Evidence-Based Practice in Heart Surgery

Washington University heart surgeons employ practices supported by scientific evidence as they strive to achieve the best possible outcomes in patients undergoing heart surgery.

Here are some of the measures taken by heart surgeons for various complications of heart surgery:

Perioperative strokes (strokes occurring during or shortly after surgery): Patients over 65 years old have a 5% incidence of stroke, and patients over 75 have an 8% incidence, during or shortly after a coronary artery bypass graft (CABG) procedure. For those having a CABG and heart valve procedure, the incidence is approximately 16%.

Three probable risk factors for perioperative stroke are atherosclerosis (hardening) of the aorta and the aortic arch; vascular disease in the brain; and carotid artery disease.

Among these factors, carotid artery disease can be treated – if screening demonstrates evidence of the disease in a patient – by performing a carotid endarterectomy (excision of material blocking the carotid artery) before, or at the same time as, a CABG procedure. This is shown to be effective in reducing the incidence of perioperative stroke.

Perioperative wound infection: Risk factors for perioperative wound infection include prolonged operative time, obesity, diabetes/use of both internal mammary arteries, chronic obstructive pulmonary disease and prolonged ventilation.

Evidence-based steps taken to prevent sternal wound infections include:

  • Searching for and eliminating active infections in other sites before elective surgery
  • Antibiotics given at the time of operation to reduce wound infections
  • The choice of antibiotics to cover likely pathogens
  • Use of prophylactic antibiotics before the surgical incision is made with enough time to ensure optimal antibiotic levels in tissues during surgery

Perioperative hemorrhage: Control of medications – along with the use of aspirin within 48 hours of the operation – has been shown to curb perioperative hemorrhage.

Perioperative arrhythmias: Perioperative arrhythmias can lead to stroke and complicate medical therapy. In addition, the therapy used to treat arrhythmias can lead to complications.

Early postoperative use of beta-blockers (drugs that reduce the heart rate and lower high blood pressure) can reduce the incidence of arrhythmias. In addition, effective discharge planning must be implemented. This includes laying the foundation for an early discharge with the patient, family and primary care physician/cardiologist; effective plans for transfer from ICU; flexibility; post-discharge follow-up; patient/family post-discharge satisfaction questionnaire; and mechanisms to correct any problems with the patient after discharge.

Physical rehabilitation and other steps that may optimize long-term outcomes: Physical rehabilitation should start before the surgery, continue the first day after surgery and shift into high gear when the patient is transferred from the ICU. The rehabilitation plan should be continued in the evenings and on weekends.

Other steps that may optimize outcomes in cardiac surgery include:

  • Use of the left internal mammary artery in CABG procedures
  • Smoking cessation
  • Aspirin use initiated within 48 hours of CABG
  • Long-term use of beta-blockers
  • Use of statin drugs to control cholesterol
  • Long-term use of ACE inhibitors to reduce blood pressure