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Sudish C. Murthy
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Bruce W. Lytle
Eugene H. Blackstone
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J Thorac Cardiovasc Surg 2007;134:484-490
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Ventilatory dependency after cardiovascular surgery

Sudish C. Murthy, MD, PhDa,*, Alejandro C. Arroliga, MDb, Peter A. Walts, MDa, Jingyuan Feng, MSc, Jean-Pierre Yared, MDd, Bruce W. Lytle, MDa, Eugene H. Blackstone, MDa,c

a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
b Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
c Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
d Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.

Received for publication November 28, 2006; revisions received February 23, 2007; accepted for publication March 8, 2007.

* Address for reprints: Sudish C. Murthy, MD, PhD, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk F24, Cleveland, OH 44195. (Email: murthys1{at}ccf.org).

Objectives: Ventilatory dependency is a widely recognized complication of cardiovascular surgery, often leading to tracheostomy. Some risk factors for its occurrence have been documented. Less well characterized are short- and long-term outcomes. Therefore, objectives were to identify risk factors for ventilatory dependency, assess its short- and long-term outcomes, and determine impact of tracheostomy.

Methods: From January 1998 to September 2001, 12,777 patients underwent cardiovascular surgery and survived at least 72 hours. Of these patients, 704 (5.5%) developed ventilatory dependency (cumulative intubation >72 hours); 185 (26%) underwent tracheostomy. Preoperative, intraoperative, and intensive care unit admission data were used sequentially to understand predictors of ventilatory dependency. Outcomes were analyzed by time-related methods, and impact of tracheostomy was assessed using competing-risks analysis.

Results: Hemodynamic status on intensive care unit admission (low cardiac output, vasopressor use, pulmonary hypertension; P < .0001) and early postoperative events (stroke, bacteremia; P < .0001) were more important than preoperative and intraoperative variables in predicting ventilatory dependency. Survival at 30 days, 1 year, and 5 years thereafter was 76%, 49%, and 33% and was strongly associated with favorable hemodynamic status. By 28 days, 24% of patients received tracheostomy; survival at 30 days and 2 years thereafter was 74% and 26%, considerably below anticipated survivals of 84% and 58%.

Conclusions: Improved operative and postoperative strategies to preserve myocardial function and restore hemodynamics should decrease the prevalence of ventilatory dependency. Unfortunately, preoperative models of ventilatory dependency are too insensitive for clinical use. Tracheostomy and its outcome are also poorly predicted, highlighting the complex interaction of events altering patients’ conditions before and after tracheostomy.

Abbreviations and Acronyms CL = confidence limit; CTA = Cardiothoracic Anesthesia registry; CVIR = Cardiovascular Information Registry; ICU = intensive care unit; NYHA = New York Heart Association; STS = The Society of Thoracic Surgeons




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