Brazilian Journal of Cardiovascular Surgery

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ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 39 (02) • 2024 • https://doi.org/10.21470/1678-9741-2023-0104 linkcopy

Difference Between Cardiopulmonary Bypass Time and Aortic Cross-Clamping Time as a Predictor of Complications After Coronary Artery Bypass Grafting

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood.

Objective: To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II.

Methods: Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome.

Results: After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60).

Conclusion: TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications.

Keywords:
Coronary Artery Bypass; Cardiopulmonary Bypass; Reoperation; Risk Assessment; Severity of Illness Index; Treatment Outcome.

Abbreviations, Acronyms & Symbols
CABG	= Coronary artery bypass grafting
CCS	= Canadian Cardiovascular Society
CI	= Confidence interval
CPB	= Cardiopulmonary bypass
CPBT	= Cardiopulmonary bypass time
CVA	= Cerebrovascular accident
IQR	= Interquartile range
NYHA	= New York Heart Association
OR	= Odds ratio
REPLICCAR	= Registro Paulista de Cirurgia Cardiovascular
STS	= Society of Thoracic Surgeons
TDC-C	= Time difference between cardiopulmonary bypass and aortic cross-clamping times

Characteristics	Total		Group 1 (n=2596)		Group 2 (n=416)		Group 3 (n=32)		Group 4 (n=46)		P-value
Characteristics	n	%	n	%	n	%	n	%	n	%
Age (years)^*	63 (57-70)		63 (57-69)		64 (57-70)		62.5 (56.75-69.25)		66 (60-70)		0.41
Gender (female)	797	25.79	687	26.46	95	22.84	8	25.00	7	15.22	0.16
Urgent admission	592	19.16	481	18.53	84	20.19	15	46.88	12	26.09	0.001
Body mass index
< 18.5	34	1.10	29	1.12	5	1.20	0	0.00	0	0.00
18.5-24.9	906	29.32	762	29.35	124	29.81	8	25.00	12	26.09	0.81
25-29.9	780	25.24	669	25.77	94	22.60	8	25.00	9	19.57
≥ 30	1370	44.34	1136	43.76	193	46.39	16	50.00	25	54.35
Previous myocardial infarction	1616	52.30	1368	52.70	206	49.52	14	43.75	28	60.87	0.45
Systemic arterial hypertension	2699	87.35	2268	87.37	370	88.94	28	87.50	33	71.74	0.02
Diabetes mellitus	1511	48.90	1251	48.19	219	52.64	20	62.50	21	45.65	0.14
Cerebrovascular disease¹	280	9.06	226	8.71	45	10.82	3	9.38	6	13.04	< 0.001
Atrial fibrillation	47	1.52	40	1.54	4	0.96	3	9.38	0	0.00	-
Ejection fraction < 30%	48	1.55	34	1.31	12	2.88	2	6.25	0	0.00	-
Kidney failure	204	6.60	161	6.20	31	7.45	5	15.63	7	15.22	< 0.001
CCS angina classification
4	302	9.77	252	9.71	41	9.86	3	9.38	6	13.04	0.83
NYHA classification
I and II	2692	87.12	2272	87.52	352	84.62	29	90.63	39	84.78	0.03
III and IV	398	12.88	324	12.48	64	15.38	3	9.38	7	15.22
STS score (mortality)^*	0.64 (0.42-1.01)		0.63 (0.41-0.99)		0.65 (0.43-1.09)		0.78 (0.40-1.49)		0.74 (0.54-1.33)		0.04
Intraoperative period
Surgery time (hours)^**	4.52 1.43		4.43±1.43		4.85±1.26		6.64±1		6.28±1.13		< 0.001
Cardiopulmonary bypass time (minutes)^**	76.78±27.53		71.06±23.3		97.51±18.81		149.84±10.81		161.04±21.65		< 0.001
Aortic cross-clamping time (minutes)^**	58.22±23.36		56.5±22.1		58.49±17.11		130.53±11.48		102.52±24.53		< 0.001
TDC-C (minutes)^**	18.56±12.07		14.56±5.93		39.02±9		19.31±6.66		58.52±27.74		< 0.001
Postoperative period
Reoperation	114	3.69	85	3.27	22	5.29	3	9.38	4	8.70	0.01
CVA	41	1.33	23	0.89	14	3.37	3	9.38	1	2.17	< 0.001
Kidney failure	193	6.25	141	5.43	41	9.86	3	9.38	8	17.39	< 0.001
Prolonged ventilation (> 24 hours)	39	1.26	32	1.23	3	0.72	2	6.25	2	4.35	0.02
Surgical wound infection	67	2.17	53	2.04	12	2.88	1	3.13	1	2.17	0.46
In-hospital mortality	93	3.01	62	2.39	21	5.05	3	9.38	7	15.22	< 0.001

Variable	OR	95% CI	P-value
Reoperation	2.67	1.20-5.95	0.01
CVA	4.34	1.51-12.50	0.006
Kidney failure	2.55	1.32-4.91	0.005
Prolonged ventilation	4.59	1.59-13.26	0.004
Surgical wound infection	1.19	0.29-4.96	0.80
In-hospital mortality	5.18	2.58-10.43	< 0.001

Variable	OR	95% CI	P-value
Reoperation	1.72	1.09-2.69	0.02
CVA	3.35	1.76-6.39	< 0.001
Kidney failure	2.04	1.45-2.87	< 0.001
Prolonged ventilation	0.83	0.32-2.14	0.7
Surgical wound infection	1.38	0.74-2.54	0.30
In-hospital mortality	2.54	1.61-4.00	< 0.001

Variable	OR	95% CI	P-value
Reoperation
Group 2	1.64	1.01-2.66	0.02
Group 3	3.05	0.91-10.22
Group 4	2.81	0.98-8.02
CVA
Group 2	3.85	1.99-7.63	< 0.001
Group 3	11.27	3.29-40.69
Group 4	2.48	0.32-18.80
Kidney failure
Group 2	1.90	1.32-2.74	< 0.001
Group 3	1.80	0.54-5.98
Group 4	3.66	1.67-8.00
Prolonged ventilation
Group 2	0.58	0.17-1.90	0.03
Group 3	5.34	1.22-23.30
Group 4	3.64	0.84-15.67
Surgical wound infection
Group 2	1.42	0.75-2.69	0.07
Group 3	1.54	0.21-11.54
Group 4	1.07	0.14-7.87
In-hospital mortality
Group 2	2.17	1.30-3.60	< 0.001
Group 3	4.22	1.25-14.25
Group 4	7.33	3.15-17.04

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E-mail: bjcvs@sbccv.org.br

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