPB and number of inotropes used influencing morbidity and mortality are consistent with the literature, despite the small size of our sample.
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Solanki et al. (2012) conducted a cohort in Elective open cardiac surgery (CABG, valve replacement, congenital heart disease correction) under cardiopulmonary bypass (n=88). Perioperative risk factors (preoperative PTI, ASA-PS grade, CARE score, NYHA class, intraoperative DCPB, intra/postoperative inotrope usage, and postoperative APACHE II-GCS score) vs. Survivors vs nonsurvivors (and lower vs higher risk scores) was evaluated on In-hospital postoperative mortality (95% CI 5.6-19.4). Perioperative factors including higher ASA-PS (p=0.00027), NYHA class (p=0.00023), CARE score (p=0.032), and inotrope use were associated with 12.5% in-hospital mortality after cardiac surgery.
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