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Circ Cardiovasc Qual Outcomes. 2012 Sep 1;5(5):638-44. Epub 2012 Jul 24.

Variability in surgeons' perioperative practices may influence the incidence of low-output failure after coronary artery bypass grafting surgery.

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  • 1Departments of Medicine, Surgery, and Community and Family Medicine, and The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. likosky@umich.edu

Abstract

BACKGROUND:

Postoperative low-output failure (LOF) is an important contributor to morbidity and mortality after coronary artery bypass grafting surgery. We sought to understand which pre- and intra-operative factors contribute to postoperative LOF and to what degree the surgeon may influence rates of LOF.

METHODS AND RESULTS:

We identified 11 838 patients undergoing nonemergent, isolated coronary artery bypass grafting surgery using cardiopulmonary bypass by 32 surgeons at 8 centers in northern New England from 2001 to 2009. Our cohort included patients with preoperative ejection fractions >40%. Patients with preoperative intraaortic balloon pumps were excluded. LOF was defined as the need for ≥2 inotropes at 48 hours, an intra- or post-operative intraaortic balloon pumps, or return to cardiopulmonary bypass (for hemodynamic reasons). Case volume varied across the 32 surgeons (limits, 80-766; median, 344). The overall rate of LOF was 4.3% (return to cardiopulmonary bypass, 2.6%; intraaortic balloon pumps, 1.0%; inotrope usage, 0.8%; combination, 1.0%). The predicted risk of LOF did not differ across surgeons, P=0.79, and the observed rates varied from 1.1% to 10.2%, P<0.001. Patients operated by low-rate surgeons had shorter clamp and bypass times, antegrade cardioplegia, longer maximum intervals between cardioplegia doses, lower cardioplegia volume per anastomosis or minute of ischemic time, and less hot-shot use. Patients operated on by higher LOF surgeons had higher rates of postoperative acute kidney injury.

CONCLUSIONS:

Rates of LOF significantly varied across surgeons and could not be explained solely by patient case mix, suggesting that variability in perioperative practices influences risk of LOF.

PMID:
22828825
DOI:
10.1161/CIRCOUTCOMES.112.967091
[PubMed - indexed for MEDLINE]
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