Cited by 286Cardiac and Coronary Surgery TechniquesMechanical Circulatory Support DevicesCardiac, Anesthesia and Surgical Outcomes

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Predictors of low cardiac output syndrome after coronary artery bypass

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Rao, Vivek, Ivanov, Joan, Weisel, Richard D., Ikonomidis, John S., Christakis, George T., David, Tirone E.·1996·The Journal of Thoracic and Cardiovascular Surgery

DOI 10.1016/s0022-5223(96)70176-9

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Abstract

The purpose of this study was to identify patients at risk for the development of low cardiac output syndrome after coronary artery bypass. Low cardiac output syndrome was defined as the need for postoperative intraaortic balloon pump or inotropic support for longer than 30 minutes in the intensive care unit to maintain the systolic blood pressure greater than 90 mm Hg and the cardiac index greater than 2.2 L/min per square meter. The preoperative patient characteristics that were independent predictors of low cardiac output syndrome were identified among 4558 consecutive patients who underwent isolated coronary artery bypass at The Toronto Hospital between July 1, 1990, and December 31, 1993. The overall prevalence of low cardiac output syndrome was 9.1% (n = 412). The operative mortality rate was higher in patients in whom low cardiac output syndrome developed than in those in whom it did not develop (16.9% versus 0.9%, p < 0.001). Stepwise logistic regression analyses identified nine independent predictors of low output syndrome (percent frequency in parentheses) and calculated the factor-adjusted odds ratios associated with each predictor: (1) left ventricular ejection fraction less than 20% (27%, odds ratio 5.7); (2) repeat operation (25%, odds ratio 4.4); (3) emergency operation (27%, odds ratio 3.7); (4) female gender (16%, odds ratio 2.5); (5) diabetes (13%, odds ratio 1.6); (6) age older than 70 years (13%, odds ratio 1.5); (7) left main coronary artery stenosis (12%, odds ratio 1.4); (8) recent myocardial infarction (16%, odds ratio 1.4); and (9) triple-vessel disease (10%, odds ratio 1.3). Low cardiac output syndrome is a clinical outcome that may result from inadequate myocardial protection or perioperative ischemic injury. Patients at high risk for the development of low cardiac output syndrome should be the focus of trials of new techniques of myocardial protection to resuscitate the ischemic myocardium.

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Background
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Background
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Banach, M., Mariscalco, G., Uğurlucan, M., Mikhailidis, D. P., Barylski, M., & Rysz, J. (2008) · EP Europace · doi:10.1093/europace/eun273 · Cited by 56
Reoperative coronary bypass surgery: Effect of patent grafts and retrograde cardioplegia
Borger, M. A., Rao, V., Weisel, R. D., Floh, A. A., Cohen, G. N., Feindel, C. M., Scully, H. E., Mickleborough, L. L., & Yau, T. M. (2001) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1067/mtc.2001.111382 · Cited by 56
Role of clinical pathologies in myocardial injury following ischaemia and reperfusion
Galiñanes, M. (2003) · Cardiovascular Research · doi:10.1016/j.cardiores.2003.11.028 · Cited by 56
Temporary biventricular pacing decreases the vasoactive-inotropic score after cardiac surgery: A substudy of a randomized clinical trial
Nguyen, H. V., Havalad, V., Aponte-Patel, L., Murata, A., Wang, D. Y., Rusanov, A., Cheng, B., Cabreriza, S. E., & Spotnitz, H. M. (2012) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2012.07.020 · Cited by 55
“The VIS in adults is expected to differ from the VIS in infants because the response of cardiac muscle and vasculature to inotropic and vasopressor mediations differs between pediatric and adult patients.(25) The VIS clearly merits further evaluation as an adjunct to management of adult patients after CPB.”
