Neeraj Mediratta

Validation of EuroSCORE II in a modern cohort of patients undergoing cardiac surgery.

OBJECTIVE We aimed to validate the new EuroSCORE II risk model in a contemporary cardiac surgery practice in the United Kingdom (UK). METHODS The original logistic EuroSCORE was compared to EuroSCORE II with regard to accuracy of predicting in-hospital mortality. Analysis was performed on isolated coronary artery bypass grafts (CABG; n = 2913), aortic valve replacement (AVR; n = 814), mitral valve surgery (MVR; n = 340), combined AVR and CABG (n = 517), aortic (n = 350) and miscellaneous procedures (n = 642), and the above cases combined (n = 5576). RESULTS In a single-institution experience, EuroSCORE II is a reasonable risk model for in-hospital mortality from isolated CABG (C-statistic 0.79, Hosmer-Lemeshow P = 0.052) and aortic procedures (C-statistic 0.81, Hosmer-Lemeshow P = 0.43), and excellent for mitral valve surgery (C-statistic 0.87, Hosmer-Lemeshow P = 0.6). EuroSCORE II is better than the original EuroSCORE, using contemporaneous data for combined AVR and CABG operations (C-statistic 0.74, Hosmer-Lemeshow P = 0.38). However, EuroSCORE II failed to improve on the original EuroSCORE model for isolated AVR (C-statistic 0.69, Hosmer-Lemeshow P = 0.07) and miscellaneous procedures (C-statistic 0.70, Hosmer-Lemeshow P = 0.99). EuroSCORE II has better calibration than the original EuroSCORE or the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) modified EuroSCORE for cumulative sum survival (CUSUM) curves. CONCLUSIONS EuroSCORE II improves on the original logistic EuroSCORE, though mainly for combined AVR and CABG cases. Concerns still exist, however, over its use for isolated AVR procedures, aortic surgery and miscellaneous procedures. There is still room for improvement in risk modelling.

Long-term survival after coronary artery bypass surgery stratified by EuroSCORE

OBJECTIVES Coronary artery bypass grafting (CABG) is performed for symptoms and for prognostic reasons. The EuroSCORE is widely utilized as a pre-operative risk prediction tool. We evaluated our long-term survival figures based on EuroSCORE. METHODS A prospective database was retrospectively analysed and cross correlated with the UK strategic tracking service to evaluate survival after primary CABG. Patients were grouped based on their logistic EuroSCORE 0 to <5, 5 to <10, 10 to <15, 15 to <20, 20 to <25 and ≥25. RESULTS We analysed 13,337 primary cardiac procedures. A total of 9961 procedures had a logistic EuroSCORE of 0 to <5, 2041 of 5 to <10, 636 of 10 to <15, 281 of 15 to <20, 137 of 20 to <25 and 281≥25. Long-term survival is significantly affected by logistic EuroSCORE, P < 0.001. Patients with a logistic EuroSCORE <5% had significantly better initial survival and a lower rate of death over a 10-year period, P<0.001. Patients with a logistic score over 25 had a significantly worse 5-year survival, P<0.001. Logistic EuroSCORE was poor at predicting survival when >5 and <25. Cox multivariate regression and neuronal network analysis confirmed that the additional factors, diabetes, body mass index (BMI), post-operative myocardial creatinine kinase myocardial isoenzyme (CKMB) and left internal mammary artery (LIMA) usage, which are not incorporated in EuroSCORE significantly predict long-term survival. CONCLUSIONS Logistic EuroSCORE is a reasonable approximation for long-term survival after CABG, if the score is <5; however, its predictive capacity is limited due to the absence of LIMA usage, BMI, diabetes and CKMB in its calculation, all of which are significant factors affecting long-term survival.

Topical aprotinin in cardiac operations

We performed a prospective, randomized, double-blind trial of topical aprotinin versus placebo in 100 patients undergoing cardiac operations with cardiopulmonary bypass. Fifty-five patients received aprotinin. Forty underwent coronary artery bypass grafting (CABG) and 15 valve replacement +/- CABG. Of 45 patients in the control group 38 underwent CABG and 7 valve replacement +/- CABG. Aprotinin (50 mL; 70 mg) or placebo was applied topically to the heart, pericardium, and mediastinum before sternal closure. There were five reentries for bleeding with a surgical site identified in four. Mean blood loss was significantly less in the aprotinin group (653 versus 903 mL; p = 0.002), and fewer aprotinin patients received blood as a volume expander (67.5% versus 88%; p = 0.03). In coronary patients alone when aspirin administration was continued until the day of operation there was no difference between treatment and placebo groups (768 versus 879 mL). When aspirin administration was discontinued 2 weeks before operation there was a significant difference (558 versus 884 mL; p = 0.016) as in the group overall. This provides the potential for intrapericardial instillation for patients with excessive postoperative bleeding.

