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Eur J Cardiothorac Surg 2004;26:535-541
© 2004 Elsevier Science NL

Influence of obesity on in-hospital and early mortality and morbidity after myocardial revascularization

Ariena H. Lindhout, Constantijn W. Wouters, Luc Noyez*

Department of Thoracic and Cardiac Surgery, 414, Heart center, Nijmegan University Hospital, St Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands

Received 3 March 2004; received in revised form 12 May 2004; accepted 20 May 2004.

* Corresponding author. Tel.: +31-24-361-3711; fax: +31-24-354-0129
e-mail: l.noyez{at}thorax.umcn.nl


   Abstract
Top
 Abstract
1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Objective: Obese patients are thought to have an increased risk for complications in coronary artery bypass surgery. Several risk stratification systems do not identify obesity as a variable for risk adjustment. The aim of this study is to evaluate the in-hospital and early (one year) mortality and morbidity in obese and non-obese patients after a CABG in the UMC St Radboud. Methods: The data of 1130 patients undergoing a myocardial revascularization from January 2000 to August 2002 were analyzed. Obesity was measured by the body mass index (BMI). A BMI≥30 kg/m2 was defined as obese. We compared 206 obese patients with 924 non-obese patients. Uni- and multivariate analysis were used to analyze the results. The 1-year survival was analyzed using Kaplan–Meier methods. Results: There were no significant differences between obese and non-obese patients according to postoperative myocardial infarction, re-operation for bleeding, in-hospital mortality, renal complications, neurological complications, pulmonary complications, gastrointestinal complications, re-intubation, re-admission on intensive care, ventilation time, days on intensive care, days in hospital and late mortality. Only the incidence of postoperative wound infections was increased in obese patients, 8.3% in the obese versus 4.4% in the non-obese (P=0.02). Multivariate analysis identified obesity only as risk factor for postoperative for wound infections (P=0.04, odds ratio: 1.97). Conclusions: Obese patients do not have an increased risk of in-hospital and early (1 year) mortality after CABG. However, obese patients have an increased risk of postoperative wound infections compared to non-obese patients.

Key Words: Myocardial revascularization • Obesity • Mortality • Morbidity


   1. Introduction
Top
 Abstract
 1. Introduction
2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 
Worldwide, the prevalence of obesity has taken on epidemic forms; over a billion people are overweight and 300 million people are obese. In The Netherlands, the prevalence is also increasing: 40% of the adults have a high body weight (body mass index, BMI≥25); 10% of the Dutch population is obese (BMI≥30) [1].

Obesity is supposed to be a risk factor for patients undergoing CABG: it is assumed that obesity increases the risk of in-hospital mortality and postoperative morbidity [2–4]. However, in several score systems [5–9], body weight is not identified as a variable needed for risk stratification in heart surgery. Some studies have even shown that the risk of in-hospital and early postoperative mortality is not by definition higher for obese patients [10–19] although, there is an increased risk of in-hospital and early postoperative morbidity [2–19].

The aim of this study is to evaluate the in-hospital and early (1-year postoperative) mortality and morbidity in obese and non-obese patients after a coronary artery bypass grafting in the UMC St Radboud.


   2. Patients and methods
Top
 Abstract
 1. Introduction
 2. Patients and methods
3. Results
 4. Discussion
 5. Conclusion
 References
 
2.1. Patients
With the aid of our database, Coronary Surgery Database Radboud Hospital (CORRAD), a registry that stores pre-, peri-, postoperative data as well as follow-up data on all patients undergoing myocardial revascularization, we identified a series of 1130 patients undergoing an isolated myocardial revascularization from January 2000 to August 2002.

Obesity was assessed using BMI, since this is the body size measurement that best correlates with the body fat content. The BMI is calculated as weight (kg)/height squared (m2). The BMI of the total group was 27.1±3.6, with a median of 26.9 and a range from 17.8 to 46.2 (Fig. 1) . Patients with a BMI≥30 were defined as obese. Of the total group, 206 patients, 18.2%, (group A) had a BMI≥30, 924 patients, 81.8%, (group B) had a BMI<30. Table 1 presents the studied variables and their definition.



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  		Fig. 1. Histogram of the distribution of the body mass index of the total population (n=1130). Mean 27.1±3.6, median 26.9, range 17.8–46.2. Percentile: 25: 24.6, 50: 26.9, 75: 29.1.

 

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  		Table 1. Variables and definitions

 
2.2. Surgical technique
Nine hundred and sixty-nine patients (85.8%) were operated using standard cardiopulmonary bypass technique, aortic and right atrial (two stage) cannulation, hypothermia (28–32 °C), and myocardial protection using St Thomas' Hospital cardioplegia. One hundred and sixty-one (14.2%) patients were operated ‘off-pump’, without using cardiopulmonary bypass. For the patients operated using cardiopulmonary bypass, the mean time on the extra-corporal circulation (ECC-time) was 78±39 min (range 39–117), and the mean duration of aortic cross-clamping (AoX-time) was 43±22 min (range 21–65). For the total group, there was a mean of 1.9±0.4 grafts (range 1.5–2.3), and a mean of 3.1±2.2 (range 0.9–5.3) distal anastomoses. Of all patients, 1034 patients (91.5%) received at least one arterial graft.

