Risk factors and perioperative outcomes of prolonged mechanical ventilation after coronary artery bypass grafting in elderly patients_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG Wuwei ^1,2 , ZHANG Hang ³ , CHEN Wen ² , LI Liangpeng ² ,  CHEN Xin ^1,2

1. School of Medicine, Southeast University, Nanjing, 210009, P. R. China;
2. Department of Cardiovascular Surgery, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing First Hospital, Nanjing Cardiovascular Hospital, Nanjing, 210006, P. R. China;
3. Department of Thoracic Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 201620, P. R. China;

Corresponding author：

CHEN Xin, Email: stevecx@njmu.edu.cn

Keywords：

Elderly patients; coronary artery bypass grafting; mechanical ventilation; extubation; risk factors

DOI：

10.7507/1007-4848.202110001

Video：

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Objective To investigate the clinical characteristics, risk factors and perioperative outcome of prolonged mechanical ventilation (PMV) in elderly patients undergoing coronary artery bypass grafting (CABG). Methods The data of elderly patients receiving CABG in the Nanjing First Hospital from January 2013 to June 2019 were collected. All patients were divided into a control group and a PMV group according to whether ventilation time≥24 h.The clinical characteristics and risk factors of PMV were compared between the two groups. Variables were 1∶1 balanced through propensity score matching (PSM) and perioperative outcomes of two groups was analyzed. Results Finally 956 patients were collected, including 187 in the PMV group and 769 in the control group. There were 586 males and 370 females aged 70-94 (74.3±3.5) years. Compared with the control group, the PMV group had higher rates of smoking, preoperative renal impairment, intraoperative blood transfusion and intra-aortic balloon pump (IABP) implantation, worse cardiac function, lower glomerular filtration rate and ejection fraction, larger left atrial diameter, longer cardiopulmonary bypass time and aortic cross-clamping time (P<0.05). There was no statistical difference in other clinical data between the two groups (P>0.05). Binary multivariate logistic regression analysis showed that females, smoking, chronic obstructive pulmonary disease, left ventricular ejection fraction≤56.0%, cardiopulmonary bypass time>106.0 min, IABP implantation and intraoperative blood transfusion were independent risk factors for PMV in elderly patients. After PSM, there were 146 patients in the control group and the PMV group, respectively. The PMV group had longer ICU stay and length of hospital stay and more drainage volume compared with the control group (all P<0.05). There was no statistical difference in perioperative mortality or other complications between the two groups (all P>0.05). Conclusion There are a lot of factors associated with PMV of the elderly patients undergoing on-pump CABG. In order to establish a complete and formal PMV prediction model, clinicians can make a further step of assessment according to perioperative elements, and improve the prognosis of such patients.

Citation： WANG Wuwei, ZHANG Hang, CHEN Wen, LI Liangpeng, CHEN Xin. Risk factors and perioperative outcomes of prolonged mechanical ventilation after coronary artery bypass grafting in elderly patients. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(7): 995-1001. doi: 10.7507/1007-4848.202110001 Copy