Preoperative red cell distribution width in patients undergoing pulmonary resections for non-small-cell lung cancer

OBJECTIVES Red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with cardiac disease. We sought to investigate the association of RDW in patients undergoing lung resections for non-small-cell lung cancer with respect to in-hospital morbidity, mortality and long-term survival. METHODS Analysis of consecutive patients on a validated prospective thoracic surgery database was performed for those undergoing potentially curative resections at a single institution. Univariate and multivariate analyses were performed for postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. RESULTS Overall mortality was 1.9% for all cases (n = 917). The median follow-up was 6.8 years. Univariate analysis demonstrated that RDW has a significant effect on hospital length of stay (P < 0.001), in-hospital mortality rates (P < 0.001), postoperative invasive and non-invasive ventilation (P < 0.001), superficial wound infections (P = 0.06) and long-term survival (P < 0.0001). Multivariate analysis revealed that RDW is a significant factor determining postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. Confounding factor analysis revealed that in the absence of anaemia, RDW was still a significant factor in the above analysis. CONCLUSIONS RDW is a significant factor after risk adjustment, determining in-hospital morbidity, mortality and long-term survival in patients post-potentially curative resections for non-small-cell lung cancer. Further work is needed to elucidate the exact mechanism of RDW impact on in-hospital morbidity, mortality and long-term survival. We speculate that subtle bone marrow dysfunction may be an issue.

Smoking status at diagnosis and histology type as determinants of long-term outcomes of lung cancer patients

OBJECTIVES The study aimed to determine the importance of smoking status at operation and histology type with regard to long-term survival after potential curative surgery for lung cancer. METHODS We analysed a prospectively validated thoracic surgery database (n = 2485). We benchmarked our 5-year survival against the International Association for the Study of Lung Cancer (IALSC) results. Univariate and Cox multivariate analyses were performed for the study group and for isolated adenocarcinoma and squamous carcinoma histological subtypes. RESULTS Benchmarking failed to reveal any differences in survival of our study cohort compared with the IALSC results, P = 0.16. Univariate analysis revealed that non-smokers have a statistically better long-term outcome, P < 0.0001, than ever smokers. Patients with adenocarcinoma, n = 1216, had a worse outcome in ever smokers, P = 0.006. In patients with squamous carcinoma, n = 1065, smoking status made no difference, P = 0.4. Long-term survival was not significantly different for adenocarcinoma or squamous carcinoma, P = 0.87. Cox multivariate analysis revealed that patients with adenocarcinoma who were current smokers had a significantly worse long-term survival compared with ex-smokers and non-smokers (hazard ratio: 1.26, 95 confidence interval: 1.01-1.56), P = 0.04. Age, body mass index, sex, T stage, N stage, predicted postoperative forced expiratory volume in one second (FEV1), residual disease, alcohol consumption and oral diabetes were additional significant factors affecting long-term survival. Pneumonectomy, pack years, bronchial resection margin, New York Heart Association class, hypertension, previous cerebrovascular event, diet or insulin-controlled diabetes and previous myocardial infarction were excluded by the analysis as significant risk factors. Smoking status did not affect long-term survival in patients with squamous cell carcinoma. CONCLUSIONS Smoking status at time of surgery does not effect long-term survival in patients with squamous cell carcinoma. Smoking status makes a significant difference to the long-term outcomes of patients with adenocarcinoma even after adjustment for their risk factors. This implies that a histological classification of adenocarcinoma may incorporate genetically diverse adenocarcinomas with regard to prognosis.

