Short-Term Outcomes of Patients with Non-Metastatic Malignant Solid Tumor after Coronary Artery Bypass Grafting: A Population-Based Study of National/Nationwide Inpatient Sample From 2015 To 2020

Li, Renxi; Prastein, Deyanira J.

doi:10.21470/1678-9741-2024-0202

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ORIGINAL ARTICLE • Braz. J. Cardiovasc. Surg. 40 (3) • 2025 • https://doi.org/10.21470/1678-9741-2024-0202 linkcopy

Short-Term Outcomes of Patients with Non-Metastatic Malignant Solid Tumor after Coronary Artery Bypass Grafting: A Population-Based Study of National/Nationwide Inpatient Sample From 2015 To 2020

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction: Previous studies found that patients with a history of cancer either have similar outcomes or face an increased risk of early morbidity following cardiac surgery. However, the applicability of these findings to clinical practice may be constrained by the heterogeneity of cancer patients. To refine our understanding, this study focuses specifically on the in-hospital outcomes of patients with non-metastatic malignant solid tumors (NMST) undergoing coronary artery bypass grafting (CABG).

Methods: Patients who underwent CABG were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Exclusion criteria included age < 18 years, concomitant procedures, and other malignancies. A 1:3 propensity-score matching was employed to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and admission status between patients with and without NMST. In-hospital outcomes after CABG were evaluated.

Results: There were 2,139 patients with NMST who underwent CABG and who were matched to 6,580 out of 164,351 patients without NMST. Patients with and without NMST had comparable mortality (2.25% vs. 2.16%, P=0.80). However, NMST patients have a higher risk of hemorrhage/hematoma (63.48% vs. 58.27%, P<0.01) and a higher rate of transfer out (28.75% vs. 25.36%, P<0.01). In addition, patients with NMST had longer time from admission to operation (P<0.01), a longer length of stay (P<0.01), and higher hospital charges (P<0.01).

Conclusion: Patients with NMST have comparable short-term outcomes after CABG, except for a higher risk of postoperative bleeding. Thus, CABG could be performed safely for NMST patients, despite long-term prognosis of these patients may require further investigation.

Keywords:
Coronary Artery Bypass; Thoracic Surgery; Neoplasms; Risk; Mortality; Morbidity; Length of Stay

Abbreviations, Acronyms & Symbols
AKI	= Acute kidney injury	MACE	= Major adverse cardiovascular event
CABG	= Coronary artery bypass grafting	MI	= Myocardial infarction
CAD	= Coronary artery disease	NIS	= National/Nationwide Inpatient Sample
CVA	= Cerebrovascular accident	NMST	= Non-metastatic malignant solid tumors
ICD-10-CM	= International Classification of Diseases, 10^th Revision, Clinical Modification	PCI PE	= Percutaneous coronary intervention = Pulmonary embolism
ICD-10-PCS	= International Classification of Diseases, 10^th Revision, Procedure Coding System	SD TIA	= Standard deviation = Transient ischemic attack
LOS	= Length of stay	VTE	= Venous thromboembolism

