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Intra-clinic variation of OPCAB performance influences the incidence of postoperative renal failure

Implications for the evaluation and retraining of OPCAB

Variabilität der Inzidenz postoperativen Nierenversagen nach Bypassoperationen ohne HLM: eine Bedeutung für OPCAB-Training und Vergleichsstudien

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Clinical Research in Cardiology Supplements Aims and scope

Zusammenfassung

Hintergrund

Das akute Nierenversagen nach Herzoperationen tritt in ca. 1–5% der Fälle. Inwiefern die Anwendung der Herz-Lungen-Maschine ein wesentlicher Risikofaktor dafür ist wird derzeit kontrovers diskutiert. In der folgenden Arbeit untersuchten wir retrospektiv ob die Bypassoperationen ohne Herz-Lungen-Maschine zu einer Reduktion der Dialysepflichtigkeit nach Bypassoperationen führten. Unsere hohen Fallzahlen und die große Datenbank ermöglichen uns eine Vielzahl von möglichen Einflussfaktoren, wie präoperative Nierenschädigungen, und diverse Begleiterkrankungen sowie die Laborwerte in den multivariaten Modellen mitzuberücksichtigen. Ein besonderes Augenmerk wird auf die Rolle des Operateurs gelegt, der im Wesentlichen die Performanz der OPCAB-Operation bestimmt.

Methoden

Es wurden 11 118 Operationen, welche von Januar 1996 und September 2006 im Herzzentrum Lahr/Baden durchgeführt, analysiert. Dabei werden multivariate Risikofaktoren für das Auftreten postoperativer Dialysepflichtigkeit bestimmt, sowohl für die Gesamtheit der Bypasspatienten als auch für die OPCAB-Operationen. Die über die Risiko-Scores vorhergesagten Dialyserisiken werden mit den beobachteten verglichen. Mit den so entwickelten Verhältnissen von beobachteter zu erwarteter Dialysepflichtigkeit (O/E ratio) wird die OPCAB Performanz einzelner Operateure statistisch verglichen.

Ergebnisse

Es werden keine Unterschiede in Letalität zwischen konventionellen Bypassoperationen und OPCAB festgestellt (1,41% vs. 1,47% mit einer Euro- SCORE erwarteter Letalität von 1,94% vs. 1,71%). Postoperatives Nierenversagen trat bei 413 Patienten auf (3,7%). Die postoperative Dialysepflichtigkeit konnte mit Hilfe der entwickelten Risiko-Scores gut vorhergesagt werden (c-indexes 0,87 für On-Pump, 0,89 für Off-pump). Es gab keine Unterschiede in der Häufigkeit des Auftretens postoperativer Dialysepflichtigkeit zischen ON- vs. Off-pump. Hochsignifikante Unterschiede zwischen den 10 Operateuren (und einer gemischten Gruppe) wurden beobachtet. Gute Ergebnisse wurden sowohl bei solchen Operateuren welche keine Selektion der Patienten betrieben als auch bei solchen welche nach eigens gewählten Kriterien die Patienten für OPCAB selektierten festgestellt.

Schlussfolgerung

Die Möglichkeit mit Hilfe der OPCAB- Operationen durch die Vermeidung Herz-Lungen-Maschinen assoziierter Risikofaktoren die Inzidenz postoperativen Nierenversagens zu mindern hängt wesentlich vom Operateur und dem Team ab. Der hämodynamischen Stabilität während der Operation sollte größte Aufmerksamkeit gewährt werden, um eine Kummulation schädigender Einflüsse zu vermeiden. Dabei könnte ein spezielles Training für Operateure nach CMEST-Prinzipien eine vorteilhafte Rolle spielen.

Summary

Background

Controversy continues regarding the relative importance of cardiopulmonary bypass vs predisposing patient factors in causing renal dysfunction after cardiac operations. We aimed to define risk factors for postoperative dialysis in off-pump coronary artery bypass surgery (OPCAB) and conventional CABG and to evaluate the role of variations in OPCAB performance by different surgeons and experience over time.

Methods

The study was conducted on 11,118 patients who had undergone coronary bypass operations at the Heart Institute Lahr/Baden between January 1996 and September 2006. Multivariate risk factors for postoperative renal dysfunction were identified for both on-pump CABG and OPCAB. Observed vs expected postoperative dialysis (O/E ratios) were calculated in both groups, as well as for individual surgeons and for different time periods. Variable dialysis adjusted displays were created for different surgeons.

Results

No significant difference in mortality (30-days) was observed between on- and off-pump (1.41% vs 1.47% with EuroSCORE predicted risk of 1.94% vs 1.71%). Renal failure after CABG needing postoperative dialysis occurred in 413 patients (3.7%). The need for postoperative dialysis can be predicted by preoperative patient-related variables with good discriminative power (c-indexes 0.87 for onpump, 0.89 for off-pump). There were no differences between onpump and off-pump cases in non-risk-adjusted and risk-adjusted analysis. Highly significant differences of O/E ratios between 10 different surgeons (and 1 mixed group) were identified. No relationship between OPCAB performance and number of cases was observed. Favorable O/E ratios were observed for those surgeons who were intensively retrained for total OPCAB and for those who properly selected their patients for the OPCAB procedure, respectively.

Conclusion

The potential of the OPCAB technique to decrease the rate of postoperative dialysis by avoidance of CPB-related risk factors depends strongly on the performance of the individual surgeon and the operative team. Awareness of cumulative damage due to pronounced hemodynamic changes during the procedure, and subsequently their avoidance, is strongly recommended. Re-training by experts according to the principles of Continuous Medical Education of Surgical Techniques (CMEST) is recommended to improve OPCAB performance.

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Authors and Affiliations

  1. Heart Institute Lahr/Baden, Hohbergweg 2, 77933, Lahr, Germany

    A. Albert, W. Hassanein & J. Ennker

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  1. A. Albert
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  2. W. Hassanein
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  3. J. Ennker
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Correspondence to A. Albert.

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Albert, A., Hassanein, W. & Ennker, J. Intra-clinic variation of OPCAB performance influences the incidence of postoperative renal failure. Clin Res Cardiol Suppl 2 (Suppl 1), S49–S56 (2007). https://doi.org/10.1007/s11789-006-0038-5

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  • DOI: https://doi.org/10.1007/s11789-006-0038-5

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