Risk factors for low cardiac output syndrome in children with congenital heart disease undergoing cardiac surgery: a retrospective cohort study
Du, X., Chen, H., Song, X., Wang, S., Hao, Z., Yin, L., & Lu, Z. (2020) · BMC Pediatrics · doi:10.1186/s12887-020-1972-y · Cited by 54
Predictors of inotrope use in patients undergoing concomitant coronary artery bypass graft (CABG) and aortic valve replacement (AVR) surgeries at separation from cardiopulmonary bypass (CPB)
Ahmed, I., House, C. M., & Nelson, W. B. (2009) · Journal of Cardiothoracic Surgery · doi:10.1186/1749-8090-4-24 · Cited by 53
“We did not find any significant association between particular gender and use of inotrope as compared to increased risk in female gender in the study by Rao et al [9].”
Influential
The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I
SICS Study Group, Hiemstra, B., Koster, G., Wiersema, R., Hummel, Y. M., van der Horst, I. C. C., Snieder, H., Eck, R. J., Kaufmann, T., Scheeren, T., et al. (2019) · Intensive Care Medicine · doi:10.1007/s00134-019-05527-y · Cited by 53
Diastolic Dysfunction, Cardiovascular Aging, and the Anesthesiologist
Sanders, D., Dudley, M., & Groban, L. (2009) · Anesthesiology Clinics · doi:10.1016/j.anclin.2009.07.008 · Cited by 51
“Other risk stratification characteristics that are typically encountered include prolonged CPB time, female sex, and diminished systolic function (42,43); however, there may exist a group of patients who are still at elevated risk for a more complicated hospital course who do not necessarily display these characterist…”
Background
Evaluating Surrogate Measures of Renal Dysfunction After Cardiac Surgery
Wijeysundera, D. N., Rao, V., Beattie, W. S., Ivanov, J., & Karkouti, A. K. (2003) · Anesthesia & Analgesia · doi:10.1213/01.ane.0000056824.69668.33 · Cited by 49
“base has previously been described (16).”
The Insulin Cardioplegia Trial: Myocardial protection for urgent coronary artery bypass grafting
Rao, V., Christakis, G. T., Weisel, R. D., Ivanov, J., Borger, M. A., & Cohen, G. N. (2002) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1067/mtc.2002.121686 · Cited by 49
Predicting the Risk of Death from Heart Failure After Coronary Artery Bypass Graft Surgery
Surgenor, S. D., O’Connor, G. T., Lahey, S. J., Quinn, R. D., Charlesworth, D. C., Dacey, L. J., Clough, R. A., Leavitt, B. J., DeFoe, G. R., Fillinger, M. P., et al. (2001) · Anesthesia & Analgesia · doi:10.1097/00000539-200103000-00008 · Cited by 49
Insulin cardioplegia for elective coronary bypass surgery
Rao, V., Borger, M. A., Weisel, R. D., Ivanov, J., Christakis, G. T., Cohen, G. N., & Yau, T. M. (2000) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1067/mtc.2000.105257 · Cited by 47
Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function
Chukwuemeka, A. O., Rao, V., Armstrong, S. M., Ivanov, J., & David, T. E. (2006) · European Journal of Cardio-Thoracic Surgery · doi:10.1016/j.ejcts.2005.11.028 · Cited by 46
Decreasing significance of left ventricular dysfunction and reoperative surgery in predicting coronary artery bypass grafting–associated mortality: A twelve-year study
Davierwala, P. M., Maganti, M. D., & Yau, T. M. (2003) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/s0022-5223(03)00936-x · Cited by 46
“Details of this database have been published elsewhere.(14) Analysis Data were collected and managed in a Microsoft Access database”
Method
Increased mortality and perioperative complications in patients with previous elective percutaneous coronary interventions undergoing coronary artery bypass surgery
Bonaros, N. E., Hennerbichler, D., Friedrich, G. J., Kocher, A. A., Pachinger, O. M., Laufer, G., & Bonatti, J. O. (2009) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2008.09.041 · Cited by 45
“1 mg/kg/min).(14) Death was considered of cardiac origin if it was caused by perioperative myocardial infarction, significant cardiac arrhythmias, or refractory low cardiac output syndrome.”
