The burden of chronic obstructive pulmonary disease in open heart surgery—a retrospective cohort analysis of postoperative complications

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Abstract

Chronic obstructive pulmonary disease (COPD) has a major impact on mortality and morbidity in patients undergoing cardiac surgery. Mortality risk increases by 50% in patients who were re-intubated or required prolonged mechanical ventilation after the operation. The aim of this study was to assess the impact of COPD on the prediction of postoperative complications and outcome including intensive care unit (ICU) and hospital stay, postoperative morbidity and mortality in patients undergoing all types of cardiac surgery.

We performed a retrospective cohort analysis of prospectively collected data from a tertiary cardiac surgery department of a university hospital between 2014 and 2016. We divided patients undergoing cardiac surgery into 2 sub-groups – the first – with a clinical diagnosis of COPD (n = 198) and the second comprised all other non-COPD patients (n = 2980).

Among patients with COPD a longer intubation time ( P = .039), longer ICU stay ( P < .001) and longer hospitalization time ( P = .006) was noted as compared with non-COPD patients. Patients with COPD required reintubation more often than non-COPD patients, reintubation occurring twice, 19 (9.60%) versus 144 (4.83%) P = .002, reintubation occurring 3 or more times, 7 (3.54%) versus 34 (1.14%) P = .006. Mortality within 30 days after surgery was higher in patients with pulmonary problems before surgery ( P = .003). Multivariable logistic regression analysis corrected for interfering variables showed an increased risk of postoperative bronchoconstriction (odds ratio [OR] = 4.40, P = .002), respiratory failure (OR = 1.67, P = .018), atrial fibrillation (OR = 1.45, P = .023), and use of hemofiltration (OR = 1.60, P = .029) for patients with COPD.

Patients with COPD undergoing all types of cardiac surgery are at increased risk of respiratory complications and mortality. The occurrence of COPD was associated with longer ICU and hospital stay. In COPD patients, undergoing cardiac surgery, treatment strategies aimed at preventing reintubation and early weaning mechanical ventilation must be employed to reduce postoperative complications.

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Most cited references 25

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European system for cardiac operative risk evaluation (EuroSCORE).

S Nashef, F. Roques, P. Michel … (1999)

To construct a scoring system for the prediction of early mortality in cardiac surgical patients in Europe on the basis of objective risk factors. The EuroSCORE database was divided into developmental and validation subsets. In the former, risk factors deemed to be objective, credible, obtainable and difficult to falsify were weighted on the basis of regression analysis. An additive score of predicted mortality was constructed. Its calibration and discrimination characteristics were assessed in the validation dataset. Thresholds were defined to distinguish low, moderate and high risk groups. The developmental dataset had 13,302 patients, calibration by Hosmer Lemeshow Chi square was (8) = 8.26 (P 200 micromol/l (2), active endocarditis (3) and critical preoperative state (3). Cardiac factors were unstable angina on intravenous nitrates (2), reduced left ventricular ejection fraction (30-50%: 1, 60 mmHg (2). Operation-related factors were emergency (2), other than isolated coronary surgery (2), thoracic aorta surgery (3) and surgery for postinfarct septal rupture (4). The scoring system was then applied to three risk groups. The low risk group (EuroSCORE 1-2) had 4529 patients with 36 deaths (0.8%), 95% confidence limits for observed mortality (0.56-1.10) and for expected mortality (1.27-1.29). The medium risk group (EuroSCORE 3-5) had 5977 patients with 182 deaths (3%), observed mortality (2.62-3.51), predicted (2.90-2.94). The high risk group (EuroSCORE 6 plus) had 4293 patients with 480 deaths (11.2%) observed mortality (10.25-12.16), predicted (10.93-11.54). Overall, there were 698 deaths in 14,799 patients (4.7%), observed mortality (4.37-5.06), predicted (4.72-4.95). EuroSCORE is a simple, objective and up-to-date system for assessing heart surgery, soundly based on one of the largest, most complete and accurate databases in European cardiac surgical history. We recommend its widespread use.

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The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery.

