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Correspondence

Reply

Division of Cardiothoracic Surgery, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX 77030

(Email: dchu{at}bcm.tmc.edu).

To the Editor:

We thank Aboyans and colleagues [1] for their interest in our article [2], and appreciate the editor for giving us the opportunity to reply. Aboyans and colleagues elegantly presented their findings of the association between subclinical peripheral arterial disease (PAD) and survival in patients undergoing coronary artery bypass grafting (CABG) [3]. With an actuarial follow-up period of 4.4 years (range, 0 to 65.1 months), the authors concluded that symptomatic and asymptomatic patients with PAD had poorer long-term prognosis than those without PAD who underwent CABG. Furthermore, they concluded that the poor prognosis of PAD patients undergoing CABG is due to cardiovascular events occurring both in the immediate and late postoperative periods.

We agree with the authors' comment regarding the poor positive predictive value of an abnormal peripheral pulse on physical examination as an indicator of PAD. This specific limitation was addressed in the discussion section of our article [2]. There is no doubt that the ankle-brachial index (ABI) provides a more complete preoperative evaluation of PAD for patients undergoing CABG. However, the ABI information was not available for the entire study cohort. Our study was performed by using the Houston component of the Veterans Affairs (VA) Continuous Improvement in Cardiac Surgery Program (CICSP) database. This database, organized by the Department of Veterans Affairs to provide continuous assessment and improvement of quality of care for all patients undergoing cardiac surgery in VA hospitals, contains comprehensive data on more than 140 variables, including demographic, clinical, outcome, and resource variables, collected prospectively at prespecified time points from all patients undergoing cardiac surgical procedures in the VA Health Care System [4]. Our definition of PAD is that defined by the CICSP board and it does not include ABI. Although the CICSP database has its inherent limitations, it has been well validated and compared with the Society of Thoracic Surgeon (STS) database for the past decade [5].

Contrary to the findings of Aboyans and colleagues [3], we did not find PAD to be an independent risk factor for early death for patients undergoing CABG. These contradictory results may be due to the heterogeneity of the type of CABG procedure involved in their study, which included off-pump CABG as well as CABG/valve replacement patients. Our study [2] only included patients who underwent isolated nonredo CABG with cardiopulmonary bypass. To minimize case-mix bias, we specifically excluded patients who underwent other concomitant cardiac operations, patients who underwent off-pump CABG, and patients who had undergone previous heart operations. Therefore, we believe our results are more representative for patients undergoing isolated nonredo CABG with cardiopulmonary bypass.

There is no perfect database; however, we believe the CICSP database is a robust and accurate database that has been validated in numerous publications in important journals throughout the world. Limitations do exist with our article [2] and the CICSP database. The use of ABI to further stratify our patient cohort might improve the specificity of our results. We appreciate the authors' interest and comments on our article [2] and plan a further manual chart review to perform subgroup analysis to include the ABI data.

	References

Top References

 

1. Aboyans V, Lacroix P, Laskar M. Coronary bypass grafting in patients with concomitant peripheral arterial disease: do not underestimate asymptomatic disease(letter) Ann Thorac Surg 2009;87:2003-2004.[Free Full Text]
2. Chu D, Bakaeen FG, Wang XL, et al. The impact of peripheral vascular disease on long-term survival after coronary artery bypass graft surgery Ann Thorac Surg 2008;86:1175-1180.[Abstract/Free Full Text]
3. Aboyans V, Lacroix P, Postil A, et al. Subclinical peripheral arterial disease and incompressible ankle arteries are both long-term prognostic factors in patients undergoing coronary artery bypass grafting J Am Coll Cardiol 2005;46:815-820.[Abstract/Free Full Text]
4. Hammermeister KE, Johnson R, Marshall G, Grover FL. Continuous assessment and improvement in quality of care: a model from the Department of Veterans Affairs Cardiac Surgery Ann Surg 1994;219:281-290.[Medline]
5. Grover FL, Shroyer AL, Hammermeister K, et al. A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases Ann Surg 2001;234:464-472.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Danny Chu Faisal G. Bakaeen Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chu, D. Articles by Bakaeen, F. G. Search for Related Content PubMed PubMed Citation Articles by Chu, D. Articles by Bakaeen, F. G. Related Collections Related Article