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Original Research |

Predictors and Early and Late Outcomes of Respiratory Failure in Contemporary Cardiac Surgery* FREE TO VIEW

Farzan Filsoufi, MD; Parwis B. Rahmanian, MD; Javier G. Castillo, MD; Joanna Chikwe, MD; David H. Adams, MD
Author and Funding Information

*From the Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY.

Correspondence to: Farzan Filsoufi, MD, Associate Professor, Associate Chief Cardiac Surgery, Mount Sinai School of Medicine, 1190 Fifth Ave, New York, NY 10029-1028; e-mail: farzan.filsoufi@mountsinai.org


Chest. 2008;133(3):713-721. doi:10.1378/chest.07-1028
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Published online

Background: Respiratory failure (RF) is a serious complication following heart surgery. The profile of patients referred for cardiac surgery has changed during the last decade, making prior investigations of RF after cardiac surgery less relevant to the current population. This study was designed to analyze the incidence, predictors of RF, and early and late outcomes following this complication in a large contemporary cardiac surgery population.

Methods: We retrospectively analyzed prospectively collected data from the New York State Department of Health database including 5,798 patients undergoing cardiac surgery between January 1998 and December 2005. Patients with RF (intubation time ≥ 72 h) were compared to patients without RF.

Results: The incidence of RF was 9.1% (n = 529). The highest incidence of RF was observed following combined valve/coronary artery bypass graft (14.8%) and aortic procedures (13.5%). Multivariate analysis revealed preoperative and operative predictors of RF such as renal failure (odds ratio [OR], 2.3), aortic procedures (OR, 2.6), hemodynamic instability (OR, 3.2), and intraaortic balloon pump (OR, 2.6). The mortality rate following RF was 15.5% (n = 82), compared to 2.4% (n = 126) in the no-RF group (p < 0.001). Kaplan-Meier survival curves showed significantly poorer survival among RF patients (p < 0.001) compared to the no-RF group.

Conclusion: RF remains a serious and common complication following cardiac surgery, particularly in patients undergoing complex procedures. RF is associated with significant comorbidity, increased hospital mortality, and reduced long-term survival. Future research efforts should focus on a more precise identification of patients at risk and the development of new treatment modalities that would potentially prevent the occurrence of this complication.

Figures in this Article

Respiratory failure (RF) after cardiac surgery is associated with increased mortality and morbidity,13 and decreased quality of life.4 The reported incidence of RF ranges from 5 to 20% depending on the definition of this complication. Previous studies2,5 that attempted to identify predictors of this complication were limited by inadequate sample sizes and have consisted of patients undergoing predominantly coronary artery bypass graft (CABG) surgery.

During the last decade, the profile of patients referred for cardiac surgery has substantially changed with the broader application of percutaneous coronary interventions.6 An increasing number of patients are currently referred for more complex procedures (combined valve/CABG and aortic procedures). In addition, patients present with a worsening risk profile due to increased age and multiple preoperative comorbidities.6 It is likely that a greater number of patients would have this complication. It is therefore important to study the epidemiology of RF in a contemporary cohort of cardiac surgery patients and to determine early and late outcomes following this complication.

Study Population

We retrospectively analyzed a series of 6,326 consecutive patients undergoing cardiac surgery at our institution between January 1998 and December 2005. Patients undergoing cardiac transplantation or ventricular-assist device implantation (n = 221) and patients with a thoracotomy approach for descending thoracic aortic surgery (n = 307) were excluded. As our database did not record preoperative ventilatory/intubation status, such patients could not be excluded. In an analysis of our last 6-month practice, however, the rate of these patients was < 1% (5 of 612 patients). The remaining 5,798 patients composed the study population (RF group, n = 529, 9.1%; no-RF group, n = 5,269, 90.9%).

The protocol was approved by our institutional review board and was compliant with Health Insurance Portability and Accountability Act regulations and ethical guidelines of the 1975 Declaration of Helsinki. The approval included a waiver of informed consent.

