Outcomes for Difficult-to-Wean Subjects After Cardiac Surgery

Abstract

BACKGROUND:The need for prolonged mechanical ventilation (PMV) after cardiac surgery is still a common problem. We hypothesized that subjects who required PMV after a single surgery (either coronary artery bypass grafting or valve surgery) would have better outcomes than those who had experienced both revascularization and valve surgery. METHODS: We retrospectively analyzed the characteristics and outcomes for patients consecutively admitted to our weaning unit (WU) after cardiac surgery between December 2007 and August 2012. Subjects' data were analyzed according to the number of procedures. Group 1 included subjects who had undergone a single surgery (valvular replacement or myocardial revascularization). Group 2 included subjects who had undergone combined surgery (valvular replacement and myocardial revascularization). Data for PMV subjects who were transferred to the WU for reasons other than cardiac surgery in the same period are also reported. RESULTS: Of 584 PMV subjects admitted, 35 (5.9%, 19 in group 1 and 16 in group 2) were referred after cardiac surgery. At WU admission, group 2 showed significantly more comorbidities and a greater clinical severity than group 1. Compared with group 1, group 2 showed a significantly lower weaning rate (43.7% vs 78.9%, P ‫؍‬ .003) and a higher in-hospital mortality (31.3% vs 5.3%, P ‫؍‬ .04). The overall 6-month survival for subjects of group 1 was 73.7% compared with 37.5% for subjects in group 2 (P ‫؍‬ .02). Adjusting for comorbidities and clinical severity, the difference between the 2 groups did not reach statistical significance for either the weaning rate or the overall 6-month survival. At discharge, health status, as assessed by means of functional independence measure, was significantly better in group 1 than in group 2 (P ‫؍‬ .035). CONCLUSIONS: These results suggest that patients needing PMV after combined cardiac surgery may suffer worse outcomes than those needing PMV after simple cardiac surgery.

Prolonged mechanical ventilation after left ventricular assist device implantation: risk factors and clinical implications

“…[1][2][3][4][5][6][7][8][9] One recent large-scale study reported a 7% rate of post-operative ventilation for more than 48 h after cardiac surgery with an inhospital death rate of 22.3%. The condition of PMV after cardiac surgery has long been the focus of clinical research, as it was early shown to be associated with an adverse clinical outcome and increased mortality.…”

“…Several studies aimed to decipher the aetiology and clinical implications of PMV in this setting. [1][2][3][4][5][6][7][8][9] One recent large-scale study reported a 7% rate of post-operative ventilation for more than 48 h after cardiac surgery with an inhospital death rate of 22.3%. 9 Circulatory assist devices were though excluded from these studies.…”

“…[1][2][3][4][5][6][7][8][9] Previous studies in patients undergoing general cardiac surgery have reported an incidence of 2-10%, with in-hospital mortality rates exceeding 40%. [1][2][3][4][5][6][7][8][9] Previous studies in patients undergoing general cardiac surgery have reported an incidence of 2-10%, with in-hospital mortality rates exceeding 40%.…”

“…Prolonged mechanical ventilation (PMV) after major cardiovascular procedures has been shown to adversely affect post-operative outcome and survival and is accompanied by incremental health costs. [1][2][3][4][5][6][7][8][9] Previous studies in patients undergoing general cardiac surgery have reported an incidence of 2-10%, with in-hospital mortality rates exceeding 40%. 2,5,6,9 In the setting of advanced heart failure refractory to conventional therapy, the implantation of a left ventricular assist device (LVAD) is nowadays an established treatment option with rapidly expanding indications and availability.…”

Strategies for weaning from mechanical ventilation: A state of the art review

“…Inappropriate decision making regarding weaning and extubation readiness also is not without risk. Patients may experience respiratory and cardiac failure associated with increased work of breathing during the reduction of ventilatory support for weaning (Jeganathan et al, 2015;Vagheggini et al, 2015). Reintubation due to postextubation respiratory failure has been shown to increase mortality from 2.5 to 10 times compared to patients that do not require reintubation (Rothaar and Epstein, 2003).…”