Coronary surgery, zero mortality
July 23, 2015
Is it conceivable to accomplish the zero mortality in coronary surgery? This operation has had since its beginnings the objective of carrying blood to all the possible coronary arteries that were obstructed or seriously narrowed –stenotics- to reach the complete revascularisation, and thereby, to restore the normal circulation of the heart, attaining its right functioning and the disappearing of the angina pectoris. This has been achieved in a noticeable way since many years ago, with a decreasing surgical mortality but still relatively high.
The percutaneous revascularisation (STENT implementation) has extended during the last years until turning into the first option to treat coronary problems, thanks to the improvement of its results and the facility of its application without the need of making an open surgery to the patient. But its mortality remains similar or even greater than with the surgery, and its results, in a long term, are clearly lower. However, using in collaboration both techniques could allow the aim of lowering even more the mortality of the surgery, minimising the surgical aggression and warranting long term results, with the realisation of hybrid procedures when necessary. Consequently, the “Mortality 0%” project in coronary surgery is born.
Can be this objective achieved? Obviously, the answer is ‘no’. Any surgical procedure, including any human activity, involves a chance of unexpected problems which can risk the life. Therefore, it is about analysing the causes of the mortality in this surgery in order to avoid them when it is possible. To do so, we have exhaustively investigated the reasons of the deceases in the last years in order to detect causes which could be theoretically avoidable for then, by applying the fund criteria, check on the possibilities of avoid or reduce to the minimum the mortality of the operated patients. We have analysed the results obtained during the last twelve months after the appliance of these new criteria and we have found that, indeed, the mortality has been reduced until values nearby the 0% objective.
Mortality according to studies and data
This research has been communicated at the 10th Conference of the SACCV, which took place in Córdoba, and was admitted for its explanation at the Spanish Society of Cardiology´s Conference that was held in Barcelona in 2009.
Materials and Methodology: During the period from 2003 to 2008, 850 patients with coronary disease were operated. We analysed the mortality causes to obtain predictive factors along the years 2003 to 2007 (722 patiens) that later were applied to those operated during 2008 (136 patients). Afterwards, we compared the average mortality, classifying the symptoms in Scheduled and Urgent Patients (SUP) and Emergencies (E), examining the mortality causes and the global mortality tendency.
Results: The risk factors found from 2003 to 2007 were the Emergency Surgery and some misguided bypasses, because of the vessels’ disrepair, an inappropriate preoperative situation or both causes.
The global mortality found was of a 2.57% in SUP (18 patients) and of a 28.57% in E (4 patients), a global 3.08%. By applying selection criteria for “necessary bypasses” in 2008, the global mortality was of a 0.75% in SUP (1 patient) and of a 66.6% in E (2 patients), a global 2.2%. p<0.0000001.
Discussion: The election of the bypasses to make to the coronary patients, putting the mortality absence before the complete revascularisation, has supposed a statistically significant improvement of the results and an approach to the “mortality 0” objective. The hybrid PTA-Surgery procedures allow yet making a selection of the bypasses to perform, whereby lots of patients benefit from the safeness and longevity provided by the arterial bypasses, especially those from mammary to the DA, with a decrease in the mortality that hadn’t been reached until now.
The emergency surgery, provided its performance in patients with cardiogenic shock without percutaneous possibilities, doesn´t admit an improvement margin since the mortality is associated to the previous extremely grave situation of the patients; therefore it must be removed from this programme.
Although a one-year period is too many short for the data to be definitive, the objective of reducing the mortality in so many patients has been achieved in a so convincing way that we are still applying these criteria to all the operated patients. Results from coming years or their approval by other surgical teams would allow to change the current criteria in which is based the coronary surgery (a complete revascularisation) for the ones that our surgical team practise at present: the mortality near to the 0%.