David Shahian, Sean M O'Brien, Giovanni Filardo … (2009)

The first version of The Society of Thoracic Surgeons National Adult Cardiac Surgery Database (STS NCD) was developed nearly 2 decades ago. Since its inception, the number of participants has grown dramatically, patient acuity has increased, and overall outcomes have consistently improved. To adjust for these and other changes, all STS risk models have undergone periodic revisions. This report provides a detailed description of the 2008 STS risk model for coronary artery bypass grafting surgery (CABG). The study population consisted of 774,881 isolated CABG procedures performed on adult patients aged 20 to 100 years between January 1, 2002, and December 31, 2006, at 819 STS NCD participating centers. This cohort was randomly divided into a 60% training (development) sample and a 40% test (validation) sample. The development sample was used to identify predictor variables and estimate model coefficients. The validation sample was used to assess model calibration and discrimination. Model outcomes included operative mortality, renal failure, stroke, reoperation for any cause, prolonged ventilation, deep sternal wound infection, composite major morbidity or mortality, prolonged length of stay (> 14 days), and short length of stay (< 6 days and alive). Candidate predictor variables were selected based on their availability in versions 2.35, 2.41, and 2.52.1 of the STS NCD and their presence in (or ability to be mapped to) version 2.61. Potential predictor variables were screened for overall prevalence in the study population, missing data frequency, coding concerns, bivariate relationships with outcomes, and their presence in previous STS or other CABG risk models. Supervised backwards selection was then performed with input from an expert panel of cardiac surgeons and biostatisticians. After successfully validating the fit of the models, the development and validation samples were subsequently combined, and the final regression coefficients were estimated using the overall combined (development plus validation) sample. The c-index for the mortality model was 0.812, and the c-indices for other endpoints ranged from 0.653 for reoperation to 0.793 for renal failure in the validation sample. Plots of observed versus predicted event rates revealed acceptable calibration in the overall population and in numerous subgroups. When patients were grouped into categories of predicted risk, the absolute difference between the observed and expected event rates was less than 1.5% for each endpoint. The final model intercept and coefficients are provided. New STS risk models have been developed for CABG mortality and eight other endpoints. Detailed descriptions of model development and testing are provided, together with the final algorithm. Overall model performance is excellent.

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Chronic obstructive pulmonary disease and comorbidities.

Wim Janssens, Marc Decramer (2013)

Results of epidemiological studies have shown that chronic obstructive pulmonary disease (COPD) is frequently associated with comorbidities, the most serious and prevalent being cardiovascular disease, lung cancer, osteoporosis, muscle weakness, and cachexia. Mechanistically, environmental risk factors such as smoking, unhealthy diet, exacerbations, and physical inactivity or inherent factors such as genetic background and ageing contribute to this association. No convincing evidence has been provided to suggest that treatment of COPD would reduce comorbidities, although some indirect indications are available. Clear evidence that treatment of comorbidities improves COPD is also lacking, although observational studies would suggest such an effect for statins, β blockers, and angiotensin-converting enzyme blockers and receptor antagonists. Large-scale prospective studies are needed. Reduction of common risk factors seems to be the most powerful approach to reduce comorbidities. Whether reduction of so-called spill-over of local inflammation from the lungs or systemic inflammation with inhaled or systemic anti-inflammatory drugs, respectively, would also reduce COPD-related comorbidities is doubtful. Copyright © 2013 Elsevier Ltd. All rights reserved.

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Author and article information

Journal

Journal ID (nlm-ta): Medicine (Baltimore)

Journal ID (iso-abbrev): Medicine (Baltimore)

Journal ID (publisher-id): MEDI

Title: Medicine

Publisher: Wolters Kluwer Health

ISSN (Print): 0025-7974

ISSN (Electronic): 1536-5964

Publication date (Electronic): 27 March 2020

Publication date Collection: March 2020

Volume: 99

Issue: 13

Electronic Location Identifier: e19675

Affiliations

[a ]Department of Medical Rehabilitation and Clinical Physiotherapy, Pomeranian Medical University, ul. Żołnierska 54

[b ]Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University

[c ]Department of Cardiac Surgery, Pomeranian Medical University, al. Powstańców Wlkp. 72, Szczecin, Poland

[d ]Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples, Federico II, Naples, Italy.

Author notes

[∗ ]Correspondence: Katarzyna Kotfis, Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland (e-mail: katarzyna.kotfis@ 123456pum.edu.pl ).

Article

Publisher ID: MD-D-19-07092 Accession ID: 19675

DOI: 10.1097/MD.0000000000019675

PMC ID: 7220196

PubMed ID: 32221097

SO-VID: 96236d7e-3522-4f1c-b1dc-fa1e9a8823d5

License:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

History

Date received : 8 September 2019

Date revision received : 29 January 2020

Date accepted : 27 February 2020

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Keywords: cardiac surgery,chronic obstructive pulmonary disease,delirium,mortality,pulmonary complications

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Keywords: cardiac surgery, chronic obstructive pulmonary disease, delirium, mortality, pulmonary complications

The burden of chronic obstructive pulmonary disease in open heart surgery—a retrospective cohort analysis of postoperative complications : STROBE compliant

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Biomarkers for Inflammatory Lung Disease

Most cited references 25

European system for cardiac operative risk evaluation (EuroSCORE).

The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery.

Chronic obstructive pulmonary disease and comorbidities.

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