Background
ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery: Summary Article A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery) Developed in Collaboration With the American Society for Thoracic Surgery and the Society of Thoracic Surgeons COMMITTEE MEMBERS
Eagle, K. A., Guyton, R. A., Davidoff, R., Edwards, F. H., Ewy, G. A., Gardner, T. J., Hart, J. C. A., Herrmann, H. C., Hillis, L. D., Lytle, B. W., et al. (2004) · Cited by 45
Incidence and risk calculation of inotropic support in patients undergoing cardiac surgery with cardiopulmonary bypass using an automated anaesthesia record-keeping system
Mu¨ller, M., Junger, A., Bra¨u, M., Kwapisz, M., Schindler, E., Akintu¨rk, H., Benson, M., & Hempelmann, G. (2002) · British Journal of Anaesthesia · doi:10.1093/bja/89.3.398 · Cited by 43
Milrinone for cardiac dysfunction in critically ill adult patients: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis
Koster, G., Bekema, H., Wetterslev, J., Gluud, C. N., Keus, F., & van der Horst, I. C. C. (2016) · Intensive Care Medicine · doi:10.1007/s00134-016-4449-6 · Cited by 40
“Low cardiac output syndrome was defined as a pre-existing or developing state of cardiac insufficiency with underlying left or right ventricular systolic dysfunction requiring inotrope support [13].”
Background
Analysis of risk factors of low cardiac output syndrome after congenital heart disease operation: what can we do
Song, B., Dang, H., & Dong, R. (2021) · Journal of Cardiothoracic Surgery · doi:10.1186/s13019-021-01518-7 · Cited by 41
“Therefore, through strict monitoring of various indicators of cardiac output, early diagnosis of LCOS, and timely search for the cause and treatment, the effects of reducing complications and improving prognosis can be achieved [36].”
Background
Anesthesia for Cardiac Surgical Procedures
Nussmeier, N. A., Hauser, M. C., Sarwar, M., Grigore, A. M., & Searles, B. E. (2010) · Elsevier eBooks · doi:10.1016/b978-0-443-06959-8.00060-1 · Cited by 41
Increased endothelin-1 production in diabetic patients after cardioplegic arrest and reperfusion impairs coronary vascular reactivity: Reversal by means of endothelin antagonism
Verma, S., Maitland, A. M., Weisel, R. D., Fedak, P. W. M., Li, S., Mickle, D. A. G., Li, R., Ko, L., & Rao, V. (2002) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1067/mtc.2002.121972 · Cited by 41
Does On-Pump/Beating-Heart Coronary Artery Bypass Grafting Offer Better Outcome in End-Stage Coronary Artery Disease Patients?
Prifti, E., Bonacchi, M., Giunti, G., Frati, G., Proietti, P., Leacche, M., Salica, A., Sani, G., & Brancaccio, G. (2010) · Journal of Cardiac Surgery · doi:10.1111/j.1540-8191.2000.tb01300.x · Cited by 40
Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis
Licker, M. J., Çıkırıkçıoğlu, M., Inan, C., Cartier, V., Kalangos, A., Theologou, T., Cassina, T., & Diaper, J. (2010) · Critical Care · doi:10.1186/cc9040 · Cited by 39
“In large cohorts of patients undergoing cardiac surgery, post-CPB LV dysfunction has been linked to age, female gender, history of heart failure, recent myocardial infarct, low LV ejection fraction, prolonged aortic cross-clamping and complexity of surgery [7-11].”
Current diagnosis and management of left main coronary disease
Chikwe, J., Kim, M., Goldstone, A. B., Fallahi, A., & Athanasiou, T. (2010) · European Journal of Cardio-Thoracic Surgery · doi:10.1016/j.ejcts.2010.03.003 · Cited by 39
“Low cardiac output states are significantly more common post-CABG in patients with significant LMCA disease [50].”
