EuroSCORE overestimates the cardiac operative risk.

INTRODUCTION: It was the purpose of our study to assess the validity of EuroSCORE (European system for cardiac operative risk evaluation) in our patient population. MATERIALS AND METHODS: Between March 1999 and August 2001, information on risk factors and mortality was collected for 1123 consecutive adult patients undergoing heart surgery with cardiopulmonary bypass. EuroSCORE was used for risk stratification. Mean age +/- standard deviation was 58.6 +/- 10.9 and 29.1% of the patients were female. The area under the receiver operating characteristic (ROC) curve was calculated as an index for the predictive value of the scoring system. RESULTS: The area under the ROC curve was 0.824 for all patients and 0.828 for the isolated CABG subgroup which shows an excellent predictive ability. When the scoring system was applied in low, medium, and high risk groups, there was no overlap between 95% confidence intervals of observed and expected mortality in all three groups both for the isolated CABG cases and for all patients. Decreased left ventricular ejection fraction, emergent operation, and preoperative unstable angina requiring i.v. nitrate treatment were significant predictive variables for early mortality. CONCLUSION: EuroSCORE is a simple and objective system for predicting the risk of heart surgery. The predictive power of the EuroSCORE is excellent, however it seems that mortality is considerably overestimated by this score.

Aortoventriculoplasty in a patient with complex left ventricular outflow tract obstruction, mitral valve stenosis and aneurysm of the ascending aorta.

We describe a new method of aortoventriculoplasty in a patient with calcified mitral stenosis, aortic valvular stenosis, severe left ventricular outflow tract obstruction, and aneurysm of the ascending aorta. This complex pathology was successfully treated with replacement of both the valves and a tubular dacron graft. The proximal end of the dacron tube was tailored as a patch for the repair of the ventricular septum and the aortic root, and the distal end was anastomosed to the distal ascending aorta. The patient had an uneventful recovery and postoperative echocardiography showed no significant residual gradient on the left ventricular outflow tract.

Magnesium infusion dramatically decreases the incidence of atrial fibrillation after coronary artery bypass grafting.

BACKGROUND: Atrial fibrillation (AF) is one of the most common complications of cardiac surgery. Magnesium, like several other pharmacologic agents, has been used in the prophylaxis of postoperative AF with varying degrees of success. However, the dose and the timing of magnesium prophylaxis need to be clarified. The purpose of this study was to assess the effect of intermittent magnesium infusion on postoperative AF. METHODS: A total of 200 consecutive patients who had elective, isolated, first-time coronary artery bypass grafting were prospectively randomized to two groups. Patients in the magnesium group (n = 100) received 6 mmol MgSO4 infusion in 100 mL 0.9% NaCl solution (25 mL/h) the day before surgery, just after cardiopulmonary bypass, and once daily for 4 days after surgery. Patients in the control group (n = 100) received only 100 mL 0.9% NaCl solution (25 mL/h) at the same time points. RESULTS: Postoperative AF occurred in 2 (2%) patients in the magnesium group and in 21 (21%) patients in the control group (p < 0.001). Atrial fibrillation started, on average, 49.4 +/- 16.8 hours postoperatively. The postoperative length of hospital stay was not significantly different in patients with AF (7.4 +/- 8.0 days) compared with patients without AF (5.4 +/- 1.1 days; p = 0.236). CONCLUSIONS: The use of magnesium in the preoperative and early postoperative periods is highly effective in reducing the incidence of AF after coronary artery bypass grafting.

Absent right superior vena cava with hypoplastic proximal inferior vena cava.

We describe the precise preoperative diagnosis of a very rare anomaly that comprises absence of the right superior vena cava, persistence of the left superior vena cava, and proximal hypoplasia of the inferior vena cava draining into the left superior vena cava via the hemiazygos vein associated with a large atrial septal defect and tricuspid regurgitation.

Critical-illness polyneuropathy complicating cardiac operation.

Critical-illness polyneuropathy is a complication of septic syndrome. However, this complication has been largely unrecognized in cardiac surgery units. Difficulty in weaning from the ventilator is an important early manifestation. Electromyography should be routinely performed to establish the diagnosis. Here we report a case of polyneuropathy complicating surgical repair of acute aortic dissection.

