Jarmo Lahtinen

Validation of EuroSCORE II in Patients Undergoing Coronary Artery Bypass Surgery

BACKGROUND The European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) has been recently developed to improve the performance of the original EuroSCORE. Herein we evaluated its discriminatory ability in predicting the immediate and late outcome after coronary artery bypass grafting (CABG). METHODS Complete data on 1,027 patients who underwent isolated CABG were available for validation of EuroSCORE II and to compare its discriminatory ability with the original EuroSCORE and its Finnish modified version. RESULTS EuroSCORE II performed somewhat better (area under the curve [AUC] 0.852, Brier score 0.031) than the original logistic EuroSCORE (AUC 0.838, Brier score 0.034) and its Finnish modified version (AUC 0.825, Brier score 0.034) in predicting operative mortality. The overall expected-to-observed operative mortality ratio for the original logistic EuroSCORE was 1.8, for its Finnish modified version was 0.6, and for EuroSCORE II was 1.2. EuroSCORE II showed expected-to-observed ratios ranging from 1.05 to 1.17 in its highest third quintiles. The best cutoff of EuroSCORE II in predicting operative postoperative mortality was 10% (21.5% vs 1.6%, p<0.0001; sensitivity 91.5%, specificity 60.5%, negative predictive value 98.4%, accuracy of 90.3%). The EuroSCORE II was predictive of de novo dialysis (AUC 0.805), prolonged use of inotropes (AUC 0.748), and intensive care unit stay 5 days or greater (AUC 0.793). The risk of late mortality significantly increased across increasing quintiles of EuroSCORE II (p<0.0001). CONCLUSIONS The EuroSCORE II performs better than its original version in predicting operative mortality and morbidity after isolated CABG. Its ability to predict 30-day mortality in high-risk patients is of particular importance. The EuroSCORE II is also a good predictor of late postoperative survival.

Preoperative C-reactive protein and outcome after coronary artery bypass surgery

BACKGROUND C-reactive protein (CRP) is a predictor of early and late outcome after coronary angioplasty, but there is scant data on its impact on the outcome after coronary artery bypass grafting (CABG). METHODS The predictive value of preoperative CRP was evaluated in a series of 764 patients who underwent on-pump CABG. RESULTS During the in-hospital stay, 13 patients (1.7%) died, 45 (4.5%) developed low cardiac output syndrome, and 28 (3.7%) suffered minor or major cerebrovascular complications. Patients with a preoperative serum concentration of CRP>/=1.0 mg/dL had a higher risk of overall postoperative death (5.3% vs 1.1%, p = 0.001), cardiac death (4.4% vs 0.8%, p = 0.002), low cardiac output syndrome (8.8% vs 3.7%, p = 0.01), and any cerebrovascular complication (4.4% vs 3.5%, p = 0.66). Preoperative serum concentration of CRP>/=1.0 mg/dL was significantly more frequent among patients with history of myocardial infarction, diabetes, lower limb ischemia, low left ventricular ejection fraction, NYHA class IV, and in those undergoing urgent or emergency operation. At multivariate analysis, preoperative serum concentration of CRP >/= 1.0 mg/dL (p = 0.01, O.R.: 6.97) and left ventricular ejection fraction (p = 0.01, O.R.: 0.95) were independent predictors of postoperative death. Postoperative mortality rate was 0.3% among patients with preoperative CRP < 1.0 mg/dL and an ejection fraction >/=50%, whereas it was 21.4% among those with a preoperative CRP >/= 1.0 mg/dL and an ejection fraction less than 50% (p < 0.0001). CONCLUSIONS Preoperative serum concentration of CRP in patients undergoing on-pump coronary artery bypass surgery is an important determinant of postoperative outcome.

Estimating the risk of complications related to re-exploration for bleeding after adult cardiac surgery: a systematic review and meta-analysis

OBJECTIVE The aim of this study was to evaluate the impact of re-exploration for bleeding after cardiac surgery on the immediate postoperative outcome. METHODS Systematic review of the literature and meta-analysis of data on re-exploration for bleeding after adult cardiac surgery were performed. RESULTS The literature search yielded eight observational studies reporting on 557,923 patients and were included in the present analysis. Patients requiring re-exploration were significantly older, more frequently males, had a higher prevalence of peripheral vascular disease and preoperative exposure to aspirin, and more frequently underwent urgent/emergency surgery. Re-exploration was associated with significantly increased risk ratio (RR) of immediate postoperative mortality (RR 3.27, 95% confidence interval (CI) 2.44-4.37), stroke, need of intra-aortic balloon pump, acute renal failure, sternal wound infection, and prolonged mechanical ventilation. The pooled analysis of four studies (two being propensity score-matched pairs analysis) reporting adjusted risk for mortality led to an RR of 2.56 (95%CI 1.46-4.50). Studies published during the last decade tended to report a higher risk of re-exploration-related mortality (RR 4.30, 95%CI 3.09-5.97) than those published in the 1990s (RR 2.75, 95%CI 2.06-3.66). CONCLUSIONS This study suggests that re-exploration for bleeding after cardiac surgery carries a significantly increased risk of postoperative mortality and morbidity.

