Florida Heart Research Institute

Miami, FL, United States

Florida Heart Research Institute

Miami, FL, United States
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Kurlansky P.A.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Dorman M.J.,Tenet Healthcare Corporation | Galbut D.L.,Florida Heart Research Institute | And 2 more authors.
European Journal of Cardio-thoracic Surgery | Year: 2013

OBJECTIVES: Coronary artery bypass grafting (CABG) has historically demonstrated higher hospital mortality in women compared with men. The influence of gender on long-term outcomes has not been clearly defined. METHODS: A retrospective analysis of 4584 consecutive CABG patients was conducted: 3647 men (1761 single internal mammary artery, [SIMA]; 1886 bilateral IMA, [BIMA]) and 937 women (608 SIMA and 329 BIMA). Propensity-score analysis and optimal matching algorithms were used to create matched groups for baseline risk factors between men and women (SIMA: 602 men and 602 women; BIMA: 328 men and 328 women). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8 years) was 96.7% complete. RESULTS: Hospital mortality was higher in unmatched female vs male patients (SIMA 36/608; 5.9 vs 72/1761; 4.1%; BIMA 11/329; 3.3 vs 47/1886; 2.5%; P = 0.010). However, in the matched groups the increased hospital mortality for females approached statistical significance in the SIMA but not in the BIMA patients. (SIMA male 21/602, 3.5%; female 35/602, 5.8%; P = 0.055; BIMA male 12/328; 3.7%; female 11/328; 3.4%; P = 0.832). When propensity matched for baseline variables, the female SIMA patients experienced prolonged survival compared with their male counterparts. (male vs female, 20-year survival 17.0 ± 2.0 vs 26.4 ± 2.3%; median 10.4 vs 11.4; P = 0.043.) However, long-term survival between the matched male and the female BIMA patients was comparable (male vs female, 20-year survival 31.3 ± 3.6 vs 30.1 ± 3.6%; median 13.7 vs 13.7; P = 0.790). CONCLUSIONS: When liberally applied, BIMA grafting ameliorates both the increased perioperative mortality in female patients and the reduced long-term survival of male patients, effectively reversing the negative influence of gender on both short- and long-term outcomes of CABG surgery. ©The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.


Dorman M.J.,Tenet Healthcare Corporation | Kurlansky P.A.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Galbut D.L.,Florida Heart Research Institute | And 2 more authors.
Circulation | Year: 2012

BACKGROUND-: The prevalence of diabetes mellitus is increasing at an unprecedented rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in this group of patients. Similarly, studies have shown the superiority of bilateral internal mammary artery (BIMA) grafting over single internal mammary artery (SIMA) grafting in select populations. However, concerns about sternal wound infection have discouraged the use of BIMA grafting in diabetics. Therefore, we studied the long-term results of BIMA versus SIMA grafting in a large population of diabetic patients in whom BIMA grafting was broadly applied. METHODS AND RESULTS-: Between February 1972 and May 1994, 1107 consecutive diabetic patients underwent coronary artery bypass grafting with either SIMA (n=646) or BIMA (n=461) grafting. Optimal matching with the propensity score was used to create matched SIMA (n=414) and BIMA (n=414) cohorts. Cross-sectional follow-up (6 weeks to 30.1 years; mean, 8.9 years) determined long-term survival. There was no difference in operative mortality, sternal wound infection, or total complications between matched SIMA and BIMA groups (operative mortality, 10 of 414 [2.4%] versus 13 of 414 [3.1%]; P=0.279; sternal wound infection, 7 of 414 [1.7%] versus 13 of 414 [3.1%]; P=0.179); total complications, 71 of 414 [17.1%] versus 71 of 414 [17.1%]; P=1.000). Late survival was significantly enhanced with the use of BIMA grafting (median survival: SIMA, 9.8 years versus BIMA, 13.1 years; P=0.001). Use of BIMA was found to be associated with late survival on Cox regression (P=0.003). CONCLUSION-: Compared with SIMA grafting, BIMA grafting in propensity score-matched patients provides diabetics with enhanced survival without any increase in perioperative morbidity or mortality. © 2012 American Heart Association, Inc.