	NMST (n = 2,139)	Pre-match		Post-match
	NMST (n = 2,139)	Control (n = 164,351)	P-value	Control (n = 6,580)	P-value
Sex
Male	1713 (80.08%)	124288 (75.62%)	< 0.01	5340 (81.16%)	0.28
Female	426 (19.92%)	40049 (24.37%)	< 0.01	1240 (18.84%)	0.28
Age
< 55 years	79 (3.69%)	22885 (13.92%)	< 0.01	266 (4.04%)	0.52
≤ 55 to < 65 years	402 (18.79%)	48156 (29.3%)	< 0.01	1248 (18.97%)	0.90
≤ 65 to < 75 years	935 (43.71%)	61135 (37.2%)	< 0.01	2889 (43.91%)	0.90
≤75 to < 85 years	654 (30.58%)	29584 (18%)	< 0.01	1975 (30.02%)	0.63
≥ 85 years	69 (3.23%)	2591 (1.58%)	< 0.01	202 (3.07%)	0.77
Race and Ethnicity
Caucasian	1688 (78.92%)	122899 (74.78%)	< 0.01	5194 (78.94%)	0.98
African American	153 (7.15%)	11447 (6.96%)	0.73	490 (7.45%)	0.70
Hispanic	113 (5.28%)	12633 (7.69%)	< 0.01	342 (5.2%)	0.87
Asian	44 (2.06%)	5410 (3.29%)	< 0.01	143 (2.17%)	0.80
Native Americans	9 (0.42%)	889 (0.54%)	0.55	28 (0.43%)	1.00
Other races	60 (2.81%)	4792 (2.92%)	0.85	161 (2.45%)	0.34
Socioeconomic Status
Income 1^st quartile (0-25%)	524 (24.5%)	45312 (27.57%)	< 0.01	1575 (23.94%)	0.64
Income 2ⁿd quartile (25-50%)	580 (27.12%)	44477 (27.06%)	0.96	1824 (27.72%)	0.62
Income 3^rd quartile (50-75%)	530 (24.78%)	39549 (24.06%)	0.45	1610 (24.47%)	0.79
Income 4^th quartile (75-100%)	466 (21.79%)	32192 (19.59%)	0.01	1462 (22.22%)	0.72
Primary Payer Status
Medicare	1514 (70.78%)	88965 (54.13%)	< 0.01	4562 (69.33%)	0.21
Medicaid	90 (4.21%)	12990 (7.9%)	< 0.01	287 (4.36%)	0.81
Private insurance	441 (20.62%)	51576 (31.38%)	< 0.01	1446 (21.98%)	0.18
Self-pay	16 (0.75%)	4828 (2.94%)	< 0.01	54 (0.82%)	0.89
No charge	6 (0.28%)	516 (0.31%)	1.00	17 (0.26%)	0.81
Other payment	70 (3.27%)	5231 (3.18%)	0.80	206 (3.13%)	0.72
Hospital characteristics
Rural hospital	37 (1.73%)	4508 (2.74%)	< 0.01	114 (1.73%)	1.00
Urban private practice	294 (13.74%)	25880 (15.75%)	0.01	940 (14.29%)	0.50
Urban teaching hospital	1808 (84.53%)	133963 (81.51%)	< 0.01	5526 (83.98%)	0.52
Small bed size	229 (10.71%)	18811 (11.45%)	0.30	679 (10.32%)	0.60
Medium bed size	561 (26.23%)	43795 (26.65%)	0.68	1673 (25.43%)	0.48
Large bed size	1349 (63.07%)	101745 (61.91%)	0.28	4228 (64.26%)	0.32
Admission type
Elective	1079 (50.51%)	75595 (46.15%)	< 0.01	3346 (50.85%)	0.80
Urgent	1057 (49.42%)	88219 (53.68%)	< 0.01	3234 (49.15%)	0.80