Clinical variables were prospectively entered into the New York State Department of Health (NYSDH) [State Cardiac Advisory Committee] data registry.7The NYSDH data registry represents a mandatory verified peer-reviewed data collection system including all cardiac surgery procedures. Medical chart review was performed to obtain additional data. The logistic European system for cardiac operative risk evaluation (EuroSCORE) was calculated for individual risk stratification.8 This risk stratification system applies multiple preoperative factors to predict operative mortality (www.euroscore.org). Patients were classified into four risk groups: low (< 3%), moderate (3 to 9%), high (9 to 25%), and very high (≥ 25%).

The main outcome parameter was respiratory failure defined according to the NYSDH registry: pulmonary insufficiency requiring intubation and ventilation for ≥ 72 h postoperatively. Information regarding long-term survival was obtained using the Web-based social security death index.9 Preoperative, intraoperative, and postoperative variables are depicted in the Appendix.

Intraoperative and Postoperative Management

All patients underwent a median sternotomy. The majority of procedures (n = 5,380, 93%) were performed utilizing cardiopulmonary bypass (CPB), whereas 7% (n = 418, all off-pump CABG surgery) were performed without CPB. Following surgery, patients were weaned from the ventilator when hemodynamic stability was achieved, when there was no major postoperative bleeding (chest tube output < 100 mL/h, no signs of tamponade, no evidence for hemothorax in chest radiograph), and when adequate consciousness was obtained. Arterial blood gas requirements (obtained with a fraction of inspired oxygen ≤ 40%) for extubation included Pao2 > 80 mm Hg (arterial oxygen saturation > 95%), Paco2 < 45 mm Hg, and pH > 7.35 with no clinical evidence of severe metabolic acidosis (base excess/deficit range − 3 to + 3 mmol/L).

Statistical Analysis

Normally distributed continuous variables are presented as mean ± SD or median and interquartile range (IQR). Categorical variables are shown as percentages; p < 0.05 was considered statistically significant. χ2 test, Fisher exact test, and the linear-by-linear test were used to identify preoperative factors that significantly influenced the occurrence of RF when considered one at a time. The preoperative variables included into this analysis are shown in the Appendix. A stepwise logistic regression analysis was performed to identify independent predictors of RF. The cut-off p value for inclusion and exclusion was 0.10. The Hosmer-Lemeshow goodness-of-fit test was used to assess the performance of the analysis10; p > 0.5 indicated that the model was well calibrated and fitted the data well. In addition, a C-statistic was performed to access the accuracy of the analysis including independent predictors of RF identified in the logistic regression analysis. An area under the receiver operator characteristic curve > 0.70 was considered to indicate accuracy of the predictive model. Similar analyses were undertaken to identify independent predictors of hospital mortality following RF. This analysis included additional postoperative variables (Appendix). Long-term survival was analyzed using Kaplan-Meier survival curves. Differences in patient characteristics were adjusted by Cox proportional hazard analysis. The proportionality assumption for all variables included into the Cox regression was assessed with log-negative-log survival distribution functions. Statistical analysis was performed using statistical software (SPSS for Windows, version 15.0; SPSS; Chicago, IL).

A total of 5,798 patients were included. Mean age was 64 ± 14 years, and 62% of patients (n = 3,612) were male. Patient demographics are shown in Table 1 . CABG surgery was performed in 47% (n = 2,749), whereas 53% of patients underwent other procedures such as valve surgery (22%, n = 1,280), combined valve/CABG procedures (16%, n = 934), and aortic surgery (15%, n = 835). Mean predicted EuroSCORE mortality rate was 11 ± 13%.

Incidence of RF

The overall incidence of RF was 9.1% (n = 529). The rate of RF was different according to surgical procedures (Fig 1 ). The incidence of RF did not differ significantly in the conventional CABG group (5.8%, n = 136) compared to the off-pump group (7.2%, n = 30) [p = 0.160]. The incidence of RF was higher following multiple-valve surgery (17%, n = 63) compared to single-valve procedures (6.1%, n = 55) [p < 0.001]. The rate of RF after aortic surgery involving the aortic arch was 22.4% (n = 50). A total of 223 tracheostomies (42%) were performed in patients with RF. The incidence of RF following stratification using the EuroSCORE is shown in Figure 2 .