Background
Risk Factors for Postoperative Heart Failure in Patients Operated on for Aortic Stenosis
Vánky, F. B., Håkanson, E., Tamás, É., & Svedjeholm, R. (2006) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2005.11.036 · Cited by 36
Perioperative outcomes in reoperative cardiac surgery guided by cardiac multidetector computed tomographic angiography
Maluenda, G., Goldstein, M. A., Lemesle, G., Weissman, G., Weigold, G., Landsman, M., Hill, P. C., Pita, F., Corso, P. J., Boyce, S. W., et al. (2010) · American Heart Journal · doi:10.1016/j.ahj.2009.11.005 · Cited by 36
Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study
Anastasiadis, K., Antonitsis, P., Vranis, K., Kleontas, A., Asteriou, C., Grosomanidis, V., Tossios, P., & Argiriadou, H. (2016) · Interactive Cardiovascular and Thoracic Surgery · doi:10.1093/icvts/ivw213 · Cited by 34
“[3] identified preoperative reduced left ven-”
Predictors of contemporary coronary artery bypass grafting outcomes
Weisel, R. D., Nussmeier, N. A., Newman, M. F., Pearl, R. G., Wechsler, A. S., Ambrosio, G., Pitt, B., Clare, R. M., Pieper, K. S., Mongero, L. B., et al. (2014) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2014.08.018 · Cited by 35
“SLVD was defined as the new use of a mechanical circulatory assist device, such as an intra-aortic balloon pump or a ventricular assist device, during or after CABG for at least 1 hour for the treatment of low cardiac output.(8) Indications for using circulatory assist devices were determined by the attending physicia…”
Method
Guías de práctica clínica para el manejo del síndrome de bajo gasto cardíaco en el postoperatorio de cirugía cardíaca
Vela, J. L. P., Benitez, J. C. M., González, M. C., López, M. Á. D. L. C., Pérez, R. H., Meneses, V. S., & Sáez, F. D. N. (2012) · Medicina Intensiva · doi:10.1016/j.medin.2012.02.007 · Cited by 33
Gene polymorphisms and cytokine plasma levels as predictive factors of complications after cardiopulmonary bypass
Jouan, J., Golmard, L., Benhamouda, N., Dürrleman, N., Golmard, J., Ceccaldi, R., Trinquart, L., Fabiani, J., Tartour, É., Jeunemaı̂tre, X., et al. (2012) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2011.12.022 · Cited by 33
The Toronto Risk Score for adverse events following cardiac surgery
Ivanov, J., Borger, M. A., Rao, V., & David, T. E. (2006) · Canadian Journal of Cardiology · doi:10.1016/s0828-282x(06)70900-x · Cited by 33
Decreasing mortality for coronary artery bypass surgery in octogenarians
Maganti, M. D., Rao, V., Brister, S. J., & Ivanov, J. (2009) · Canadian Journal of Cardiology · doi:10.1016/s0828-282x(09)70481-7 · Cited by 33
“The details of this database have been published previously (5,7).”
BackgroundResult
A randomized, blinded trial of the antioxidant pegorgotein: No reduction in neuropsychological deficits, inotropic drug support, or myocardial ischemia after coronary artery bypass surgery
Butterworth, J. F. I., Legault, C., Stump, D. A., Coker, L. H., Hammon, J. W., Troost, B. T., Royster, R. L., & Prough, D. S. (1999) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1016/s1053-0770(99)90121-0 · Cited by 33
Prognostic Value of Tissue Doppler‐Derived E/e′ on Early Morbid Events after Cardiac Surgery
Groban, L., Sanders, D. M., Houle, T. T., Antonio, B. L., Ntuen, E. C., Zvara, D. A., Kon, N. D., & Kincaid, E. H. (2010) · Echocardiography · doi:10.1111/j.1540-8175.2009.01076.x · Cited by 32
“In this study, left ventricular diastolic filling pressures were classified into three groups: (1) normal was characterized by E/e′ < 8; (2) moderately elevated was characterized by E/e′ ≥ 8 and ≤ 15; and (3) severely elevated was characterized by E/e′ > 15.”