1.	Wise ES, Stonko DP, Glaser ZA, et al. Prediction of prolonged ventilation after coronary artery bypass grafting: Data from an artificial neural network. Heart Surg Forum, 2017, 20(1): E007-E014.
2.	Légaré JF, Hirsch GM, Buth KJ, et al. Preoperative prediction of prolonged mechanical ventilation following coronary artery bypass grafting. Eur J Cardiothorac Surg, 2001, 20(5): 930-936.
3.	Mendes RG, de Souza CR, Machado MN, et al. Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: A comparison between artificial neural networks and logistic regression models. Arch Med Sci, 2015, 11(4): 756-763.
4.	Hefner JL, Tripathi RS, Abel EE, et al. Quality improvement intervention to decrease prolonged mechanical ventilation after coronary artery bypass surgery. Am J Crit Care, 2016, 25(5): 423-430.
5.	Shahian DM, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: Part 1-background, design considerations, and model development. Ann Thorac Surg, 2018, 105(5): 1411-1418.
6.	Mangukia C, Kachhadia M, Meswani M. Fast-track off-pump coronary artery bypass: Single-center experience. Asian Cardiovasc Thorac Ann, 2019, 27(4): 256-264.
7.	van Mastrigt GA, Maessen JG, Heijmans J, et al. Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials. Crit Care Med, 2006, 34(6): 1624-1634.
8.	Medalion B, Mohr R, Ben-Gal Y, et al. Arterial coronary artery bypass grafting is safe and effective in elderly patients. J Thorac Cardiovasc Surg, 2015, 150(3): 607-612.
9.	Marangoni E, Alvisi V, Ragazzi R, et al. Respiratory mechanics at different PEEP level during general anesthesia in the elderly: A pilot study. Minerva Anestesiol, 2012, 78(11): 1205-1214.
10.	Gumus F, Polat A, Yektas A, et al. Prolonged mechanical ventilation after CABG: Risk factor analysis. J Cardiothorac Vasc Anesth, 2015, 29(1): 52-58.
11.	Saleh HZ, Shaw M, Al-Rawi O, et al. Outcomes and predictors of prolonged ventilation in patients undergoing elective coronary surgery. Interact Cardiovasc Thorac Surg, 2012, 15(1): 51-56.
12.	Hsu H, Lai HC, Liu TJ. Factors causing prolonged mechanical ventilation and peri-operative morbidity after robot-assisted coronary artery bypass graft surgery. Heart Vessels, 2019, 34(1): 44-51.
13.	Rodriguez Blanco YF, Candiotti K, Gologorsky A, et al. Factors which predict safe extubation in the operating room following cardiac surgery. J Card Surg, 2012, 27(3): 275-280.
14.	Akhtar MI, Sharif H, Hamid M, et al. Fast track extubation in adult patients on pump open heart surgery at a tertiary care hospital. J Ayub Med Coll Abbottabad, 2016, 28(4): 639-643.
15.	Guller U, Anstrom KJ, Holman WL, et al. Outcomes of early extubation after bypass surgery in the elderly. Ann Thorac Surg, 2004, 77(3): 781-788.
16.	Figueiredo Neto JA, Barroso LC, Nunes JK, et al. Sex differences in mortality after CABG surgery. Braz J Cardiovasc Surg, Nov-Dec 2015, 30(6): 610-614.
17.	Jabagi H, Tran DT, Hessian R, et al. Impact of gender on arterial revascularization strategies for coronary artery bypass grafting. Ann Thorac Surg, 2018, 105(1): 62-68.
18.	Swaminathan RV, Feldman DN, Pashun RA, et al. Gender differences in in-hospital outcomes after coronary artery bypass grafting. Am J Cardiol, 2016, 118(3): 362-368.
19.	Guru V, Fremes SE, Austin PC, et al. Gender differences in outcomes after hospital discharge from coronary artery bypass grafting. Circulation, 2006, 113(4): 507-516.
20.	Jones R, Nyawo B, Jamieson S, et al. Current smoking predicts increased operative mortality and morbidity after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg, 2011, 12(3): 449-453.
21.	Sepehripour AH, Lo TT, McCormack DJ, et al. Is there benefit in smoking cessation prior to cardiac surgery? Interact Cardiovasc Thorac Surg, 2012, 15(4): 726-732.
22.	Andell P, Sjögren J, Batra G, et al. Outcome of patients with chronic obstructive pulmonary disease and severe coronary artery disease who had a coronary artery bypass graft or a percutaneous coronary intervention. Eur J Cardiothorac Surg, 2017, 52(5): 930-936.
23.	Amaral Gonçalves Fusatto H, Castilho de Figueiredo L, Ragonete Dos Anjos Agostini AP, et al. Factors associated with pulmonary dysfunction in patients undergoing coronary artery bypass graft surgery with use of intra-aortic balloon pump. Rev Port Cardiol (Engl Ed), 2018, 37(1): 15-23.
24.	Wigfield CH, Lindsey JD, Muñoz A, et al. Is extreme obesity a risk factor for cardiac surgery? An analysis of patients with a BMI > or = 40. Eur J Cardiothorac Surg, 2006, 29(4): 434-440.
25.	Branca P, McGaw P, Light R. Factors associated with prolonged mechanical ventilation following coronary artery bypass surgery. Chest, 2001, 119(2): 537-546.
26.	Leme Silva P, Pelosi P, Rocco PR. Mechanical ventilation in obese patients. Minerva Anestesiol, 2012, 78(10): 1136-1145.
27.	Bartz RR, Ferreira RG, Schroder JN, et al. Prolonged pulmonary support after cardiac surgery: Incidence, risk factors and outcomes: A retrospective cohort study. J Crit Care, 2015, 30(5): 940-944.
28.	Minakata K, Bando K, Tanaka S, et al. Preoperative chronic kidney disease as a strong predictor of postoperative infection and mortality after coronary artery bypass grafting. Circ J, 2014, 78(9): 2225-2231.
29.	Ghotkar SV, Grayson AD, Fabri BM, et al. Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting. J Cardiothorac Surg, 2006, 1: 14.
30.	Zangrillo A, Pappalardo F, Dossi R, et al. Preoperative intra-aortic balloon pump to reduce mortality in coronary artery bypass graft: A meta-analysis of randomized controlled trials. Crit Care, 2015, 19(1): 10.
31.	Huffmyer JL, Groves DS. Pulmonary complications of cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol, 2015, 29(2): 163-175.
32.	Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med, 2009, 361(19): 1827-1837.
33.	Zah-Bogovic T, Mesaric J, Hrabac P, et al. Possible transfusion-related acute lung injury (TRALI) in cardiac surgery patients. Croat Med J, 2014, 55(2): 138-145.
34.	Eder AF, Herron RM, Strupp A, et al. Effective reduction of transfusion-related acute lung injury risk with male-predominant plasma strategy in the American Red Cross (2006-2008). Transfusion, 2010, 50(8): 1732-1742.
35.	Fonseca L, Vieira FN, Azzolin Kde O. Factors associated to the length of time on mechanical ventilation in the postoperative period of cardiac surgery. Rev Gaucha Enferm, 2014, 35(2): 67-72.
36.	Flegler S, Paro FM. Factors associated with intubation time and ICU stay after CABG. Braz J Cardiovasc Surg, 2015, 30(6): 631-635.
37.	Ji Q, Chi L, Mei Y, et al. Risk factors for late extubation after coronary artery bypass grafting. Heart Lung, 2010, 39(4): 275-282.