Predictors of RF

Differences in patient characteristics in univariate analysis are shown in Table 1. Patients with RF had a prolonged CPB time (196 ± 82 min vs 153 ± 70 min, p < 0.001) and aortic cross-clamp time (136 ± 61 min vs 115 ± 50 min, p < 0.001). Patients with RF were more likely to undergo aortic and combined valve/CABG procedures.

Stepwise multivariate logistic regression analysis of preoperative factors revealed female gender, age > 70 years, ejection fraction (EF) ≤ 30%, hypertension, peripheral vascular disease (PVD), COPD, congestive heart failure, renal failure, active endocarditis, reoperation, hemodynamic instability, and intraaortic balloon pump (IABP) insertion as independent predictors for the occurrence of RF (Table 2 ). Aortic surgery and combined valve/CABG procedures were the only procedure-related variables that independently predicted RF. The Hosmer-Lemeshow goodness-of-fit test was not statistically significant (p = 0.38), indicating good calibration of the model. Furthermore, the C-statistic including the independent predictors of RF from the logistic regression analysis (Table 2) was performed. The area under the receiver operating characteristic curve for the multivariate prediction model was 0.81 and indicated the predictive power of the regression analysis.

Outcome of Patients With RF

Overall hospital mortality rate among RF patients was 15.5% (n = 82), compared to 2.4% (n = 126) in the no-RF group (p < 0.001). Patients with RF were more likely to have other major complications (Table 3 ). The median length of hospital stay was significantly increased in RF patients (30 days [IQR, 17 to 52 days] vs 7 days [IQR, 5 to 10 days], p < 0.001).

The increased mortality associated with RF was observed across all EuroSCORE groups. Although there were more RF-related deaths in patients with a high EuroSCORE, the relative risk of dying after this complication was significantly higher in patients with low EuroSCORE (Table 4 ). In other words, following the development of RF, patients in the low EuroSCORE group had a 15-times greater risk of hospital mortality, whereas in patients with high EuroSCORE the risk was twice as high. Preoperative renal failure, reexploration for bleeding, and postoperative renal failure requiring dialysis were predictors of hospital mortality in RF patients (Table 5 ).

Late Survival

Mean follow-up was 4.2 ± 2.5 years. Long-term survival of RF patients was significantly decreased compared to those without this complication (Fig 3 ). When long-term survival was stratified by the EuroSCORE, RF appeared to have the least impact on long-term survival in patients with a EuroSCORE ≤ 3 (Fig 4 , top left, A). In patients with a EuroSCORE > 3, 5-year survival was reduced by 30 to 50% (Fig 4, top right, B, through bottom right, D). Independent predictors of decreased long-term survival were age > 70 years, PVD, and renal failure requiring dialysis (Table 6 ).

Incidence

The reported incidence of respiratory failure following cardiac surgery varies from 5 to > 20%,1,10 reflecting wide variation in study design, inclusion criteria, and definition of this complication. Most investigators use a cut-off value of ventilation lasting > 48 h to define RF and focus on patients undergoing CABG surgery, with the majority reporting an incidence of RF from 5 to 9%.5,1215 Higher values are reported following non-CABG procedures.1,16 The NYSDH definition of RF is pulmonary insufficiency requiring reintubation or ventilation for a cumulative period ≥ 72 h at any time during the postoperative course. Three previous studies2,14,17 that excluded patients undergoing procedures other than CABG used this definition, reporting an incidence of 5.9 to 6.5%. In this study, the incidence of RF in patients undergoing isolated CABG was 5.8%, compared to the overall incidence of RF of 9.1%, reflecting the higher incidence of this complication in patients undergoing more complex procedures.