Kurlansky P.,Florida Heart Research Institute | Kurlansky P.,Columbia University | Herbert M.,Medical City Dallas Hospital | Prince S.,Cardiopulmonary Research Science and Technology Institute | Mack M.J.,Baylor Health Care System
Annals of Thoracic Surgery | Year: 2015

Background Diabetes is increasing at an alarming rate, affecting nearly 8% of the population. Previous studies have demonstrated a potential benefit for surgical over interventional revascularization in diabetics. However, randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) many not accurately reflect current clinical practice. We therefore undertook a prospective registry of coronary revascularization (CR) in diabetic patients with CABG, on-pump and off-pump, and PCI with bare-metal and drug-eluting stents to determine long-term clinical outcomes. Methods All patients undergoing isolated CR in 8 community hospitals were enrolled. Follow-up was obtained after 5 to 8 years; all mortalities were checked against the Social Security Death Index. The ST-elevation myocardial infarction and salvage patients were excluded. Propensity matching was used to account for differences between PCI and CABG groups. Survival curves were derived using Kaplan-Meier methods, whereas hazard ratios and cumulative hazards were calculated using the Cox proportional hazard model. Results Of the 3,156 patients in the registry, there were 1,082 diabetics; 334 CABG and 748 PCI. Due to the differences in baseline characteristics between the 2 groups, propensity score matching was used to achieve clinically comparable groups of 240 patients each. In matched patient groups mortality was more common in the PCI group with an odds ratio (OR) of 0.60 (95% confidence interval [CI] 0.39% to 0.93%; p = 0.023). Similarly, occurrence of any major cardiac adverse event (MACE) (mortality, non-fatal myocardial infarction, or revascularization) was more frequent in the PCI group with an OR of 0.57 (95% CI 0.31% to 0.70%, p < 0.001). Kaplan-Meier event-free survival of matched groups was significantly improved in the CABG versus PCI group (p = 0.001). Conclusions In the current era of on-pump and off-pump CABG surgery and bare-metal and drug-eluting stents, this registry which unselectively records all non-ST elevation myocardial infarction patients undergoing coronary revascularization, diabetic patients benefit from improved long-term survival and reduced MACE with CABG versus PCI. These findings corroborate recent evidence from prospective randomized trials and thus provide clinically relevant validation of their broad applicability to diabetics with extensive coronary artery disease in need of revascularization. © 2015 The Society of Thoracic Surgeons.


Kurlansky P.,Florida Heart Research Institute
World Journal of Surgery | Year: 2010

As a profession, surgery is well into its fourth decade of experience with bilateral internal thoracic artery (BITA) grafting for the treatment of ischemic cardiovascular disease. Numerous compelling retrospective analyses appear to have documented a clear bene?t for BITA grafting over the use of a single internal thoracic artery (SITA) graft in reducing the long-term risk of mortality, cardiac mortality, and cardiac events. Despite this wealth of literature and scienti?c as well as clinical investigation, the chilling fact remains that the STS database reports that less than 4% of coronary bypass (CABG) operations involve the use of BITA grafting. The historic, physiologic, and clinical aspects of BITA grafting are reviewed. Clini- cal challenges and technical advances are addressed. The future of BITA grafting is explored, both from a research perspective and from a clinical point of view. © Société Internationale de Chirurgie 2009.


Kurlansky P.,Florida Heart Research Institute
Journal of the American Heart Association | Year: 2013

Data from randomized clinical trials comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) may not accurately reflect current clinical practice, in which there is off-label usage of drug-eluting stents (DES). We undertook a prospective registry of coronary revascularization by CABG on- and off-pump and PCI with bare-metal stents (BMSs), DESs, or percutaneous transluminal coronary angioplasty (PTCA) to determine clinical outcomes. All patients undergoing isolated coronary revascularization in 8 community-based hospitals were enrolled. Final follow-up was obtained after 5 years by patient and/or physician contact and the Social Security Death Index. ST-elevation myocardial infarction and salvage patients were excluded. Five or more years of follow-up was obtained on 81.5% (3156) of the eligible patients-968 CABG patients (82.0%) and 2188 PCI patients (81.3%). Overall follow-up was 63.5±27.9 months (median, 79.7 months). The incidence of initial major adverse cardiac events (MACEs) at follow-up for CABG versus PCI was 29.2% versus 41.8% (P<0.001). Analysis of stent subgroups showed more events with BMSs (equivalent to PTCA alone) compared with DESs. All stents had more events than on- or off-pump CABG groups. Using propensity score-matched groups, the odds ratio for CABG to PCI was 0.69 (95% confidence interval [CI], 0.56 to 0.85; P<0.001) for mortality and 0.58 (95% CI, 0.45 to 0.75; P<0.001) for any MACE. In the current era of DES and off-pump surgery, in a community hospital setting, comparable patients undergoing coronary revascularization appear to benefit from improved long-term survival and reduced MACE with CABG versus PCI.