Intermittent aortic cross-clamping and cold crystalloid cardioplegia for low-risk coronary patients.

BACKGROUND: Blood cardioplegic strategies have been shown to increase myocardial oxygen uptake, replenish depleted energy stores, and improve myocardial function and survival in the high-risk subset of patients. However, the superiority of these techniques over intermittent aortic cross-clamping and crystalloid cardioplegia in low-risk patients is still controversial. METHODS: This study consisted of two parts. In the first part, we assessed the results of a recent cohort of 399 consecutive low-risk patients undergoing their first coronary artery bypass grafting between 1993 and 1995 using cold crystalloid cardioplegia (n = 128) and intermittent aortic cross-clamping (n = 271). In the second part of the study, 40 consecutive low-risk patients undergoing elective first time coronary artery bypass grafting were randomly divided into two equal groups. One group received cold crystalloid cardioplegia and the other group had myocardial management with intermittent aortic cross-clamping. The two groups were compared with respect to hemodynamic, biochemical and ultrastructural changes. RESULTS: The overall mortality rate, the perioperative myocardial in the need for intraaortic balloon pumps, and the need for inotropic agents were 0.25%, 1.5%, 1%, and 5.8%, respectively. No significant differences were observed between the groups with respect to these clinically defined end points. CONCLUSIONS: Both intermittent aortic cross-clamping and cold crystalloid cardioplegia techniques may be used safely in low-risk patients undergoing first-time coronary artery bypass grafting.

Comparative assessment of chordal preservation versus chordal resection in mitral valve replacement for mitral stenosis.

Mitral valve replacement with preserving all chordae tendineae in patients with mitral regurgitation has been proved to be beneficial for left ventricular performance in the postoperative period. To evaluate the effectiveness of this technique in patients with mitral stenosis a comparison of the hemodynamic and echocardiographic data between patients having operation with this technique (Group P, n = 15, mean age = 37.5 +/- 12 years), and those having operation with the conventional method of mitral valve replacement (Group C, n = 15, mean age = 39 +/- 10.4 years) was made. The study population was limited to patients who had no clinical evidence of coronary artery disease and if over 40 years of age had normal coronary artery anatomy on coronary arteriography; patients with no evidence of aortic stenosis and/or regurgitation; and patients who had pure mitral stenosis or mitral stenosis with slight regurgitation (Grade 2 or less) with a mean gradient across the mitral valve greater than 10 mmHg. Hemodynamic parameters improved in both groups after the operation. However, echocardiographic measurements obtained six months postoperatively revealed a significant decrease in left ventricular ejection fraction in Group C (61.33 +/- 9.29% preoperatively versus 53.2 +/- 10.3% postoperatively; p < 0.05). The difference between left ventricular ejection fraction diminution of the two groups was statistically significant (-0.71 +/- 6.28% in Group P versus -8.07 +/- 13.35% in Group C; p < 0.01). Left ventricular end systolic and end diastolic dimensions decreased in patients with preserved valves and increased in patients operated on with conventional method without reaching a statistical significance. Sizes of prosthetic valves inserted were in the same range and no significant differences were found in preoperative and postoperative comparison of the two groups in respect to effective mitral orifice area and transvalvular gradient. There were no evidence of prosthetic valve dysfunction and paravalvular leakage and no operative or late deaths. It is concluded that if it is suitable, mitral valve replacement with preservation of chordae tendineae is expected to have a beneficial effect on postoperative left ventricular performance in patients with mitral stenosis.

[Results of endarterectomy combined with angioplasty in aortocoronary bypass]. / Les résultats des endartériectomies combinées avec angioplasties dans les opérations de pontages aorto-coronaires.