Predictors of RF

Several studies5,1314,17have analyzed predictors of postcardiotomy RF: most were limited by small sample sizes or restricted their analysis to patients undergoing CABG surgery. Cardiac surgery has seen a progressive decrease in the numbers of patients referred for CABG surgery, and an increase in patients undergoing complex surgical procedures.18 This study reflects these trends: > 50% of the patients included had procedures other than CABG surgery. Consequently, the risk factors identified in this series predict the occurrence of this complication in a heterogeneous group of patients undergoing cardiac surgery more accurately than risk factors derived from more highly selected patient groups.

The independent preoperative risk factors for RF may be classified into three broad groups: demographic, vascular, and cardiac. The demographic predictors of RF were female gender and age (> 70 years). Elderly patients not only have decreased physiologic reserve but are more likely to present with multiple comorbidity that may act as confounding variables. The impact of gender remains controversial. Although female gender was not shown to be an independent predictor of RF in a recent large cohort study,2 two smaller studies17,19 identified a strong association between female gender and the incidence of RF after cardiac surgery. In our cohort, female patients were 40% more likely than male patients to have RF. Despite several potential explanations for this finding,17,19 the mechanisms underlying this association remain poorly understood.

The vascular risk factors found to be independent predictors of RF included diabetes, renal failure, hypertension, and a history of PVD. These markers of systemic atherosclerotic disease are associated with increased risk of all major complications.2021 Renal failure was a particularly strong predictor of RF (odds ratio [OR], 2.3) confirming the findings of several studies.2,13,2223 This may firstly reflect adverse outcome associated with delayed investigation, referral, and intervention in these patients; and secondly the increased atherosclerotic burden associated with renal failure.

Cardiovascular variables that were independent predictors of RF included EF ≤ 30%, New York Heart Association class III–IV, hemodynamic instability, IABP insertion, endocarditis, and reoperation. The impact of low EF on the occurrence of RF is well recognized: the incidence of RF may be up to three times higher in patients with poor left ventricular function.2,5,17,2425 Our multivariate analysis (Table 2) reveals that patients with an EF < 30% were 40% more likely to have RF than those with an EF > 30%. We were also able to identify active endocarditis as a risk factor for RF independent of hemodynamic instability and left ventricular dysfunction. A twofold increase in the risk of RF was observed in the 140 patients with active endocarditis. This correlation may be explained by the fact that infective endocarditis is frequently associated with systemic inflammatory response and lung injury.

Preoperative COPD was also identified as an independent risk factor, confirming previous findings.2,2425 In our series, patients with COPD who underwent valve surgery or CABG surgery had two- and three-times-increased rates of RF, respectively. Severe COPD has been associated with excess postoperative mortality in patients undergoing CABG surgery.26 Sternotomy and CPB have an adverse effect on patients with COPD, although excess mortality is most frequently attributed to nonrespiratory causes in these patients.26 The association between COPD and adverse outcome has been reported to be less significant when COPD, which represents a broad disease spectrum, is defined in terms of spirometry, arterial blood gas measurement, or chest radiography.5,27

As has been identified in the noncardiac surgical population, postoperative RF is more likely in patients undergoing more complex procedures28; thus, efforts to reduce operative complexity, for example, with hybrid strategies,29percutaneous valve technologies,3031 and utilization of endovascular stent-graft techniques in patients with aortic arch aneurysms32 may reduce the incidence of RF after cardiac operations.

Hospital Mortality and Long-term Survival

The hospital mortality rate associated with RF has typically been > 10%. In large studies of patients2,13 undergoing CABG surgery, in-hospital mortality rates > 20% have been reported following this complication. The overall 30-day mortality rate in our cohort was 15.5%, ranging from 12% in the CABG group and 14% for combined valve/CABG procedures, to 18% for aortic procedures. Although these patients also had additional complications including stroke, renal failure, sepsis, and GI pathology, we were unable to identify a clear causal relationship between other complications and RF. We were, however, able to identify three independent predictors of hospital mortality in RF patients: preoperative renal failure (OR, 4.1), reexploration for bleeding (OR, 4.3), and postoperative renal failure requiring dialysis (OR, 1.9). Patients with preoperative renal failure who had RF were four times more likely to die within 30 days of surgery than patients without this complication.