2.3. Follow-up
Our follow-up concerns the first year postoperative, all patients were included. These data are the results of our yearly organized follow-up. This consists of written survey directed to all patients. In this survey, survival/mortality and non-fatal cardiac events were registered. Mortality was divided in cardiovascular-related and non-cardiovascular-related mortality. A new non-fatal cardiac event was registered in case of a new myocardial infarction, the return of angina pectoris, a new positive treadmill test after a negative one, angioplasty, re-operation, congestive heart failure, rhythm disturbances and stroke.

2.4. Statistic analysis
Characteristics of patients are presented as percentage for dichotome variables, and as mean±standard deviation (SD), and range for numerical variables. Differences in percentages were tested with the {chi}2-test, and numerical variables were tested with the t-test. Logisitic regression was used to assess the relationship between BMI (yes/no) and outcome. One-year survival was analyzed using Kaplan–Meier method and compared with the log-rank test. Statistical significance was assumed at P≤0.05 (P=0.000 means P<0.0005).


   3. Results
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
4. Discussion
 5. Conclusion
 References
 
3.1. Preoperative data
Univariate analysis showed no statistical significant differences for age, family history of heart diseases, vascular diseases, neurological diseases, renal diseases, pulmonary diseases and gastrointestinal diseases. Obese patients were especially men (P<0.002) and had a higher incidence of diabetes (P<0.001), hypertension (P<0.02) and hyperlipidemia (P<0.02) (Table 2).


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  		Table 2. Preoperative variables

 
From the cardial preoperative variables, no significant differences were found for preoperative PTCA, previous myocardial infarction, recent preoperative infarction (<30 days), no sinus rhythm, mild valve disease, extent of coronary disease, main stem stenosis, NYHA-class, operative priority and left ventricle function. A significant difference was found for the re-operations (P<0.01) (Table 2).

3.2. Peroperative data
The univariate analysis of peroperative variables showed no significant differences for diffuse coronary pathology, aortic root pathology, number of grafts, number of distal anastomoses, the use of minimal one graft, aortic cross-clamp time, ECC-time and off-pump time (Table 3).


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  		Table 3. Peroperative variables

 
3.3. Postoperative and follow-up data
Univariate analysis showed no statistical significant differences between obese and non-obese patients according to postoperative myocardial infarction, re-operation for bleeding, in-hospital mortality, renal complications, neurological complications, pulmonary complications, gastrointestinal complications, re-intubation, re-admission on intensive care, ventilation time, days on intensive care, days in hospital (UMCN) and late mortality. The percentage of postoperative wound infections was increased in obese patients (P<0.02). There was also no significant difference for the early mortality, late admission in hospital, late admission cardiovascular and late admission non-cardiovascular (Table 4). Obesity was determined to be an independent multivariate predictor of wound problems (Table 5).


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  		Table 4. Postoperative and follow-up variables

 

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  		Table 5. Relation of obesity to outcome

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
5. Conclusion
 References
 
Obesity is considered to be a major risk factor in patients undergoing CABG surgery. A high body weight (BMI>25 kg/m2) and especially obesity (BMI>30 kg/m2) is attended with the presentation of comorbidity, like cardiovascular diseases, diabetes mellitus, hyperlipidemia, hypertension, different forms of cancer and problems with the musculoskeletal system. With an increasing BMI, the comorbidity increases [1]. Obesity also alters the pulmonary function leading to an increase in functional residual capacity, and a decrease in vital capacity and maximum voluntary ventilation [20,21].

On the other hand, in several score systems, obesity is not identified as a variable needed for risk stratification. (Table 6) in the publication of Jones et al. weight and heights are identified as level 2 variables. Variables were not clearly shown to relate directly to short-term CABG mortality but with potential reseach or administrative interest [5–12,22]. Several recent publications suggest that obesity has no influence on the mortality. Although, there is an increased risk of in-hospital and early postoperative morbidity after CABG [2–19].


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  		Table 6. Review of risk score systems related to the variable body weight

 
4.1. Patient characteristics
Our obese patients were more likely to be men, diabetic, hypertensive and they have a higher incidence of hyperlipidemia (Table 2). This was also found in other studies [11,15–17]. Several studies found that obese patients who underwent coronary revascularization were younger than non-obese patients who underwent coronary revascularization [11,12,15–19]. We did not find this difference.

4.2. Mortality
Our study has shown that obesity is not a risk factor for in-hospital mortality (Table 4). This is in concurrence with previous studies [9–17]. Prabhakar et al. found a significant increase for in-hospital mortality in obese patients who had a BMI higher than 35 kg/m2. He found that moderate obesity (BMI>35 kg/m2) was associated with a slight but statistically significant increase in risk-adjusted increase in mortality and those with extreme obesity (BMI>40 kg/m2) had a nearly 50% increase in risk-adjusted mortality [19]. The fact that previous studies did not find this higher mortality for obese patients after CABG explains Prabhakar et al. because of their large group of patients who had a BMI more than 40 kg/m2 [19]. We could not assess the effect of extreme obesity (BMI>40 kg/m2) on mortality because of the small proportion of patients (six patients) who were extreme obese in our study population.