BackgroundMethod
Prevention of TNFα-associated myocardial dysfunction resulting from cardiopulmonary bypass and cardioplegic arrest by glucocorticoid treatment
Liakopoulos, O. J., Teucher, N., Mühlfeld, C., Middel, P., Heusch, G., Schöndube, F. A., & Dörge, H. (2006) · European Journal of Cardio-Thoracic Surgery · doi:10.1016/j.ejcts.2006.04.019 · Cited by 32
“Compromised left ventricular function due to acute ischemia in patients with unstable angina referred for urgent coronary artery bypass grafting is a strong predictor of postoperative low cardiac output failure [1,2].”
Background
Is Vasoactive-Inotropic Score a Predictor for Mortality and Morbidity in Patients Undergoing Coronary Artery Bypass Surgery?
Baysal, P. K., Güzelmeriç, F., Kahraman, E., Gürcü, M. E., Erkılınç, A., & Örki, T. (2021) · Brazilian Journal of Cardiovascular Surgery · doi:10.21470/1678-9741-2020-0219 · Cited by 31
“Cardiac dysfunction and intraoperative factors are the most important predictors for mortality and morbidity in open-heart surgery[2-5].”
Background
Predictive accuracy study: comparing a statistical model to clinicians’ estimates of outcomes after coronary bypass surgery
Ivanov, J., Borger, M. A., David, T. E., Cohen, G. N., Walton, N. A., & Naylor, C. D. (2000) · The Annals of Thoracic Surgery · doi:10.1016/s0003-4975(00)01387-4 · Cited by 31
A Clinical Score to Predict the Need for Intraaortic Balloon Pump in Patients Undergoing Coronary Artery Bypass Grafting
Miceli, A., Duggan, S. M. J., Capoun, R., Romeo, F., Caputo, M., & Angelini, G. D. (2010) · The Annals of Thoracic Surgery · doi:10.1016/j.athoracsur.2010.04.035 · Cited by 30
“such as low ejection fraction, advanced age, left main stenosis, redo operation, recent myocardial infarction, poor ejection fraction, and New York Heart Association III-IV class have been identified as predictors of intraoperative or postoperative use of IABP [11-14].”
Background
Management of perioperative ventricular dysfunction
Griffin, M. J., & Hines, R. L. (2001) · Journal of Cardiothoracic and Vascular Anesthesia · doi:10.1053/jcan.2001.20283 · Cited by 30
Intravenous ivabradine versus placebo in patients with low cardiac output syndrome treated by dobutamine after elective coronary artery bypass surgery: a phase 2 exploratory randomized controlled trial
Nguyen, L. S., Squara, P., Amour, J., Carbognani, D., Bouabdallah, K., Thierry, S., Apert-Verneuil, C., Moyne, A., & Cholley, B. (2018) · Critical Care · doi:10.1186/s13054-018-2124-8 · Cited by 29
Prediction of low cardiac output syndrome in patients following cardiac surgery using machine learning
Hong, L., Xu, H., Ge, C., Hong, T., Shen, X., Song, X., Guan, D., & Zhang, C. (2022) · Frontiers in Medicine · doi:10.3389/fmed.2022.973147 · Cited by 29
“According to previous reports (10, 13), the criteria for LCOS in our study included: (1) Patients with a cardiac index (CI) reduced to < 2.”
BackgroundMethod
Coronary revascularization in diabetic patients: Current state of evidence.