More recently, we have adopted a policy of early tracheostomy because we have shown that it is not associated with an increased risk of deep sternal wound infection.33Tracheostomy offers several benefits, such as frequent and effective pulmonary toilet, reduced sedation requirements,34earlier mobilization of patient-facilitated weaning from mechanical ventilation,35 and reduced risk of ventilator-associated pneumonia and associated systemic sepsis.35

Finally, long-term survival was reduced in RF patients. The burden of this complication continued beyond the initial hospitalization, with a significantly higher rate of death during the first postoperative year. By the end of the first year, there was a 30% absolute survival difference between patients who did not have RF and those who had this complication. After this early hazard phase, the comparative survival curves were similar, reflecting a similar mid-term and late mortality rate in all patients.

The preoperative predicted mortality from the EuroSCORE logistic regression equation was also significantly and independently associated with an increasing risk of postoperative RF and reduced long-term survival. Although primarily designed for the purpose of hospital mortality prediction, in our study this scoring system was also able to predict reduced survival following the occurrence of RF. Patients with RF and a EuroSCORE > 3 had a 30 to 50% decreased 5-year survival rate compared to patients without this complication, in contrast to patients with RF and a EuroSCORE ≤ 3, whose long-term outcome was very similar to patients who did not have RF.

Limitations

This was a retrospective observational study, and conclusions are necessarily limited in their application. Risk models can only adjust for data that have been collected. Our study did not examine some previously reported risk factors for the occurrence of RF such as smoking.17 Clinical outcome analysis focused on postoperative mortality and morbidity, and we were not able to provide information on late complications, quality of life, and cause of death following discharge.

The poor long-term survival of patients with RF underlines the need to direct more resources toward prevention of this complication in cardiac surgery patients. This large analysis of a heterogenous cohort of patients within a contemporary practice underlines the profoundly negative impact that postoperative RF has on both immediate and late surgical outcomes. Knowledge of independent predictors for this devastating complication may enable patients at high risk for RF to be more accurately identified and aggressively optimized preoperatively. It may also help in the design of studies assessing the benefits of hybrid and novel percutaneous therapeutic approaches in patients with complex valvular and coronary heart disease.

Abbreviations: CABG = coronary artery bypass graft; CPB = cardiopulmonary bypass; EF = ejection fraction; EuroSCORE = European system for cardiac operative risk evaluation; IABP = intraaortic balloon pump; IQR = interquartile range; NYSDH = New York State Department of Health; OR = odds ratio; PVD = peripheral vascular disease; RF = respiratory failure

None of the authors has an actual or potential interest related to this article to disclose.

Table Graphic Jump Location
Table 1. Patient Demographics*
* 

Data are presented as No. (%) or mean ± SD.

Figure Jump LinkFigure 1. The incidence of RF by procedure performed.Grahic Jump Location
Figure Jump LinkFigure 2. Incidence of RF by EuroSCORE mortality risk (linear-by-linear test, p = 0.001).Grahic Jump Location
Table Graphic Jump Location
Table 2. Independent Predictors of RF Following Cardiac Surgery (Multivariate Logistic Regression)
Table Graphic Jump Location
Table 3. Postoperative Complications (Univariate Analysis)*
* 

Data are presented as No. (%) unless otherwise indicated.

Table Graphic Jump Location
Table 4. Impact of EuroSCORE Risk Group on Hospital Mortality in Patients With or Without RF
Table Graphic Jump Location
Table 5. Predictors of Hospital Mortality in Patients With RF
Figure Jump LinkFigure 3. Postdischarge survival curves for RF (n = 529) and no-RF (n = 5,269) patients. Top, A: Kaplan-Meier unadjusted data. Bottom, B: Cox proportional hazards-adjusted curves.Grahic Jump Location
Figure Jump LinkFigure 4. Postdischarge survival by EuroSCORE mortality risk category (mean follow-up of 4.2 years). Top left, A: Low risk (EuroSCORE < 3%). Top right, B: Moderate risk (EuroSCORE 3 to 9%). Bottom left, C: High risk (EuroSCORE ≥ 9 to 25%). Bottom right, D: Very high risk (EuroSCORE > 25%).Grahic Jump Location
Table Graphic Jump Location
Table 6. Predictors of Long-term Mortality in Patients With RF
Table Graphic Jump Location
Table 7. Variables Used in This Study*
Table Graphic Jump Location
Table 7A. (Continued)
* 