The use of statins and fate of small abdominal aortic aneurysms.

The aim of this study was to evaluate the value of statins in reducing abdominal aortic aneurysm (AAA) growth rate and improving freedom from aneurysm repair or rupture. One hundred and twenty-one patients with AAA undergoing ultrasonographic surveillance for at least one year were included in this retrospective study. Patients treated with statins had a decreased linear aneurysm growth rate than those not receiving statins (1.9+/-1.8 mm/year vs. 2.6+/-2.4 mm/year, P=0.27), but this difference did not reach statistical significance. Statin users had a better survival freedom from aneurysm repair or rupture (at 5 years: 72.3% vs. 52.5%, P=0.048). The impact of treatment with statins was even more evident in patients with a baseline aneurysm diameter<40 mm (at 5 years: 84.0% vs. 58.8%, P=0.022). When adjusted for age, coronary artery disease and baseline aneurysm diameter, treatment with statins had significantly better survival freedom from aneurysm repair or rupture (P=0.012, RR 0.34, 95% CI 0.14-0.78). The use of statins seems to slightly decrease the AAA growth rate and to significantly improve freedom from aneurysm repair and rupture.

Early and intermediate outcome after aortic valve replacement with a sutureless bioprosthesis: Results of a multicenter study

OBJECTIVE The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). METHODS This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. RESULTS The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively (P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. CONCLUSIONS The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.

Options for the management of poststernotomy mediastinitis

The management of 27 consecutive deep sternotomy wound infections is reviewed. In 22 cases the initial treatment was debridement, sternal refixation and dilute antibiotic irrigation via multiple irrigation-suction catheters. In the nine cases (41%) in which these measures failed, more extensive sternal and costal cartilage debridement and closure with a muscle flap were performed. Five cases were initially managed with major reconstructive surgery. For reconstruction, a bilateral pectoralis major myocutaneous flap was used alone in eight cases, while in six the flap was insufficient to obliterate the whole poststernectomy space, and was supplemented with rectus abdominis muscle. Early mediastinitis can be effectively treated with thorough wound debridement and mediastinal irrigation, but if there is a two-week delay from the initial sternotomy to manifestation of infection, radical debridement with muscle flap closure should be seriously considered.

Use of blood products and risk of stroke after coronary artery bypass surgery

BACKGROUND The impact of blood transfusion on the development of post-operative stroke after coronary artery bypass grafting (CABG) is not well established. We, therefore, investigated this issue. MATERIALS AND METHODS Complete data on peri-operative blood transfusion were available for 2,226 patients who underwent CABG in three Finnish hospitals. RESULTS Stroke occurred post-operatively in 53 patients (2.4%). Logistic regression showed that pre-operative creatinine (OR 1.003, 95% CI 1.000-1.006), extracardiac arteriopathy (OR 2.344, 95% CI 1.133-4.847), pre-operative atrial fibrillation (OR 2.409, 95% CI 1.149-5.052), and the number of packed red blood cell units transfused (OR 1.121, 95% CI 1.065-1.180) were significantly associated with post-operative stroke. When the various blood product transfusions instead of transfused units were included in the multivariable analysis, solvent/detergent treated plasma (Octaplas) transfusion (OR 2.149, 95% CI 1.141-4.047), but not red blood cell transfusion, was significantly associated with postoperative stroke. Use of blood products ranging from no transfusion (stroke rate 1.6%) to combined transfusion of red blood cells, platelets and Octaplas was associated with a significant increase in post-operative stroke incidence (6.6%, adjusted analysis: OR 1.727, 95% 1.350-2.209). Patients who received >2 units of red blood cells, >4 units of Octaplas units and >8 units of platelets had the highest stroke rate of 21%. CART analysis showed that increasing amount of transfused Octaplas, platelets and history of extracardiac arteriopathy were significantly associated with post-operative stroke. CONCLUSIONS Transfusion of blood products after CABG has a strong, dose-dependent association with the risk of stroke. The use of Octaplas and platelet transfusions seem to have an even larger impact on the development of stroke than red blood cell transfusions.

Individual Surgeon's Impact on the Risk of Re-exploration for Excessive Bleeding After Coronary Artery Bypass Surgery