Kurlansky P.,Florida Heart Research Institute
Current Opinion in Cardiology | Year: 2012

PURPOSE OF REVIEW: Octogenarians represent the fastest-growing segment of the population. Over 40% manifest cardiovascular disease, frequently in an advanced state requiring surgical revascularization. Increased mortality, morbidity, and expense in this high-risk group, with decreased longevity, present a growing challenge to our healthcare system. RECENT FINDINGS: Results of coronary artery bypass graft (CABG) surgery in octogenarians show a consistent pattern of improvement over time, with documented long-term survival and quality of life that rivals the age-matched population. Comparison with alternative therapies appears to be favorable. Clearer understanding of costs will provide a more rational context for treatment decisions. Increasing interest in the specific issues regarding frailty will help to guide the most appropriate patient selection. SUMMARY: Although it is clear that CABG surgery in octogenarians can be accomplished with increasingly good results, future research will need to focus on what specific surgical strategies are most appropriate for this elderly cohort; how the collaborative 'Heart Team' approach can be most effectively applied to determination of the most appropriate therapeutic course for these complex, frequently high-risk patients; what strategies can be applied to best manage and possibly reverse patient frailty; and what economic models most meaningfully inform clinical and public policy decision-making. © 2012 Wolters Kluwer Health Lippincott Williams & Wilkins.


Kurlansky P.A.,Florida Heart Research Institute | Williams D.B.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Zucker M.,Florida Heart Research Institute | Ebra G.,Florida Heart Research Institute
Journal of Thoracic and Cardiovascular Surgery | Year: 2011

Objective: Octogenarians comprise the fastest growing population segment. Numerous reports have documented improved accomplishment of coronary artery bypass grafting in this high-risk cohort. But what is the quality of life after surgery, and how sustainable are the clinical benefits? Methods: Sequential cross-sectional analyses were performed on 1062 consecutive patients 80 years old and older who underwent isolated on-pump coronary artery bypass grafting at a single institution from 1989 to 2001. After mean follow-up of 3.4 years (1 month-12.6 years), the Short Form 36 quality of life survey was administered to all survivors. Late follow-up for survival was performed after a mean 5.6 years (1 month-17.9 years). Multivariate analyses assessed risk factors associated with operative mortality, Short Form 36 self-assessment, and late survival. Results: Mean age at operation was 83.1 ± 2.8 years (range, 80-99 years). Overall in-hospital mortality was 9.7%, decreasing progressively to 2.2% during the course of the study. At midterm follow-up, 97.1% of patients were in Canadian Cardiovascular Society class I or II; Short Form 36 scores were comparable to age-adjusted norms in both physical and mental health summary scores. Actuarial survivals were 42.2% ± 1.5% at 7 years and 9.9% ± 1.4% at 14 years. Median survival was 5.9 years; 5.2 years for male patients and 6.7 for female patients (P =.004). Conclusions: The risk of coronary artery bypass grafting for octogenarians now rivals that of a younger population. Midterm quality of life and long-term survival approach those of the general population. Copyright © 2011 by The American Association for Thoracic Surgery.


Galbut D.L.,Aventura | Kurlansky P.A.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Ebra G.,Aventura
Journal of Thoracic and Cardiovascular Surgery | Year: 2012

Objective: Bilateral internal thoracic artery (BITA) grafting has been shown to improve long-term survival after coronary artery bypass grafting. However, there has been reluctance to use this technique in higher-risk patients. Patients with reduced ejection fraction (EF) have been shown to present a higher operative risk and reduced long-term survival. We studied the perioperative and long-term results of BITA versus single internal thoracic artery grafting (SITA) in a large population of patients with reduced EF in whom BITA grafting was broadly applied. Methods: Between February 1972 and May 1994, 4537 consecutive patients in whom EF was recorded underwent SITA (2340) or BITA (2197) grafting. Prospectively collected clinical data recorded EF categorically as less than 0.30 (group I; n = 233), 0.30 to 0.50 (group II; n = 1256), or greater than 0.50 (group III; n = 3048). Multivariable analyses were performed to determine correlates of operative and late mortality. Optimal matching using propensity scoring was used to create matched SITA and BITA cohorts: group I, SITA and BITA, n = 87 each; group II, SITA and BITA, n = 448 each; group III, SITA and BITA, n = 1137 each. Equality of survival distribution was tested by the log-rank algorithm. Results: There was no difference in operative mortality between matched SITA and BITA groups (group I: SITA vs BITA, 10.3% vs 6.9%, P = .418; group II: 4.7% vs 4.5%, P = .873; group III: 3.2% vs 2.0%, P = .086). SITA versus BITA was not a predictor of operative mortality on logistic regression analysis. There was no difference in freedom from any postoperative complication, including sternal wound infection, between matched SITA and BITA groups. Late survival was significantly enhanced with the use of BITA grafting in groups II and III (10- and 20-year survival, SITA vs BITA, in group II: 57.7% ± 0.3% and 19% ± 2.5% vs 62.0% ± 2.3% and 33.1% ± 3.4%, respectively, P = .016; and in group III: 67.1% ± 1.4% and 35.8% ± 1.7% vs 74.6% ± 1.3% and 38.1% ± 2.1%, respectively, P = .012). Likewise, choice of SITA versus BITA was a significant predictor of late mortality on Cox regression in both groups II (P < .007) and III (P < .001). Conclusions: Broadly applied BITA compared with SITA grafting in propensity-matched patients provides enhanced long-term survival with no increase in operative mortality or morbidity for patients with normal and reduced EF. The expanded use of BITA grafting should be seriously considered. Copyright © 2012 by The American Association for Thoracic Surgery.