Patients undergoing cardiac transplantation, ventricular assist device implantation, or surgery approached by thoracotomy were excluded (n = 528).

Kollef, MH, Wragge, T, Pasque, C (1995) Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation.Chest107,1395-1401
 
Canver, CC, Chanda, J Intraoperative and postoperative risk factors for respiratory failure after coronary bypass.Ann Thorac Surg2003;75,853-857; discussion 857–858
 
Hein, OV, Birnbaum, J, Wernecke, KD, et al Three-year survival after four major post-cardiac operative complications.Crit Care Med2006;34,2729-2737
 
Combes, A, Costa, MA, Trouillet, JL, et al Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥ 14 days of mechanical ventilation.Crit Care Med2003;31,1373-1381
 
Spivack, SD, Shinozaki, T, Albertini, JJ, et al Preoperative prediction of postoperative respiratory outcome: coronary artery bypass grafting.Chest1996;109,1222-1230
 
Ferguson, TB, Jr, Hammill, BG, Peterson, ED, et al A decade of change: risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990–1999; a report from the STS National Database Committee and the Duke Clinical Research Institute, Society of Thoracic Surgeons.Ann Thorac Surg2002;73,480-489discussion 489–490
 
 Adult Cardiac Surgery in New York State 2001–2003. 2005; New York State Department of Health. New York, NY:.
 
Nashef, SA, Roques, F, Michel, P, et al European system for cardiac operative risk evaluation (EuroSCORE).Eur J Cardiothorac Surg1999;16,9-13
 
Web based social security death index, 2007. Available at: www.ancestry.com. Accessed February 2, 2008.
 
Pappalardo, F, Franco, A, Landoni, G, et al Long-term outcome and quality of life of patients requiring prolonged mechanical ventilation after cardiac surgery.Eur J Cardiothorac Surg2004;25,548-552
 
Hosmer, DW, Lemeshow, S. Applied logistic regression. 1989; Wiley. New York, NY:.
 
Kern, H, Redlich, U, Hotz, H, et al Risk factors for prolonged ventilation after cardiac surgery using APACHE II, SAPS II, and TISS: comparison of three different models.Intensive Care Med2001;27,407-415
 
Cohen, AJ, Katz, MG, Frenkel, G, et al Morbid results of prolonged intubation after coronary artery bypass surgery.Chest2000;118,1724-1731
 
Serrano, N, Garcia, C, Villegas, J, et al Prolonged intubation rates after coronary artery bypass surgery and ICU risk stratification score.Chest2005;128,595-601
 
Yende, S, Wunderink, R Validity of scoring systems to predict risk of prolonged mechanical ventilation after coronary artery bypass graft surgery.Chest2002;122,239-244
 
Rankin, JS, Hammill, BG, Ferguson, TB, Jr, et al Determinants of operative mortality in valvular heart surgery.J Thorac Cardiovasc Surg2006;131,547-557
 
Branca, P, McGaw, P, Light, R Factors associated with prolonged mechanical ventilation following coronary artery bypass surgery.Chest2001;119,537-546
 
Keogh, B. The Society of Cardiothoracic Surgeons of Great Britain and Ireland Fifth National Adult Cardiac Surgical Database Report. 2003; Dendrite Clinical Systems. Henley-on-Thames, UK:.
 