	NMST (n = 2,139)	Pre-match		Post-match
	NMST (n = 2,139)	Control (n = 164,351)	P-value	Control (n = 6,580)	P-value
Comorbidities and relevant diagnoses
Acquired immune deficiency syndrome	10 (0.47%)	599 (0.36%)	0.37	22 (0.33%)	0.41
Alcohol abuse	88 (4.11%)	5580 (3.4%)	0.07	276 (4.19%)	0.95
Autoimmune conditions	43 (2.01%)	4126 (2.51%)	0.16	118 (1.79%)	0.52
Cerebrovascular disease	44 (2.06%)	3261 (1.98%)	0.81	121 (1.84%)	0.52
Heart failure	0 (0%)	140 (0.09%)	0.43	0 (0%)	NA
Dementia	30 (1.4%)	1726 (1.05%)	0.11	86 (1.31%)	0.74
Depression	200 (9.35%)	14508 (8.83%)	0.40	603 (9.16%)	0.83
Diabetes without chronic complications	335 (15.66%)	27721 (16.87%)	0.15	1058 (16.08%)	0.68
Diabetes with chronic complications	631 (29.5%)	53060 (32.28%)	0.01	1864 (28.33%)	0.32
Drug abuse	31 (1.45%)	2904 (1.77%)	0.32	106 (1.61%)	0.69
Complicated hypertension	878 (41.05%)	58708 (35.72%)	< 0.01	2660 (40.43%)	0.61
Uncomplicated hypertension	996 (46.56%)	85691 (52.14%)	< 0.01	3083 (46.85%)	0.80
Moderate to advanced liver disease	7 (0.33%)	136 (0.08%)	< 0.01	19 (0.29%)	0.82
Chronic pulmonary disease	554 (25.9%)	35513 (21.61%)	< 0.01	1663 (25.27%)	0.57
Obesity	482 (22.53%)	48018 (29.22%)	< 0.01	1464 (22.25%)	0.77
Paralysis	33 (1.54%)	2336 (1.42%)	0.65	87 (1.32%)	0.45
Peripheral vascular disease	418 (19.54%)	23004 (14%)	< 0.01	1265 (19.22%)	0.80
Advanced renal failure	41 (1.92%)	3948 (2.4%)	0.15	129 (1.96%)	1.00
Hypothyroidism	267 (12.48%)	18012 (10.96%)	0.03	802 (12.19%)	0.70
Other thyroid disorders	22 (1.03%)	1671 (1.02%)	0.91	59 (0.9%)	0.60
Valvular diseases	13 (0.61%)	856 (0.52%)	0.54	42 (0.64%)	1.00
Left ventricular dysfunction	8 (0.37%)	460 (0.28%)	0.40	30 (0.46%)	0.71
Pulmonary hypertension	100 (4.68%)	7352 (4.47%)	0.64	306 (4.65%)	0.95
Endocarditis	6 (0.28%)	182 (0.11%)	0.04	19 (0.29%)	1.00
Nonrheumatic mitral valve disorders	169 (7.9%)	12682 (7.72%)	0.74	501 (7.61%)	0.64
Nonrheumatic aortic valve disorders	110 (5.14%)	6497 (3.95%)	0.01	330 (5.02%)	0.82
Nonrheumatic tricuspid valve disorders	12 (0.56%)	1213 (0.74%)	0.44	42 (0.64%)	0.87
Nonrheumatic pulmonary valve disorders	5 (0.23%)	262 (0.16%)	0.40	12 (0.18%)	0.58
Atrial fibrillation	852 (39.83%)	55011 (33.47%)	< 0.01	2643 (40.17%)	0.78
Atrial flutter	134 (6.26%)	6985 (4.25%)	< 0.01	382 (5.81%)	0.43
Ventricular fibrillation	45 (2.1%)	3356 (2.04%)	0.82	144 (2.19%)	0.86
Ventricular flutter	1 (0.05%)	27 (0.02%)	0.30	4 (0.06%)	1.00
Sick sinus syndrome	36 (1.68%)	2230 (1.36%)	0.19	116 (1.76%)	0.85
First-degree atrioventricular block	37 (1.73%)	2342 (1.42%)	0.23	112 (1.7%)	0.92
Second-degree atrioventricular block	15 (0.7%)	977 (0.59%)	0.48	47 (0.71%)	1.00
Complete atrioventricular block	30 (1.4%)	1984 (1.21%)	0.42	105 (1.6%)	0.61
Carotid artery disease	218 (10.19%)	12079 (7.35%)	< 0.01	631 (9.63%)	0.45
Hyperlipidemia	1662 (77.7%)	133099 (80.98%)	< 0.01	5155 (78.34%)	0.51
Anemia	138 (6.45%)	7245 (4.41%)	< 0.01	425 (6.46%)	1.00
Thrombocytopenia	452 (21.13%)	31245 (19.01%)	0.01	1384 (21.03%)	0.98
Sleep apnea	308 (14.4%)	25732 (15.66%)	0.12	936 (14.22%)	0.83
Tobacco use	1132 (52.92%)	83369 (50.73%)	0.05	3451 (52.45%)	0.75
Previous MI	359 (16.78%)	29957 (18.23%)	0.09	1082 (16.44%)	0.74
Previous CVA	331 (15.47%)	28535 (17.36%)	0.02	1000 (15.2%)	0.78
Previous CABG	43 (2.01%)	3582 (2.18%)	0.65	131 (1.99%)	0.93
Previous PCI	162 (7.57%)	11633 (7.08%)	0.37	463 (7.04%)	0.44
Previous valve replacement	8 (0.37%)	501 (0.3%)	0.55	26 (0.4%)	1.00