4.3. Morbidity
This study found that obesity only increases the risk of wound infections. We found no increased risk of any other form of morbidity among obese patients undergoing myocardial revascularization compared to non-obese patients (Table 4).

The significant increase in wound infections was also found in other studies [10–13,15,16,18,19]. A previous study done by our group found that obesity is an independent preoperative risk factor for sternal wound complications after CABG [23]. This is in association with Lu et al. and Schwann et al. [24,15]. Schwann suggests that this higher risk of wound infections may be due to a decreased perfusion of adipose tissue and increased incidence of diabetes in obese patients [15]. He also has a relative increase in operative time in obese patients. This suggests an increased open-chest exposure to the environment and may result in an increased incidence of sternal wound infections. As we have no registration of the operative time, we studied the ECC-time. But ECC-time was not significantly different between both groups. Schwann also had no significant difference in ECC-time and aortic cross-clamp time. It is unclear for us that while the ECC-time and aortic cross-clamp time are not significantly different, the operative time is significantly different.

Like Kuduvalli et al. we also could not find a significant difference for postoperative myocardial infarction [16]. This is in contrast with the study by Prasad et al. where obese patients were more likely to have a myocardial infarction [10]. The obese and non-obese group in the study of Prasad had a similar preoperative cardiac status, aortic cross-clamp time, and similar myocardial protection. Still the obese group had a significant higher incidence of myocardial infarction. In the obese group, there are significantly more hypertensive patients compared to our obese patients, which could be a risk for myocardial infarctions. On the other hand, the number of hypertensive patients in Prasads' total population is much less than in our study. This can be due to the profile of the patients and to the operation period (1984–1987). Therefore, we must hold back comparing this study with ours.

We did not find a significant difference for renal complications, neurological complications, gastrointestinal complications, re-intubation, re-admission on intensive care and re-operation for bleeding. This is in concurrence with other studies [10,11,14–17,19]. However, some studies found a significant reduction for the risk of postoperative bleeding in obese patients [12,13].

In this study, we were not focussed on the relation between graft choice, especially bilateral internal mammary-use, and sternal wound problems. In our previous study, we concluded that there was an indication that BIMA use was an independent predictor of sternal wound problems. There is, however, an interaction of graft-use, pre-, and postoperative predictors, that mask the precise effect of the graft-use [23]. A practical point in the discussion about sternal wound problems is the use of different sternal closing techniques. In this series, however, all patients' sternal closure was performed using twisted stainless steel wires and in our previous study we could not find a relation between techniques of sternal closure and sternal wound problems [23]. Another point is the influence of off-pump surgery (group A 2/30 (6.6%) versus 15/176 (8.5), group B 4/131 (3.0%) versus 37/793 (4.9%)). The limited number of patients operated off-pump, however, did not allow to analyse the influence between obesity, wound problems and off-pump surgery. Certainly because here also we have the interaction of preoperative variables and the decision to perform off-pump surgery.

4.4. Duration of mechanical ventilation and hospital stay
We did not find a significant increase for the duration of hospital stay and for the prolonged mechanical ventilation, like some other studies [10–14]. Other studies did find a significant difference [15–17,19]. Kuduvalli et al. thought that prolonged ventilation could be due to impaired respiratory function as a result of relatively decreased vital capacity and a prolonged depression of respiratory drive due to slow release of anaesthetic agents stored in fatty tissues into the bloodstream. The increase in duration of hospital stay could be a direct result of the increased incidence of wound infections [16].

4.5. Follow-up
For the follow-up, we had data from 1097 patients, because 33 patients died in the first year after CABG. The one-year follow-up of the 1097 hospital survivors was complete.

We found no significant difference in early mortality (Table 4). Kuduvalli et al. also did not find an association between obesity and in-hospital mortality [16] but he showed, using multivariat analysis, a significant difference for mortality over a 4-year follow-up period. Schwann et al. compared the relative survival at 2 and 5 years after surgery [15]. After 2 years, there was no significant difference for mortality, but after 5 years, he found a reduced 5-year survival in small (BMI<24 kg/m2) and moderate obese patients relative to those who are obese. Gurm et al. did not find an association between BMI and short-term outcome after CABG, but he did find that long-term mortality after CABG appears to be strongly influenced by BMI [25]. Kim et al. found no association between BMI and mortality after 1 and 5 years [18]. An explanation may be because of the small number of obese patients (14%). We did not find a difference in mortality after 1 year, but looking at the results of other studies, this could be after 5 years.


   5. Conclusion
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
References
 
Patients who are obese are not at greater risk of in-hospital and early mortality after coronary artery bypass grafting compared with non-obese patients. However, obese patients appear to have a greater risk of wound infections after CABG compared to non-obese patients.


   References
Top
 Abstract
 1. Introduction
 2. Patients and methods
 3. Results
 4. Discussion
 5. Conclusion
 References
 

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