Shroyer, AL, Coombs, LP, Peterson, ED, et al The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models.Ann Thorac Surg2003;75,1856-1864discussion 1864–1865
 
Sharony, R, Grossi, EA, Saunders, PC, et al Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease.J Thorac Cardiovasc Surg2004;127,406-413
 
Ghosh, S, Roberts, N, Firmin, RK, et al Risk factors for intestinal ischaemia in cardiac surgical patients.Eur J Cardiothorac Surg2002;21,411-416
 
Wong, DT, Cheng, DC, Kustra, R, et al Risk factors of delayed extubation, prolonged length of stay in the intensive care unit, and mortality in patients undergoing coronary artery bypass graft with fast-track cardiac anesthesia: a new cardiac risk score.Anesthesiology1999;91,936-944
 
Engoren, M, Buderer, NF, Zacharias, A Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery.Crit Care Med2000;28,2742-2749
 
Legare, JF, Hirsch, GM, Buth, KJ, et al Preoperative prediction of prolonged mechanical ventilation following coronary artery bypass grafting.Eur J Cardiothorac Surg2001;20,930-936
 
Rady, MY, Ryan, T Perioperative predictors of extubation failure and the effect on clinical outcome after cardiac surgery.Crit Care Med1999;27,340-347
 
Samuels, LE, Kaufman, MS, Morris, RJ, et al Coronary artery bypass grafting in patients with COPD.Chest1998;113,878-882
 
Geraci, JM, Rosen, AK, Ash, AS, et al Predicting the occurrence of adverse events after coronary artery bypass surgery.Ann Intern Med1993;118,18-24
 
Johnson, RG, Arozullah, AM, Neumayer, L, et al Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study.J Am Coll Surg2007;204,1188-1198
 
Byrne, JG, Leacche, M, Unic, D, et al Staged initial percutaneous coronary intervention followed by valve surgery (“hybrid approach”) for patients with complex coronary and valve disease.J Am Coll Cardiol2005;45,14-18
 
Feldman, T, Wasserman, HS, Herrmann, HC, et al Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST Phase I Clinical Trial.J Am Coll Cardiol2005;46,2134-2140
 
Cribier, A, Eltchaninoff, H, Tron, C, et al Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis.J Am Coll Cardiol2004;43,698-703
 
Szeto, WY, Bavaria, JE, Bowen, FW, et al The hybrid total arch repair: brachiocephalic bypass and concomitant endovascular aortic arch stent graft placement.J Card Surg2007;22,97-102discussion 103–104
 
Rahmanian, PB, Adams, DH, Castillo, JG, et al Tracheostomy is not a risk factor for deep sternal wound infection following cardiac surgery.Ann Thorac Surg2007;84,1984-1992
 
Nieszkowska, A, Combes, A, Luyt, CE, et al Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients.Crit Care Med2005;33,2527-2533
 
Rumbak, MJ, Newton, M, Truncale, T, et al A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients.Crit Care Med2004;32,1689-1694
 

Figures

Figure Jump LinkFigure 1. The incidence of RF by procedure performed.Grahic Jump Location
Figure Jump LinkFigure 2. Incidence of RF by EuroSCORE mortality risk (linear-by-linear test, p = 0.001).Grahic Jump Location
Figure Jump LinkFigure 3. Postdischarge survival curves for RF (n = 529) and no-RF (n = 5,269) patients. Top, A: Kaplan-Meier unadjusted data. Bottom, B: Cox proportional hazards-adjusted curves.Grahic Jump Location
Figure Jump LinkFigure 4. Postdischarge survival by EuroSCORE mortality risk category (mean follow-up of 4.2 years). Top left, A: Low risk (EuroSCORE < 3%). Top right, B: Moderate risk (EuroSCORE 3 to 9%). Bottom left, C: High risk (EuroSCORE ≥ 9 to 25%). Bottom right, D: Very high risk (EuroSCORE > 25%).Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Patient Demographics*
* 

Data are presented as No. (%) or mean ± SD.

Table Graphic Jump Location
Table 2. Independent Predictors of RF Following Cardiac Surgery (Multivariate Logistic Regression)
Table Graphic Jump Location
Table 3. Postoperative Complications (Univariate Analysis)*
* 

Data are presented as No. (%) unless otherwise indicated.