Kurlansky P.A.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Galbut D.L.,Florida Heart Research Institute
Annals of Thoracic Surgery | Year: 2011

Background: Although the use of two internal mammary arteries (IMA) in coronary artery bypass graft surgery has been associated with improved patient survival and clinical status, the optimal use of the second IMA graft remains controversial. We, therefore, explored clinical outcomes in a large cohort of patients undergoing bilateral IMA grafting. Methods: Between February 1972 and May 1994, 2,215 consecutive patients underwent bilateral IMA grafting. The second IMA was used to revascularize the left coronary system (LCS) in 1,479 and the right coronary system (RCS) in 736 patients. Propensity score optimal matching algorithm was used to create the matched LCS group (n = 730) and RCS group (n = 730). Cross-sectional follow-up (6 weeks to 32.1 years; mean 12.8; 96.7% complete) was performed. Multivariable analyses were performed to determine correlates of operative mortality and late mortality. Patient clinical status and Short Form-36 scores of late survivors were compared. Results: There was no difference in either operative mortality or late survival between LCS and RCS patients, in either unmatched or matched groups. Operative mortality unmatched was LCS 38 of 1,479 (2.6%) versus RCS 20 of 736 (2.7%; p = 0.837). For matched groups, it was LCS 13 of 730 (1.8%) versus RCS 20 of 736 (2.7%; p = 0.284). Median survival in unmatched patients was LCS 15.8 years versus RCS 16.1 years (p = 0.803); for matched patients, it was LCS 16.1 years versus RCS 16.1 years (p = 0.671). Site of second IMA was not associated with either operative mortality or late survival on multivariable analysis. At follow-up, both groups demonstrated excellent clinical outcomes, with 98.4% of LCS patients and 96.8% of RCS patients in Canadian Cardiovascular Society class I or II, and no significant difference in either the physical (p = 0.142) or mental (p = 0.542) health summary scores on the Short Form-36. Conclusions: Use of two IMA grafts demonstrates excellent long-term results with no demonstrable difference in outcome between RCS and LCS patients. © 2011 The Society of Thoracic Surgeons.


Kurlansky P.A.,Florida Heart Research Institute | Traad E.A.,Florida Heart Research Institute | Galbut D.L.,Florida Heart Research Institute
Annals of Thoracic Surgery | Year: 2010

Background: The value of the left internal mammary artery (LIMA) graft is well established. However, the incremental value of a second IMA graft is controversial. Despite reports of improved survival with bilateral IMA (BIMA) grafting, the Society of Thoracic Surgeons reports its use in 4% of coronary artery bypass graft operations. We report the influence of BIMA vs SIMA grafting on hospital and late mortality in comparable groups. Methods: Retrospective review was conducted of 4584 consecutive isolated coronary artery bypass graft operations (2369 SIMA and 2215 BIMA) performed from 1972 to 1994. The influence of the second IMA was assessed by multivariate analyses of risk factors associated with hospital and late mortality and by propensity score analysis that compares patients with similar baseline characteristics for receiving a second IMA graft. All patients were monitored clinically to assess outcomes. Results: Hospital mortality was 4.5% for SIMA vs 2.6% for BIMA patients (p = 0.001). When stratified by propensity score to undergo BIMA grafting, no difference in hospital mortality was found. Multivariate analyses showed SIMA grafting was significantly associated with late but not hospital mortality. Survival curves after 52,572 patient-years of follow-up (mean, 11.5 years; range, 6 weeks to 32 years) demonstrated improved long-term survival for BIMA vs SIMA patients in all quintiles except those with the greatest propensity for SIMA, wherein late survival was comparable between groups. In matched groups, survival favored BIMA patients (p = 0.001). Conclusions: BIMA grafting offers a long-term survival advantage over SIMA grafting in propensity-matched groups. © 2010 The Society of Thoracic Surgeons.

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