Perforation of the right cardiac ventricle as a late complication of a displaced sternal fracture following blunt trauma.

Cardiac tamponade is a rare but possibly fatal complication of blunt thoracic trauma complicated by a sternal fracture. A delayed presentation of cardiac tamponade days or weeks after initial trauma has been described in a few cases. In these cases, the presumed mechanism of cardiac tamponade is pericardial irritation, caused by osseous fragments of the fractured sternum. This case describes a direct mechanical perforation of the right ventricle, caused by a displaced sternal fracture, presenting 5 days after initial trauma. To our knowledge, this mechanism of late cardiac tamponade has not been described in recent literature.

A thousand pericardial valves in aortic position: risk factors for postoperative acute renal function impairment in elderly.

AIM: Postoperative renal dysfunction after aortic valve replacement is a serious complication. To minimize its occurrence, risk factors have to be identified, and if possible eliminated. METHODS: Of 1000 consecutive patients, who underwent AVR, a file study was performed chi(2)nd logistic regression analysis were performed to study the effect of 24 preoperative, 7 peroperative and 7 postoperative factors on the occurrence of 30-day postoperative worsening of renal function. RESULTS: Fifty-three patients had a 30-day postoperative decrease of renal function. Nine of these patients died, which is significantly more than the mortality without this complication (P<0.0001). In those nine patients, another complication (postoperative heart failure, thromboembolism or respiratory failure) was present. Thirteen factors were significant in an univariate analysis: preoperative renal dysfunction (P<0.001), age>80 (P<0.001), atrial fibrillation (P<0.001) , preoperative pulmonary edema (P=0.001), conduction defect (P=0.002), diabetes (P=0.006), myocardial infarction (P=0.006), postoperative heart failure (P=0.007), cross clamp time >75 min (P=0.015), previous coronary artery bypass grafting (CABG) (P=0.018), concomitant CABG (P=0.031), ejection fraction <50% (P=0.033) and CVA (P=0.035). Four factors were identified as independent predictors in a multivariate analysis: renal dysfunction (P<0.001, Odds ratio [OR] 5.5; 95% confidence interval [CI] 2.9-10.4), preoperative atrial fibrillation (P=0.010, OR=2.3, 95% CI=1.2-4.2), age>80 (P=0.014, OR=2.2, 95% CI=1.2-4.1) and myocardial infarction (P=0.022, OR=2.2, 95% CI=1.1-4.4). CONCLUSIONS: Few factors are liable for therapeutic intervention, especially in elderly and patients with comorbidity. In patients with risk factors, shortening of cross clamping time or installation of minimal extracorporeal circulation might be beneficial.

Single centre, single domain validation of the EuroSCORE on a consecutive sample of primary and repeat CABG.

OBJECTIVES: Intra- and interdepartmental benchmarking require scoring systems with excellent performance on several properties: discrimination (resolution), reliability (calibration) and stability over the complete spectrum of peri-procedural risk. This single centre, single domain study validates the European system for cardiac operative risk evaluation (EuroSCORE) on an independent sample of primary and repeat coronary artery bypass grafting (CABG) patients and will evaluate these different properties. METHODS: The study population is a consecutive series of 2051 isolated primary and repeat CABG patients, inclusive of patients in cardiogenic shock or resuscitation, operated on in a single institution from January 1997 to July 2000. The age of the patients was 66+/-9 years, 77% were males and 7% were repeat procedures. The EuroSCORE was 5.0+/-3%, with a range from 0 to 22. The studied event was in-hospital death, defined as mortality during hospital stay, which was unlimited in time and included a stay in a secondary hospital without discharge home. RESULTS: The EuroSCORE predicted 102 deaths versus 81 deaths observed (P=0.14, Fisher exact test). The EuroSCORE described only 20% of the variance of in-hospital mortality. The EuroSCORE created an area under the receiver operating characteristic curve of 0.83+/-0.03. The highest discriminative accuracy was obtained with 8% EuroSCORE risk (only 64% sensitivity and 87% specificity). Further exploration identified an over score in the EuroSCORE range 0-8 (57%, P<0.0001). There was an equal score (-2%, P=1) in the range 9-11, but an under score in the range 12-22 (-133%, P=0.003). CONCLUSIONS: On the condition that these single centre results could be extended to any European cardiac surgery centre, it can be concluded that the overall acceptable performance of the EuroSCORE is the result of an over score in the lower risk and insufficient correction in the higher risk spectrum. The EuroSCORE is probably refined enough for improved informed consent versus aggregated results but should only be used for inter-institutional benchmarking with great caution, preferably below the 12% risk pivot.

The challenge of departmental quality control in the reengineering towards off-pump coronary artery bypass grafting.

OBJECTIVE: Off pump coronary surgery is a major reengineering effort of the surgical systems. There are no perfect tools available to guide every centre in the confrontation with the complete spectrum of risk and the limited number of events. This study analyses the use of a hospital mortality risk-stratifying system in the complete shift towards off-pump CABG. METHODS: All 535 off-pump CABG patients from January 1997 till September 2000 underwent a comparison of their hospital mortality versus the EuroSCORE predictions. The mean risk predicted by the EuroSCORE was 4.5+/-3% (range 0-14) and the mean age was 65+/-10 years (range 36-89). The series includes 23 repeat procedures, also 77 patients with per oral or insulin-treated diabetes. The number of distal anastomoses was 2.5+/-1 and of arterial grafts 1.3+/-0.6. RESULTS: The observed hospital mortality was 15 patients, 2.8% (Fisher exact test P=0.19 versus the EuroSCORE). The 1 and 3 month Kaplan-Meier survival, irrespective from hospital discharge, was 97.4+/-0.7 and 97.2+/-0.7%, respectively. A cumulative risk-adjusted mortality plot is constructed. The area under the ROC curve was 0.886. A stepwise sampling of patients according to increasing risk identified the difference between the EuroSCORE-predicted and observed hospital mortality for the complete spectrum of risk. The P value of this difference was 0.06 for the grouping including all patients from 0-5% risk (78% reduction), 0.04 for the grouping 0-8% risk (61% reduction), and 0.05 for the grouping 0-11% risk (52% reduction of risk). The loss of statistical significant difference was due to the inclusion of the patients at extremely high risk. CONCLUSION: A hospital mortality risk-stratifying system can provide guidance but different and in depth approaches are mandatory to improve the insight, certainly in the presence of a large spectrum of risk.