The long-term effects of developing renal failure post-coronary artery bypass surgery, in patients with normal preoperative renal function

OBJECTIVES Renal failure post-cardiac surgery is associated with an increased in hospital morbidity and mortality. We investigated the effect of new onset renal risk, injury or failure [risk, injury, failure, loss and end-stage kidney disease (RIFLE)] post-coronary artery bypass graft (CABG) on long-term survival, in patients with normal preoperative renal function. METHODS The effect of developing postoperative renal risk, injury or failure as defined by the RIFLE criteria on the long-term survival of patients undergoing isolated CABG with a normal renal function was studied. Two separate multivariate analyses were performed based on preoperative serum creatinine or glomerular filtration rate (GFR). Univariate, multivariate, interaction and confounding factor analyses were performed. RESULTS A total of 4029 isolated CABG patients were included in the study. 46.5% of patients had chronic kidney disease (CKD) stage 1 (GFR ≥90 ml/min/1.73 m(2)), 50.4% had CKD stage 2 (GFR 60-89 ml/min/1.73 m(2)) and 3.1% had CKD stage 3 (GFR 30-59 ml/min/1.73 m(2)) on admission, despite having a normal serum creatinine. The study group had a median follow-up of 3.6 years (95% CI 0-13.7). Renal risk, injury and failure were associated with a significantly reduced long-term survival (P < 0.001). In patients with normal preoperative serum creatinine, Cox regression analysis revealed that age (P = 0.026), preoperative creatinine (P =0.006) and logistic EuroSCORE (P < 0.0001) were significant factors in addition to the development of postoperative renal risk, injury or failure (P < 0.0001), with regard to determining long-term survival. A confounding factor analysis revealed that discharge creatinine (P = 0.0001) and discharge GFR (P = 0.0006) were significant determinants of long-term survival. In patients with a preoperative GFR >90 ml/min, Cox regression analysis revealed that diabetes (P = 0.004) sex (P = 0.019) and logistic EuroSCORE (P < 0.0001), were also significant factors in addition to the development of postoperative renal risk, injury or failure (P = 0.0001) with regard to determining long-term survival. A significant interaction between diabetes and the development of renal risk, injury or failure exists (P = 0.04). A confounding factor analysis revealed that discharge creatinine was a significant determinant (P = 0.0001) of long-term survival, and discharge GFR was not. CONCLUSIONS Despite being a biochemically reversible process, the development of renal risk, injury and failure as defined by the RIFLE criteria post-cardiac surgery in patients with a normal preoperative renal function is associated with a significantly worse long-term outcome.

Clinical Upstaging of Non-Small Cell Lung Cancer That Extends Across the Fissure: Implications for Non-Small Cell Lung Cancer Staging

BACKGROUND Little data exist as to the long-term outcome of non-small cell lung cancer that extends across the fissure into the adjacent lobe that requires either a bilobectomy or a lobectomy and wedge resection. METHODS Lobectomy survival data was benchmarked with the International Association for the Study of Lung Cancer (IALSC) dataset. Matched analysis of a prospective thoracic surgery database of 1,020 patients who had undergone lobectomy during a 6-year period was analyzed to elucidate the effect on long-term survival of tumors that extend across the interlobar fissure. RESULTS Benchmarking revealed our data are not significantly different from the IALSC dataset, allowing survival recommendations to be drawn. Histopathologic staging of matched patients was IA, 11.7%; IB, 51.1%; IIA, 1.7%; IIB, 21.1%; IIIA, 10.0%; IIIB, 2.8%; and IV, 1.7%. Stage I tumors crossing the interlobar fissure had a reduction in survival that is significant (10% to 15%) after 5 years (p = 0.037). The 5-year survival for stage I tumors extending across a lung fissure was 50%. This places the 5-year survival between stage I and II (60% and 40%, respectively). There was no difference in survival for tumors stage IIA and above with regard to importance of interlobar extension. The number of patients was too small to detect a significant difference between bilobectomy versus lobectomy and wedge. CONCLUSIONS Non-small cell lung cancer that extends across the fissure into an adjacent lobe requiring a bilobectomy or a lobectomy and wedge resection has a 5-year survival between stages I and II.

Red cell distribution width and coronary artery bypass surgery

OBJECTIVES The red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with coronary artery disease with or without heart failure. We sought to investigate the role of RDW in patients undergoing isolated coronary artery bypass graft surgery (CABG). METHODS Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Univariate and multivariate analysis was performed for in hospital mortality, long-term survival, length of hospital stay, length of intensive care unit stay and creatinine kinase muscle-brain (CKMB) release. RESULTS Overall mortality was 2.1% for all cases, N = 8615. Median follow up was 5.8 years. Univariate analysis demonstrated that the RDW has a significant effect on CKMB release, P = 0.001, in-hospital mortality, P < 0.0001, and long-term survival, P < 0.0001, but no significant effect on the ITU length of stay, P = 0.9, or hospital length of stay, P = 0.2. Multivariate analysis revealed that the RDW was a significant factor determining in-hospital mortality and long-term survival, but had no significant effect on CKMB release, ITU or hospital length of stay. Confounding factor analysis revealed that in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival. CONCLUSIONS The RDW is a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated CABG. The mechanism of association requires further study.