1. Wise ES, Stonko DP, Glaser ZA, et al. Prediction of prolonged ventilation after coronary artery bypass grafting: Data from an artificial neural network. Heart Surg Forum, 2017, 20(1): E007-E014.
2. Légaré JF, Hirsch GM, Buth KJ, et al. Preoperative prediction of prolonged mechanical ventilation following coronary artery bypass grafting. Eur J Cardiothorac Surg, 2001, 20(5): 930-936.
3. Mendes RG, de Souza CR, Machado MN, et al. Predicting reintubation, prolonged mechanical ventilation and death in post-coronary artery bypass graft surgery: A comparison between artificial neural networks and logistic regression models. Arch Med Sci, 2015, 11(4): 756-763.
4. Hefner JL, Tripathi RS, Abel EE, et al. Quality improvement intervention to decrease prolonged mechanical ventilation after coronary artery bypass surgery. Am J Crit Care, 2016, 25(5): 423-430.
5. Shahian DM, Jacobs JP, Badhwar V, et al. The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: Part 1-background, design considerations, and model development. Ann Thorac Surg, 2018, 105(5): 1411-1418.
6. Mangukia C, Kachhadia M, Meswani M. Fast-track off-pump coronary artery bypass: Single-center experience. Asian Cardiovasc Thorac Ann, 2019, 27(4): 256-264.
7. van Mastrigt GA, Maessen JG, Heijmans J, et al. Does fast-track treatment lead to a decrease of intensive care unit and hospital length of stay in coronary artery bypass patients? A meta-regression of randomized clinical trials. Crit Care Med, 2006, 34(6): 1624-1634.
8. Medalion B, Mohr R, Ben-Gal Y, et al. Arterial coronary artery bypass grafting is safe and effective in elderly patients. J Thorac Cardiovasc Surg, 2015, 150(3): 607-612.
9. Marangoni E, Alvisi V, Ragazzi R, et al. Respiratory mechanics at different PEEP level during general anesthesia in the elderly: A pilot study. Minerva Anestesiol, 2012, 78(11): 1205-1214.
10. Gumus F, Polat A, Yektas A, et al. Prolonged mechanical ventilation after CABG: Risk factor analysis. J Cardiothorac Vasc Anesth, 2015, 29(1): 52-58.
11. Saleh HZ, Shaw M, Al-Rawi O, et al. Outcomes and predictors of prolonged ventilation in patients undergoing elective coronary surgery. Interact Cardiovasc Thorac Surg, 2012, 15(1): 51-56.
12. Hsu H, Lai HC, Liu TJ. Factors causing prolonged mechanical ventilation and peri-operative morbidity after robot-assisted coronary artery bypass graft surgery. Heart Vessels, 2019, 34(1): 44-51.
13. Rodriguez Blanco YF, Candiotti K, Gologorsky A, et al. Factors which predict safe extubation in the operating room following cardiac surgery. J Card Surg, 2012, 27(3): 275-280.
14. Akhtar MI, Sharif H, Hamid M, et al. Fast track extubation in adult patients on pump open heart surgery at a tertiary care hospital. J Ayub Med Coll Abbottabad, 2016, 28(4): 639-643.
15. Guller U, Anstrom KJ, Holman WL, et al. Outcomes of early extubation after bypass surgery in the elderly. Ann Thorac Surg, 2004, 77(3): 781-788.
16. Figueiredo Neto JA, Barroso LC, Nunes JK, et al. Sex differences in mortality after CABG surgery. Braz J Cardiovasc Surg, Nov-Dec 2015, 30(6): 610-614.
17. Jabagi H, Tran DT, Hessian R, et al. Impact of gender on arterial revascularization strategies for coronary artery bypass grafting. Ann Thorac Surg, 2018, 105(1): 62-68.
18. Swaminathan RV, Feldman DN, Pashun RA, et al. Gender differences in in-hospital outcomes after coronary artery bypass grafting. Am J Cardiol, 2016, 118(3): 362-368.
19. Guru V, Fremes SE, Austin PC, et al. Gender differences in outcomes after hospital discharge from coronary artery bypass grafting. Circulation, 2006, 113(4): 507-516.