OBJECTIVE Excessive bleeding requiring re-exploration is a severe complication that may affect the outcome after coronary artery bypass grafting. The authors hypothesized that surgeon performance may contribute significantly to such a complication. DESIGN Retrospective. SETTING Tertiary referral center in a university hospital. PARTICIPANTS Two thousand one patients. INTERVENTIONS Isolated coronary artery bypass grafting. RESULTS Re-exploration for bleeding was performed in 113 patients (5.3%). Re-exploration was performed ≥3 days after surgery in 11 patients. The surgical site of bleeding was identified in 83 patients (73.5%). Rates of re-exploration for excessive bleeding ranged from 1.4% to 11.7% according to different surgeons (p < 0.0001). When adjusted for the additive European System for Cardiac Operative Risk Evaluation, re-exploration for bleeding was associated with increased risks of low-cardiac-output syndrome (odds ratio [OR] 2.239, 95% confidence interval [CI] 1.328-3.777), prolonged need for inotropes (OR 1.894, 95% CI 1.198-2.994), and an intensive care unit stay ≥5 days (OR 2.129, 95% CI 1.202-3.770). Logistic regression showed that an individual surgeon (p < 0.0001), preoperative body mass index <25 kg/m(2) (OR 2.733, 95% CI 2.145-3.481), and estimated glomerular filtration rate <30 mL/min/1.73 m(2) (OR 3.891, 95% CI 1.669-9.076) were independent predictors of re-exploration for excessive bleeding. An individual surgeon also was an independent predictor of a postoperative blood loss ≥1,600 mL. CONCLUSIONS An individual surgeon has a major impact on postoperative bleeding, and a meticulous surgical technique is expected to decrease significantly such a severe complication.

Off-pump versus on-pump coronary artery bypass surgery in patients aged 80 years and older: institutional results and meta-analysis

Patients aged ≥80 years are at high risk of adverse events after coronary artery bypass grafting. This study was performed to evaluate whether off-pump coronary artery bypass surgery (OPCAB) is superior to conventional surgery (CCAB) in these high-risk patients. The outcome of 185 patients aged ≥80 years who underwent OPCAB or CCAB at our institution was reviewed and a meta-analysis on this issue was performed. Similar immediate postoperative results were observed after OPCAB and CCAB at our institution, despite significantly different operative risk (mean logistic EuroSCORE, OPCAB 20.3% vs CCAB 13.4%, P = 0.003). Among 56 propensity score matched pairs a trend toward lower postoperative stroke (0%, 95% CI 0–0 vs 3.6%, 95% CI 0–10.0, P = 0.50) was observed after OPCAB. No significant differences were observed in the other outcome end points. Five-year survival was 81.0% after OPCAB and 78.1% after CCAB (P = 0.239). Pooled analysis of eight studies including 3416 patients showed a significantly higher risk of postoperative stroke after CCAB (pooled rates: 4.2%, 95% confidence interval (95% CI) 2.4–7.1 vs 1.5%, 95% CI 0.9–2.5, risk ratio (RR) 2.15, 95% CI 1.17–3.96, P = 0.01). A trend toward higher immediate postoperative mortality was observed after CCAB (15 studies including 4409 patients, pooled rates: 6.5%, 95% CI 5.2–8.0 vs 5.6%, 95% CI 4.2–7.4, RR 1.29, 95% CI 0.86–1.93, P = 0.21). Generic inverse variance analysis showed similar intermediate survival after CCAB and OPCAB (RR 1.31, 95% CI 0.85–2.01, P = 0.22). At 2 years, survival was 82.8% (95% CI 76.4–89.2) after CCAB and 88.3% (95% CI 82.9–93.7) after OPCAB. Current results indicate that OPCAB compared with CCAB in patients aged ≥80 years is associated with significantly lower postoperative stroke and with a trend toward better early survival. However, suboptimal quality of the available studies, particularly the lack of comparability of the study groups, prevents conclusive results on this controversial issue.

Immediate and Intermediate Outcome After Off-Pump and On-Pump Coronary Artery Bypass Surgery in Patients With Unstable Angina Pectoris

BACKGROUND We have evaluated the immediate and intermediate outcome after off-pump (OPCAB) and conventional on-pump coronary artery bypass surgery (CCAB) in patients with unstable angina pectoris requiring nitrates infusion until arrival in the operating room. METHODS A consecutive series of 153 and 161 patients with unrelenting angina pectoris underwent CCAB and OPCAB, respectively. Conversion from OPCAB to beating heart surgery with perfusion occurred in 4 patients. RESULTS The OPCAB patients had a significantly higher operative risk than CCAB patients (logistic European System for Cardiac Operative Risk Evaluation [EuroSCORE]: 13.8 +/- 12.8% vs 10.5 +/- 10.0%, p = 0.005). In the overall series, a lower 30-day postoperative mortality was observed among OPCAB patients (1.9% vs 3.9%, p = 0.33), the difference increased along the logistic EuroSCORE tertiles (upper tertile: 3.2% vs 9.5%, p = 0.14), but failed to reach statistical significance. Similar results have been observed among one-to-one propensity score matched pairs. The results of three surgeons who treated most of their patients (96.9%) with OPCAB were compared with those of three surgeons who used, in most of cases (97.1%), the CCAB technique. When adjusted for logistic EuroSCORE, patients operated on by CCAB surgeons had a significantly higher 30-day postoperative mortality (7.1% vs 2.1%, p = 0.04; odds ratio [OR] 10.143; 95% confidence interval [CI] 1.084 to 94.945) as well as a higher risk of combined adverse events (47.1% vs. 35.1%, p = 0.009; OR 2.586; 95% CI 1.274 to 5.250). CONCLUSIONS This study provided further evidence on the safety and efficacy of OPCAB in the treatment of high-risk patients. A dedicated approach to OPCAB seems to provide particularly good results. Such findings further support a more confident approach with OPCAB in these patients.