Long-term survival of patients with pulmonary disease undergoing coronary artery bypass surgery.

OBJECTIVES We sought to investigate the long-term survival of patients with obstructive, restrictive and chronic obstructive pulmonary disease (COPD) as defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD). METHODS A prospective database was retrospectively analysed and cross-correlated with the UK strategic tracking service to evaluate survival after primary coronary artery bypass grafts (CABG). Univariate and multivariate Cox regression analyses were performed. Three separate multivariate analyses were performed: COPD GOLD criteria for obstructive and/or restrictive lung disease, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and the FEV1/FVC ratio to investigate the effect of FEV1 and FVC individually. RESULTS We analysed 13 337 primary CABG procedures. The median follow-up was 7 years. Univariate analysis demonstrated that obstructive (P < 0.0001), restrictive (P < 0.0001) and mixed obstructive and restrictive pulmonary disease (P < 0.0001), and COPD as defined by the GOLD criteria (P < 0.0001), are all significant factors determining long-term survival. Cox regression analysis identified age, diabetes, moderate LV, poor LV, peripheral vascular disease, dialysis, left internal mammary artery (LIMA) usage, EuroSCORE, cardiopulmonary bypass and creatinine kinase muscle-brain isoenzyme as significant factors in addition to pulmonary disease that determine long-term survival. Moderate and severe COPD defined by GOLD criteria were significant factors determining long-term survival, but mild COPD had no significant effect. Obstructive and restrictive lung disease were both significant factors determining long-term survival. Restrictive lung disease, however, carried a greater prognostic significance (higher hazard ratio 2.2 vs 1.6) than obstructive. LIMA utilization in patients with COPD was not associated with an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate. CONCLUSIONS Pulmonary disease is a significant factor determining long-term survival. Patients with severe COPD still have a relatively good long-term survival and should not be denied surgery. LIMA utilization in patients with COPD results in a significantly increased long-term survival, without an increased intensive care unit stay, re-intubation rate or in-hospital mortality rate.

Prediction of in-hospital mortality following pulmonary resections: improving on current risk models

OBJECTIVES Using a large, prospectively collected and independently validated thoracic database, we created a risk-prediction tool for in-hospital mortality with the aim of improving on the accuracy of Thoracoscore. METHODS A prospectively collected and independently validated database containing lung resections was utilized, N = 2574. Logistic regression analysis with bootstrapping, and by the use of a random training and test set was utilized. Comparisons against the Thoracoscore, ESOS.01 and the Society of Thoracic Surgeons (STS) models were performed. RESULTS A logistic model identified age [odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.2, P = 0.0002], sex (OR 0.34, 95% CI 0.14-0.83, P = 0.02), predicted postoperative FEV1 (OR 0.96, 95% CI 0.94-0.99, P = 0.002), emphysema (OR 3.2, 95% CI 1.0-9.9, P = 0.04), excess alcohol consumption (OR 1.0, 95% CI 1.0-1.0, P = 0.04), pre-existing renal disease (OR 4.3, 95% CI 1.1-17.1, P = 0.04), predicted in-hospital mortality with an receiver operating curve (ROC) of 0.81 and a Hosmer-Lemeshow test of 0.9. Bootstrap analysis confirmed the above risk factors (ROC 0.82 and Hosmer-Lemeshow 0.2). Comparisons between Thoracoscore, ESOS.01 and the STS risk models demonstrated that none was very accurate, as all had low ROC values of 0.69, 0.70 and 0.61, respectively. The STS risk model does not apply to our population (ROC 0.61, Hosmer-Lemeshow, P = 0.004), and the ESOS.01 has poor predictive power (Hosmer-Lemeshow, P < 0.0001). CONCLUSIONS Logistic regression based on age, sex, predicted postoperative FEV1, alcohol consumption and pre-existing renal disease predicts in-hospital mortality with improved accuracy compared with the use of Thoracoscore, ESOS.01 and the STS risk model.