Comorbidities and Diagnosis	ICD-10-CM and ICD-10-PCS
Acquired immune deficiency syndrome	Elixhauser comorbidity
Alcohol abuse	Elixhauser comorbidity
Autoimmune conditions	Elixhauser comorbidity
Lymphoma	Elixhauser comorbidity
Leukemia	Elixhauser comorbidity
Metastatic cancer	Elixhauser comorbidity
Solid tumor without metastasis, in situ	Elixhauser comorbidity
Solid tumor without metastasis, malignant	Elixhauser comorbidity
Cerebrovascular disease	Elixhauser comorbidity
Heart failure	Elixhauser comorbidity
Dementia	Elixhauser comorbidity
Depression	Elixhauser comorbidity
Diabetes without chronic complications	Elixhauser comorbidity
Diabetes with chronic complications	Elixhauser comorbidity
Drug abuse	Elixhauser comorbidity
Complicated hypertension	Elixhauser comorbidity
Uncomplicated hypertension	Elixhauser comorbidity
Moderate to advanced liver disease	Elixhauser comorbidity
Chronic pulmonary disease	Elixhauser comorbidity
Obesity	Elixhauser comorbidity
Paralysis	Elixhauser comorbidity
Peripheral vascular disease	Elixhauser comorbidity
Advanced renal failure	Elixhauser comorbidity
Hypothyroidism	Elixhauser comorbidity
Other thyroid disorders	Elixhauser comorbidity
Valvular diseases	Elixhauser comorbidity
Left ventricular dysfunction	I50.1
Pulmonary hypertension	I27.2
Endocarditis	I33, I38, I39
Nonrheumatic mitral valve disorders	I34
Nonrheumatic aortic valve disorders	I35
Nonrheumatic tricuspid valve disorders	I36
Nonrheumatic pulmonary valve disorders	I37
Atrial fibrillation	I48.0, I48.1, I48.2, I48.91
Atrial flutter	I48.3, I48.4, I48.92
Ventricular fibrillation	I49.01
Ventricular flutter	I49.02
Sick sinus syndrome	I49.5
First-degree atrioventricular block	I44.0
Second-degree atrioventricular block	I44.1
Complete atrioventricular block	I44.2
Carotid artery disease	I65.21, I65.22, I65.23, I65.29
Hyperlipidemia	E78.0, E78.1, E78.2, E78.3, E78.5, E78.5
Anemia	D63
Thrombocytopenia	D69.5, D69.6
Sleep apnea	G47.3
Tobacco use	F17, Z72.0, Z87.891
Previous myocardial infarction	I25.2
Previous cerebrovascular accident	Z86.73
Previous coronary artery bypass grafting	Z95.1
Previous percutaneous coronary intervention	Z98.61, Z95.5
Previous valve replacement	Z95.2, Z95.3, Z95.4