Singh, M., Arora, R. R., Kodumuri, V., Khosla, S., & Jawad, E. (2011) · Europe PMC (PubMed Central) · Cited by 29
Calcium antagonists are associated with reduced mortality after cardiac surgery: a propensity analysis
Wijeysundera, D. N., Beattie, W. S., Rao, V., Ivanov, J., & Karkouti, K. (2004) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/s0022-5223(03)00695-0 · Cited by 29
High levels of B-type natriuretic peptide predict weaning failure from mechanical ventilation in adult patients after cardiac surgery
Lara, T. M., Hajjar, L. A., de Almeida, J. P., Fukushima, J. T., Barbas, C. S. V., Rodrigues, A. R. B., Nozawa, E., Feltrim, M. I. Z., de Almeida, E. P. M., Coimbra, V. R. D. M., et al. (2013) · Clinics · doi:10.6061/clinics/2013(01)oa05 · Cited by 28
“73 [28-127], p = 0.”
Síndrome de bajo gasto cardiaco en el postoperatorio de cirugía cardiaca. Perfil, diferencias en evolución clínica y pronóstico. Estudio ESBAGA
Vela, J. L. P., Rivera, J. J. J., Llorente, M. A., de Marcos, B. G., Torrado, H., Laborda, C. G., Zamora, M. D. F., Fernández, F. J. G., & Benitez, J. C. M. (2017) · Medicina Intensiva · doi:10.1016/j.medin.2017.05.009 · Cited by 29
Cardioprotective effect of pretreatment with β-glucan in coronary artery bypass grafting
Aarsæther, E., Rydningen, M. B., Engstad, R. E., & Busund, R. (2006) · Scandinavian Cardiovascular Journal · doi:10.1080/14017430600868567 · Cited by 27
“‘‘Low cardiac output syndrome’’ affects 9% of patients undergoing coronary artery bypass grafting (CABG) and is associated with increased mortality (8).”
Background

Authors: Rao, V., Ivanov, J., Weisel, R. D., Ikonomidis, J. S., Christakis, G. T., & David, T. E.
Affiliations: University of Toronto (CA)
ORCID: Rao, Vivek
Ikonomidis, John S.
David, Tirone E.
Venue: The Journal of Thoracic and Cardiovascular Surgery
Publisher: Elsevier BV
Published: 1996-07
Volume: 112
Issue: 1
Pages: 38-51
ISSN: 0022-5223 (ISSN-L)
DOI: 10.1016/s0022-5223(96)70176-9
OpenAlex: W2072841444
Cited by: 286
References: 32
Citations by year: 2026: 4 · 2025: 7 · 2024: 6 · 2023: 14 · 2022: 6 · 2021: 9 · 2020: 15 · 2019: 7 · 2018: 11 · 2017: 9 · 2016: 10 · 2015: 7 · 2014: 12 · 2013: 9 · 2012: 17
FWCI: 5.41
Type: journal article
Language: en
Open access: bronze
doi.org
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 7310 d)
Locations: Journal of Thoracic and Cardiovascular Surgery (publishedVersion)
PubMed (publishedVersion)
Funders: Heart and Stroke Foundation of Canada
Medical Research Council Canada
Medical Research Council
Topics: Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Mechanical Circulatory Support Devices
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
Keywords: low cardiac output syndrome, coronary artery bypass grafting, risk factors, left ventricular ejection fraction, reoperation, emergency surgery, female sex, diabetes mellitus, old age, left main coronary artery stenosis, recent myocardial infarction, three-vessel coronary artery disease, postoperative mortality, cardioprotection, perioperative myocardial ischemia, intra-aortic balloon pump, inotropic support
MeSH terms: Aged, Coronary Artery Bypass, Cardiac Output, Low, Female, Humans, Male, Middle Aged, Postoperative Complications, Prognosis, Prospective Studies, Sex Factors, Syndrome, Survival Rate, Odds Ratio, Ventricular Dysfunction, Left, Diabetes Complications

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Predictors of low cardiac output syndrome after coronary artery bypass

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