CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 118 AFRICA All of the patients underwent pre-operative carotid artery colour Doppler ultrasound. Patients with bilateral severe carotid bifurcation stenosis, a previous history of stroke or transient ischaemic attack, valvular lesions, ventricular aneurysms, singlevessel disease, pre- or postoperative atrial arrhythmia or intraoperative haemodynamic instability, and those scheduled for combined surgery (carotid endarterectomy + CABG) due to severe carotid artery disease were excluded. Postoperative strokewas defined as amajor neurological deficit of vascular origin presenting with global or focal dysfunction of longer than 24 hours. The diagnosis of stroke was confirmed by a neurologist based on postoperative computed tomography (CT) and magnetic resonance imaging (MRI) findings. Written informed consent was obtained from each patient. The study protocol was approved by the Ministry of Health Mersin Provincial Health Directorate local ethics committee (02.04.2019/24). The study was conducted in accordance with the principles of the Declaration of Helsinki. All of the operations were performed by two cardiovascular surgeons. The patients underwent sternotomy with a midsternal incision. Once the aorta was reached, aortic calcifications and plaques were identified by palpation. Before CPB, anticoagulation was administered with 300 IU/kg heparin. During CPB, additional doses of heparin were administered to maintain an activated clotting time of > 400 s. Aortic cannulation was applied to the distal segment of the ascending aorta below the innominate artery. For proximal anastomosis, an antegrade cardioplegia cannula was inserted into the most suitable side of the ascending aorta. Following two-stage venous cannulation, CPB was initiated. Myocardial protection was achieved by antegrade cold-blood cardioplegia and moderate systemic hypothermia (28–32°C). Using the singlethread suture technique, distal and proximal anastomoses were performed. For proximal anastomoses, a side-biting clamp was used in the patients in whom MCT was applied. Statistical analysis Statistical analysis was performed using SPSS software, version 13.0 for Windows (SPSS Inc, Chicago, IL, USA). Descriptive data are expressed as the mean ± standard deviation (SD), median (min–max) or number and percentage. The Student’s t-test was used to compare normally distributed quantitative data, while the Mann–Whitney U-test was used to compare non-normally distributed quantitative data between the groups. The chi-squared test and Fisher’s exact chi-squared test were performed to compare qualitative data between the groups. A p-value of < 0.05 was considered statistically significant at the 95% confidence interval. Results Of the patients, 127 were men and 44 were women. The mean age was 83.05 ± 8.81 years in group 1 and 82.14 ± 8.92 years in group 2. All of the patients were operated on under CPB. The baseline demographic and clinical characteristics of the patients are shown in Table 1. The mean cross-clamp time was significantly longer in group 1 than in group 2 (p < 0.01) (Table 2). However, there was no statistically significant difference in the mean CPB time between the groups (p > 0.005). The mean number of grafts was 2.82 in group 1 and 2.98 in group 2. The ratio of cross-clamp time to the number of grafts was significantly higher in group 1 than in group 2 (p < 0.001). Stroke was seen in one patient (1.13%) in group 1 and one patient (1.20%) in group 2, indicating no statistically significant difference between the groups (p > 0.005). In addition, two patients died from stroke, one in each group, indicating no significant difference in the mortality rate between the groups (p > 0.005). The mean length of intensive care unit stay was significantly shorter in group 2 than in group 1 (p = 0.001); however, there was no significant difference in the mean length of hospital stay between the groups (p = 0.122) (Table 3). One patient in group 1 was diagnosed with stroke in the early postoperative period. Another patient in group 2 developed postoperative stroke and associated symptoms on the second day after surgery (Table 4). The number of patients undergoing urgent operations was significantly higher in group 2 (p = 0.008). There was no statistically significant difference in incidence of diabetes mellitus, congestive heart failure or hypertension between the groups (p = 0.012, 0.064 and 0.007, respectively). Discussion In recent years, the evaluation of surgical outcomes after CABG in elderly individuals has gained importance. In our study, we included octogenarians who were definitely high-risk cases for Table 1. Baseline demographic and clinical characteristics of the patients Characteristics Group 1 (n = 88) % Group 2 (n = 83) % Statistic of test; p-value Gender Female Male 23 66 26.1 75 21 61 25.3 74.49 χ2 = 0.001; 0.980 Age, years 83.05 ± 8.81 82.14 ± 8.92 t = –1.119; 0.268 Diabetes mellitus yes no 30 58 34.09 65.9 38 45 45.7 54.2 χ2 = 6.135; 0.012* Hypertension yes no 67 21 76.1 23.8 73 10 87.9 12.04 χ2 = 7.236; 0.007** Chronic heart failure yes no 16 72 18.1 8.8 22 61 26.5 73.4 χ2 = 3.530; 0.064 Chronic renal failure yes no 1 87 1.13 98.8 1 82 1.2 98.7 Fχ2 = 0.142; 1.000 Urgent surgery yes no 1 87 1.1 98.8 6 77 7.2 92.7 χ2 = 7.123; 0.008** Table 2. Intra-operative data Characteristics Group 1 (n = 88) Mean ± SD Group 2 (n = 83) Mean ± SD Statistic of test; p-value Number of grafts, n 2.82 ± 0.50 2.98 ± 0.56 U = 11316.6; 0.001** Cross-clamp time, min 58.80 ± 14.40 39.08 ± 14.11 U = 5008.9; 0.001** Cross-clamp time/graft number ratio 21.15 ± 6.11 12.15 ± 6.01 U = 3001,0; 0.001** Cardiopulmonary bypass time, min 75.39 ± 20.12 73.58 ± 18.01 U = 12798.4; 0.383 SD: standard deviation.
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