Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY.
Division of Cardiac Surgery, Department of Surgery, Columbia University, New York, NY.
J Thorac Cardiovasc Surg. 2021 Jul;162(1):56-67.e44. doi: 10.1016/j.jtcvs.2019.11.131. Epub 2019 Dec 24.
Recent single-center and experimental data suggested greater adverse cardiac events for patients undergoing aortic valve replacement (AVR) in the morning (AM) versus the afternoon (PM). However, previous studies in patients undergoing coronary artery bypass grafting (CABG) have found no similar time-related difference. We examined the impact of AM versus PM operative time on surgical outcomes of CABG and AVR in a diverse, multi-institutional cardiac surgery network between January 2008 and September 2018.
The AM group included patients whose surgery start time was between 6:30 and 9 AM, whereas noon to 2:30 PM was considered PM (8901 AM/1962 PM) for CABG and (2598 AM/617 PM) for AVR. Because of imbalances in sample size, risk factors, and Society of Thoracic Surgeons predicted risk between groups, propensity score matching using all baseline characteristics was used to create 2 well-matched patient groups whose outcomes were compared.
After propensity score matching, there was no difference in mortality, stroke, prolonged ventilation, renal failure, deep sternal wound infection, reoperation, myocardial injury, atrial fibrillation, or readmission between AM and PM groups for both isolated CABG and AVR. However, there were mixed differences noted in intensive care unit length of stay, postoperative length of stay, blood product use, and crossclamp time. Findings were stable when accounting for site and physician effects, whereas subgroup analyses showed similar findings in the elective, diabetic, Hispanic, and off-pump patient populations.
There were no differences in operative mortality nor in major morbidity between well-matched AM and PM patients undergoing either CABG or AVR.
最近的单中心和实验数据表明，与下午（PM）相比，上午（AM）接受主动脉瓣置换术（AVR）的患者发生心脏不良事件的风险更高。然而，之前在接受冠状动脉旁路移植术（CABG）的患者中进行的研究并未发现类似的与时间相关的差异。我们在 2008 年 1 月至 2018 年 9 月期间，在一个多元化的多机构心脏手术网络中，研究了 AM 与 PM 手术时间对 CABG 和 AVR 手术结果的影响。
AM 组患者的手术开始时间在 6:30 至 9:00 AM 之间，而中午至 2:30 PM 被认为是 PM（CABG 为 8901 AM/1962 PM，AVR 为 2598 AM/617 PM）。由于组间样本量、危险因素和胸外科医生协会预测风险存在不平衡，因此使用所有基线特征进行倾向评分匹配，创建了两组匹配良好的患者，比较其结果。
在进行倾向评分匹配后，无论是单独进行 CABG 还是 AVR，AM 和 PM 组之间在死亡率、中风、长时间通气、肾衰竭、深部胸骨伤口感染、再次手术、心肌损伤、心房颤动或再入院方面均无差异。然而，在重症监护病房住院时间、术后住院时间、血液制品使用和体外循环时间方面存在差异。在考虑到地点和医生的影响后，结果仍然稳定，而亚组分析显示在择期手术、糖尿病、西班牙裔和非体外循环患者群体中也有类似的发现。
在接受 CABG 或 AVR 的匹配良好的 AM 和 PM 患者中，手术死亡率或主要发病率没有差异。