From January 1989 until April 1990, 472 consecutive patients were operated for coronary artery bypass grafting. The patients were classified into three different groups. In group I, 412 patients were operated without endarterectomy. Group II consisted of 37 cases operated with endarterectomy-bypass to 41 vessels. Group III consisted of 23 cases of endarterectomy combined with patch-plastybypass to 24 vessels. The length of the segment endarterectomized was 25 to 70 mm (mean 37.86 +/- 12.18 mm). Peri-operative myocardial infarction occurred in 19 cases in group I (4.61%), 6 cases in group II (16.21%), and 3 cases in group III (13.04%). The percentage of IABP utilization was 2.91% in group I; 10.81% in group II; 8.69% in group III. The hospital mortality for group I, group II and group III was 3.88%; 8.10% and 8.69%. Mean follow-up was 16.4 months for 72% of patients. In 5 cases of group I (1.80%), in 8 cases of group II (27.58%) and in one case of group III (5.55%), myocardial infarction occurred in the late post-operative period. Late mortality was 1.44% for group I; 17.24% for group II and 5.55% for group III. There was no statistically significant difference between groups II and III, but the late results of group III are probably better.

[Results of endarterectomy combined with angioplasty in aortocoronary bypass operations]. / Les résultats des endartériectomies combinées avec angioplasties dans les opérations de pontages aorto-coronaires.

From January 1989 until April 1990, 472 consecutive patients were operated for coronary artery bypass grafting. The patients were classified into three different groups. In group I, 412 patients were operated without endarterectomy. Group II consisted of 37 cases operated with endarterectomy-bypass to 41 vessels. Group III consisted of 23 cases of endarterectomy combined with patch-plasty-bypass to 24 vessels. The length of the segment endarterectomized was 25 to 70 mm (mean 37.86 +/- 12.18 mm). Peri-operative myocardial infarction occurred in 19 cases in group I (4.61%), 6 cases in group II (16.21%), and 3 cases in group III (13.04%). The percentage of IABP utilization was 2.91% in group I; 10.81% in group II; 8.69% in group III. The hospital mortality for group I, group II and group III was 3.88%; 8.10% and 8.69%. Mean follow-up was 16.4 months for 72% of patients. In 5 cases of group I (1.80%), in 8 cases of group II (27.58%) and in one case of group III (5.55%), myocardial infarction occurred in the late post-operative period. Late mortality was 1.44% for group I; 17.24% for group II and 5.55% for group III. There was no statistically significant difference between groups II and III, but the late results of group III are probably better.

Is continuous normothermic blood cardioplegia really a practical way of myocardial preservation? Comparison with intermittent cold crystalloid cardioplegia.

Commencing in September 1991, 30 consecutive patients who underwent coronary artery bypass grafting were operated on employing continuous normothermic blood cardioplegia (Group 1). 2.83 +/- 0.81 distal anastomoses per patient were performed. The next 30 consecutive patients were operated on employing intermittent cold crystalloid cardioplegia (Group 2). 2.72 +/- 0.95 distal anastomoses per patient were performed in this group. Cross clamping and cardiopulmonary bypass times were similar in both groups. Electromechanical activity beginning time (69.00 +/- 94.04 sec. versus 101.50 +/- 78.26 sec., p < 0.001) and QRS recovery time (10.92 +/- 8.35 min. verus 19.60 +/- 33.65 min., p < 0.05) were significantly shorter in Group 1 than in Group 2. Maximal potassium levels during cardiopulmonary bypass and in the postoperative period did not significantly differ between the groups. Postoperative serum CPK-MB values were similar. Three patients in Group 1 and four in Group 2 needed IABP support in the early postoperative period. In Group 1, one and in Group 2 three patients suffered perioperative myocardial infarction (difference not significant). Postoperative cardiac index augmentation was significantly higher in Group 1 than in Group 2 (from 2.40 +/- 0.57 L/min/m2 to 3.04 +/- 0.60 L/min/m2 in Gr I, from 2.39 +/- 0.64 L/min/m2 to 2.86 +/- 0.49 L/min/m2 in Gr II, p < 0.01). Coronary sinus oxygen saturations during aortic cross-clamping were significantly higher in Group 1 (53.32 +/- 12.18% versus 17.82 +/- 2.75%, p < 0.001). There were no rhythm disturbances in Group 1 (0%) but atrial fibrillation occurred in 5 (16.66%) cases of the hypothermic group in the postoperative period. In Group 1, two patients, and in Group 2, three patients (difference is not significant) were lost in the early postoperative period. We can say that continuous normothermic blood cardioplegia is a safe alternative way of myocardial protection with good clinical results despite its discomfortable and complicated delivery technique.