Assessing the risk of waiting for coronary artery bypass graft surgery among patients with stenosis of the left main coronary artery.

BACKGROUND

Significant controversy remains over how urgently coronary artery bypass graft surgery (CABG) should be scheduled, particularly for patients with stenosis of the left main coronary artery. Our main objective was to evaluate the safety of waiting for CABG among patients with left main coronary artery disease using a standardized triage system.

METHODS

We identified 561 consecutive patients with stenosis of the left main coronary artery who were scheduled to undergo CABG between Apr. 1, 1999, and Mar. 31, 2003. Using standardized triage criteria, patients were assigned to 1 of 4 waiting queues: "emergent," "in-hospital urgent," "out-of-hospital semi-urgent A" and "out-of-hospital semi-urgent B." Postoperative outcome measures were in-hospital death from any cause and a composite outcome measure of in-hospital death from any cause, a prolonged requirement for postoperative mechanical ventilation (> 24 h) and a prolonged postoperative hospital stay (> 9 d). Waiting-time variables included the specific queue, whether patients waited longer than the standard time established for each queue and whether patients were upgraded to a more urgent queue. Logistic regression analysis was used to identify independent predictors of the composite outcome; propensity scores (probability of being assigned to a specific queue) were entered into the model to adjust for patient variability among queues.

RESULTS

Of the 561 patients, 65 (11.6%) were assigned to the emergent group, 343 (61.1%) to the in-hospital urgent group, 91 (16.2%) to the semi-urgent A queue and 62 (11.1%) to the semi-urgent B queue. Four patients (0.7%) died while waiting for surgery. The median waiting times were as follows: emergent group, 0 days; in-hospital urgent group, 2 days; 30 days in the semi-urgent A group and 49 days in the semi-urgent B group. A total of 52 patients (9.3%) were upgraded to a more urgent queue, and 147 patients (26.2%) waited longer than the standard times for their respective queue. The overall in-hospital mortality was 5.5% (n = 31), and the composite outcome was 32.6% (n = 183). Independent predictors of the composite outcome were myocardial infarction within 7 days before surgery, preoperative renal failure, ejection fraction of less than 40%, age greater than 70 years and stenosis of left main coronary artery greater than 70%. Waiting-time variables were associated with neither a significantly higher mortality nor morbidity outcome.

INTERPRETATION

For selected patients with stenosis of the left main coronary artery, waiting for CABG did not appear to be associated with increased mortality or morbidity.