Perioperative outcomes	ICD-10-CM and ICD-10-PCS
MACE
MI	I97.710, I97.711, I97.120, I97.121, I46.9
Stroke	I60.9, I61.9, I63.22, I63.139, I63.239, I63.019, I63.119, I63.219, I97.811, I97.820, I97.821, I97.810
Postprocedural cardiogenic shock	T81.11XA
Postprocedural heart failure	I97.130, I97.131
Postprocedural cardiac insufficiency	I97.110, I97.111
MI	I97.710, I97.711, I97.120, I97.121, I46.9
Stroke	I60.9, I61.9, I63.22, I63.139, I63.239, I63.019, I63.119, I63.219, I97.811, I97.820, I97.821, I97.810
Transient ischemic attack	G45.9, I67.848
Neurological complications
Nervous system complication, unspecified	G97.81
Central nervous system complication	G97.81, G97.82
Iatrogenic cerebrovascular infarction or hemorrhage	I97.811, I97.821, I97.810, I97.820
Transient ischemic attack	G45.9, I67.848
Any stroke	160.9, 161.9, 163.22, 163.139, 163.239; 163.019, 163.119, 163.219
Pericardial complications
Hemopericardium	I31.2
Tamponade	I31.4
Pericardiocentesis	0W9DXXX, 0W9CXXX, 0W9D40Z
Acute pericarditis	I30.1, I30.8, I30.9
Pacemaker implantation	0JH606Z, 0JH636Z, 0JH806Z, 0JH836Z, 0JH60PZ, 0JH63PZ, 0JH80PZ, 0JH83PZ, 0JH604Z, 0JH634Z, 0JH804Z, 0JH834Z, 0JH605Z, 0JH635Z, 0JH805Z, 0JH835Z, 02H73KZ, 02HK3KZ, 02HL3KZ, 02HN0KZ, 02HN4KZ, 0JH608Z, 0JH638Z, 0JH808Z, 0JH838Z, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, 02HL4KZ, 0JH608Z, 0JH638Z, 0JH808Z, 0JH838Z, 02H60KZ, 02H63KZ, 02H64KZ, 02H70KZ, 02H73KZ, 02H74KZ, 02HK0KZ, 02HK3KZ, 02HK4KZ, 02HL0KZ, 02HL3KZ, 02HL4KZ, 0JH608Z, 0JH638Z, 0JH808Z, 0JH838Z,
Cardiogenic shock	R57.0
Respiratory complications
Pneumothorax/hemothorax	J95.811, J95.812, J95.830, J95.831, J94.2
Diaphragm paralysis	J98.6
Postoperative respiratory failure	J95.821, J96.00, J95.822, J96.20
Pulmonary insufficiency	J95.2, J95.3
Respiratory arrest	R09.2
Other iatrogenic respiratory complications	J95.88, J95.89, J95.850, J95.851, J95.859
Mechanical ventilation	5A1935Z, 5A1945Z, 5A1955Z
Acute kidney injury	N17.9, N17.0, N17.1, N17.2
Postprocedural renal failure	N99.0
Venous thromboembolism	I82.401, I82.402, I82.403, I82.409, I82.411, I82.412, I82.413, I82.419, I82.421, I82.422, I82.423, I82.429, I82.431, I82.432, I82.433, I82.439, I82.441, I82.442, I82.443, I82.449, I82.451, I82.452, I82.453, I82.459, I82.461, I82.462, I82.463, I82.469, I82.491, I82.492, I82.493, I82.499, I82.4Y1, I82.4Y2, I82.4Y3, I82.4Y9, I82.4Z1, I82.4Z2, I82.4Z3, I82.4Z9
Pulmonary embolism	I26.02, I26.09, I26.92, I26.93, I26.94
Hemorrhage/hematoma
Hemorrhage/hematoma complicating a procedure	I97.411, I97.418, I97.42, I97.611, I97.618, I97.620, I97.411, I97.418, I97.42, I97.621, I97.631, I97.638
Acute post-hemorrhagic anemia	D62
Hemorrhage requiring transfusion	3023XXX, 3024XXX
Infection
Fever	T82.6, T82.7, R50.82
Septicemia	A41.9, A65.20, T81.12XA
Postprocedural aspiration pneumonia	J95.89
Sepsis	T81.12XA, T81.44XA
Deep wound complication	T81.32XA, T81.43XA
Superficial wound complications	L76.34, L76.32, T81.31XA, T81.41XA, T81.42XA, T81.40XA
Vascular complication
Accidental puncture or laceration during a procedure	I97.51, I97.52
Injury to blood vessels	S25.X, S35.X
Arteriovenous fistula	I77.0
Injury to retroperitoneum	S36.899A
Vascular complication requiring surgical/percutaneous repair	03QY0ZZ, 03QY3ZZ, 03QY4ZZ, 04QY0ZZ, 04QY3ZZ, 04QY4ZZ, 05QY0ZZ, 05QY3ZZ, 05QY4ZZ, 06QY0ZZ, 06QY3ZZ, 06QY4ZZ, 02QW0ZZ, 02QW3ZZ, 02QX4ZZ, 03Q00ZZ, 03Q03ZZ, 03Q04ZZ, 03Q10ZZ, 03Q13ZZ, 03Q14ZZ, 03Q20ZZ, 03Q23ZZ, 03Q24ZZ, 03Q30ZZ, 03Q40ZZ, 03Q33ZZ, 03Q43ZZ, 03Q44ZZ, 03Q50ZZ, 03Q53ZZ, 03Q54ZZ, 03Q60ZZ, 03Q63ZZ, 03Q64ZZ, 03Q74ZZ 03Q70ZZ, 03Q73ZZ, 03Q80ZZ, 03Q83ZZ, 03Q84ZZ, 03Q90ZZ, 03Q93ZZ, 03Q94ZZ, 03QA0ZZ, 03QA3ZZ, 03QA4ZZ, 03QB0ZZ, 03QB3ZZ, 03QB4ZZ,03QC0ZZ, 03QC3ZZ, 03QC4ZZ,03QY0ZZ, 03QY3ZZ,03QY4ZZ,04Q00ZZ, 04Q03ZZ, 04QC0ZZ, 04QC3ZZ, 04Q04ZZ, 04QC4ZZ,04QD0ZZ, 04QD3ZZ,04QD4ZZ, 04QE0ZZ 04QE3ZZ, 04QE4ZZ, 04QF0ZZ, 04QF3ZZ, 04QF4ZZ, 04QH0ZZ, 04QH3ZZ, 04QH4ZZ,04QJ0ZZ, 04QJ3ZZ, 04QJ4ZZ,04QK0ZZ, 04QK3ZZ, 04QL0ZZ, 04QL3ZZ, 04QL4ZZ, 04QY0ZZ, 04QY3ZZ
Hemorrhage from vascular procedures	T82.838, T82.837
Other artery and vein complications	T81.72XA, T81.719A
Diaphragmatic paralysis	J98.6
Reopen surgery	0W390ZZ, 0W3B0ZZ, 0W3C0ZZ, 0W3D0ZZ, 0W3Q0ZZ