Table Graphic Jump Location
Table 4. Impact of EuroSCORE Risk Group on Hospital Mortality in Patients With or Without RF
Table Graphic Jump Location
Table 5. Predictors of Hospital Mortality in Patients With RF
Table Graphic Jump Location
Table 6. Predictors of Long-term Mortality in Patients With RF
Table Graphic Jump Location
Table 7. Variables Used in This Study*
Table Graphic Jump Location
Table 7A. (Continued)
* 

Patients undergoing cardiac transplantation, ventricular assist device implantation, or surgery approached by thoracotomy were excluded (n = 528).

References

Kollef, MH, Wragge, T, Pasque, C (1995) Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation.Chest107,1395-1401
 
Canver, CC, Chanda, J Intraoperative and postoperative risk factors for respiratory failure after coronary bypass.Ann Thorac Surg2003;75,853-857; discussion 857–858
 
Hein, OV, Birnbaum, J, Wernecke, KD, et al Three-year survival after four major post-cardiac operative complications.Crit Care Med2006;34,2729-2737
 
Combes, A, Costa, MA, Trouillet, JL, et al Morbidity, mortality, and quality-of-life outcomes of patients requiring ≥ 14 days of mechanical ventilation.Crit Care Med2003;31,1373-1381
 
Spivack, SD, Shinozaki, T, Albertini, JJ, et al Preoperative prediction of postoperative respiratory outcome: coronary artery bypass grafting.Chest1996;109,1222-1230
 
Ferguson, TB, Jr, Hammill, BG, Peterson, ED, et al A decade of change: risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990–1999; a report from the STS National Database Committee and the Duke Clinical Research Institute, Society of Thoracic Surgeons.Ann Thorac Surg2002;73,480-489discussion 489–490
 
 Adult Cardiac Surgery in New York State 2001–2003. 2005; New York State Department of Health. New York, NY:.
 
Nashef, SA, Roques, F, Michel, P, et al European system for cardiac operative risk evaluation (EuroSCORE).Eur J Cardiothorac Surg1999;16,9-13
 
Web based social security death index, 2007. Available at: www.ancestry.com. Accessed February 2, 2008.
 
Pappalardo, F, Franco, A, Landoni, G, et al Long-term outcome and quality of life of patients requiring prolonged mechanical ventilation after cardiac surgery.Eur J Cardiothorac Surg2004;25,548-552
 
Hosmer, DW, Lemeshow, S. Applied logistic regression. 1989; Wiley. New York, NY:.
 
Kern, H, Redlich, U, Hotz, H, et al Risk factors for prolonged ventilation after cardiac surgery using APACHE II, SAPS II, and TISS: comparison of three different models.Intensive Care Med2001;27,407-415
 
Cohen, AJ, Katz, MG, Frenkel, G, et al Morbid results of prolonged intubation after coronary artery bypass surgery.Chest2000;118,1724-1731
 
Serrano, N, Garcia, C, Villegas, J, et al Prolonged intubation rates after coronary artery bypass surgery and ICU risk stratification score.Chest2005;128,595-601
 
Yende, S, Wunderink, R Validity of scoring systems to predict risk of prolonged mechanical ventilation after coronary artery bypass graft surgery.Chest2002;122,239-244
 
Rankin, JS, Hammill, BG, Ferguson, TB, Jr, et al Determinants of operative mortality in valvular heart surgery.J Thorac Cardiovasc Surg2006;131,547-557
 
Branca, P, McGaw, P, Light, R Factors associated with prolonged mechanical ventilation following coronary artery bypass surgery.Chest2001;119,537-546
 
Keogh, B. The Society of Cardiothoracic Surgeons of Great Britain and Ireland Fifth National Adult Cardiac Surgical Database Report. 2003; Dendrite Clinical Systems. Henley-on-Thames, UK:.
 
Shroyer, AL, Coombs, LP, Peterson, ED, et al The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models.Ann Thorac Surg2003;75,1856-1864discussion 1864–1865
 
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