Coronary Artery Bypass Grafting in Patients With COPD: Conclusion


5 May 2014

Postoperatively, there are several events that influence outcome. As demonstrated by Gaynes et al, the development of pneumonia following CABG in a patient with COPD was associated with a 27% mortality. Although the mortality was lower in our series (11%), this figure is nearly five times higher than the general mortality of CABG at our institution. As a result of this, we are currently examining the role of broader-spectrum antibiotic coverage, particularly Gram negative, in this population of patients, since it is well known that patients with COPD are colonized with a variety of organisms. Although this may not be justified in the non-COPD patients, the immune suppressing effects of CPB combined with the respiratory flora of COPD patients may predispose them to an increased risk for lower respiratory tract infections. Atrial arrhythmias are another postoperative problem that has been observed more frequently in patients with COPD. In addition to the hemodynamic compromise, atrial arrhythmias are associated with increased incidence of stroke and length of stay. Furthermore, it has been shown that the major causes of mortality in COPD patients undergoing CABG were arrhythmia and other nonpulmonary factors. The situation is further compounded by the problem of using β-blockers to control atrial arrhythmias in COPD patients with a bronchospastic component. To address this issue, we are now investigating the use of prophylactic calcium-channel blockers (diltiazem) in the prevention of atrial arrhythmias. Thus far, we have reduced the incidence of atrial fibrillation by 50%. Finally, the fact that COPD patients are at risk of prolonged ventilation is well observed. Indeed, in our study, the incidence of prolonged ventilation was twofold that of non-COPD patients. In addition, the need for tracheostomy postoperatively is higher in patients with preexisting pulmonary dysfunction and is associated with a significant mortality. As a result of these findings, we have modified our criteria for extubation in COPD patients. Rather than focus on ABGs and weaning parameters, we emphasize the clinical assessment of the patient. This change has enabled us to extubate sooner with satisfactory results.

In summary, the treatment of COPD patients undergoing open heart surgery has evolved considerably over the past 3 decades from a relative contraindication to an everday encounter. Nevertheless, the presence of COPD remains a formidable problem in the perioperative period. Depending on the severity of the COPD, the morbidity and mortality can be almost prohibitive. This was the case in elderly patients with steroid-dependent COPD. In such cases, it would be imperative to institute vigorous preoperative measures to maximize the respiratory status. If this were not possible, then consideration toward an alternative approach, such as minimally invasive direct coronary arteiy bypass, without the use of CPB should be entertained. In conclusion, it is incumbent on the physicians and surgeons treating these high-risk patients to provide appropriate preoperative, intraoperative, and postoperative care.

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