	NMST (n = 2,139)	Control (n = 6,580)	P-value
Mortality	48 (2.25%)	142 (2.16%)	0.80
MACE	65 (3.04%)	198 (3.01%)	0.94
MI	36 (1.69%)	115 (1.75%)	0.92
Stroke	17 (0.8%)	45 (0.68%)	0.56
TIA	9 (0.42%)	18 (0.27%)	0.27
Neurological complications	26 (1.22%)	63 (0.96%)	0.32
Pericardial complications	40 (1.87%)	112 (1.7%)	0.63
Pacemaker implantation	28 (1.31%)	128 (1.95%)	0.06
Cardiogenic shock	169 (7.91%)	458 (6.96%)	0.15
Respiratory complications	222 (10.39%)	697 (10.59%)	0.81
Mechanical ventilation	203 (9.5%)	596 (9.06%)	0.55
AKI	526 (24.63%)	1609 (24.45%)	0.88
Postprocedural renal failure	15 (0.7%)	36 (0.55%)	0.42
VTE	18 (0.84%)	50 (0.76%)	0.67
PE	2 (0.09%)	3 (0.05%)	0.60
Hemorrhage/hematoma	1356 (63.48%)	3834 (58.27%)	< 0.01
Infection	94 (4.4%)	232 (3.53%)	0.07
Sepsis	0 (0%)	4 (0.06%)	0.58
Deep wound complication	3 (0.14%)	16 (0.24%)	0.59
Superficial wound complication	27 (1.26%)	58 (0.88%)	0.13
Vascular complication	13 (0.61%)	44 (0.67%)	0.88
Diaphragmatic paralysis	4 (0.19%)	16 (0.24%)	0.80
Reopen surgery	18 (0.84%)	57 (0.87%)	1.00
Transfer out	614 (28.75%)	1669 (25.36%)	< 0.01
	Mean ± SD	Mean ± SD	P-value
Admission to operation (days)	2.74 ± 3.97	2.30 ± 3.06	< 0.01
LOS (days)	10.62 ± 7.55	9.87 ± 6.96	< 0.01
Total hospital charge (US$)	245,370 ± 198,736	224,851 ± 195,042	< 0.01

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