20. Jones R, Nyawo B, Jamieson S, et al. Current smoking predicts increased operative mortality and morbidity after cardiac surgery in the elderly. Interact Cardiovasc Thorac Surg, 2011, 12(3): 449-453.
21. Sepehripour AH, Lo TT, McCormack DJ, et al. Is there benefit in smoking cessation prior to cardiac surgery? Interact Cardiovasc Thorac Surg, 2012, 15(4): 726-732.
22. Andell P, Sjögren J, Batra G, et al. Outcome of patients with chronic obstructive pulmonary disease and severe coronary artery disease who had a coronary artery bypass graft or a percutaneous coronary intervention. Eur J Cardiothorac Surg, 2017, 52(5): 930-936.
23. Amaral Gonçalves Fusatto H, Castilho de Figueiredo L, Ragonete Dos Anjos Agostini AP, et al. Factors associated with pulmonary dysfunction in patients undergoing coronary artery bypass graft surgery with use of intra-aortic balloon pump. Rev Port Cardiol (Engl Ed), 2018, 37(1): 15-23.
24. Wigfield CH, Lindsey JD, Muñoz A, et al. Is extreme obesity a risk factor for cardiac surgery? An analysis of patients with a BMI > or = 40. Eur J Cardiothorac Surg, 2006, 29(4): 434-440.
25. Branca P, McGaw P, Light R. Factors associated with prolonged mechanical ventilation following coronary artery bypass surgery. Chest, 2001, 119(2): 537-546.
26. Leme Silva P, Pelosi P, Rocco PR. Mechanical ventilation in obese patients. Minerva Anestesiol, 2012, 78(10): 1136-1145.
27. Bartz RR, Ferreira RG, Schroder JN, et al. Prolonged pulmonary support after cardiac surgery: Incidence, risk factors and outcomes: A retrospective cohort study. J Crit Care, 2015, 30(5): 940-944.
28. Minakata K, Bando K, Tanaka S, et al. Preoperative chronic kidney disease as a strong predictor of postoperative infection and mortality after coronary artery bypass grafting. Circ J, 2014, 78(9): 2225-2231.
29. Ghotkar SV, Grayson AD, Fabri BM, et al. Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting. J Cardiothorac Surg, 2006, 1: 14.
30. Zangrillo A, Pappalardo F, Dossi R, et al. Preoperative intra-aortic balloon pump to reduce mortality in coronary artery bypass graft: A meta-analysis of randomized controlled trials. Crit Care, 2015, 19(1): 10.
31. Huffmyer JL, Groves DS. Pulmonary complications of cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol, 2015, 29(2): 163-175.
32. Shroyer AL, Grover FL, Hattler B, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med, 2009, 361(19): 1827-1837.
33. Zah-Bogovic T, Mesaric J, Hrabac P, et al. Possible transfusion-related acute lung injury (TRALI) in cardiac surgery patients. Croat Med J, 2014, 55(2): 138-145.
34. Eder AF, Herron RM, Strupp A, et al. Effective reduction of transfusion-related acute lung injury risk with male-predominant plasma strategy in the American Red Cross (2006-2008). Transfusion, 2010, 50(8): 1732-1742.
35. Fonseca L, Vieira FN, Azzolin Kde O. Factors associated to the length of time on mechanical ventilation in the postoperative period of cardiac surgery. Rev Gaucha Enferm, 2014, 35(2): 67-72.
36. Flegler S, Paro FM. Factors associated with intubation time and ICU stay after CABG. Braz J Cardiovasc Surg, 2015, 30(6): 631-635.
37. Ji Q, Chi L, Mei Y, et al. Risk factors for late extubation after coronary artery bypass grafting. Heart Lung, 2010, 39(4): 275-282.

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Risk factors and perioperative outcomes of prolonged mechanical ventilation after coronary artery bypass grafting in elderly patients

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