Consecutive Observational Study to Validate EuroSCORE II Performances on a Single-Center, Contemporary Cardiac Surgical Cohort.

OBJECTIVE: To compare and validate the original EuroSCORE risk stratification models with the renewed EuroSCORE II model in a contemporary cardiac surgical practice. DESIGN: A consecutive observational study to validate EuroSCORE II performances, conducted as retrospective analysis of prospectively collected data. SETTING: A tertiary university institute for cardiovascular diseases. PARTICIPANTS: Adult patients undergoing cardiac surgery between January and December 2012. METHODS: One thousand eight hundred sixty-four consecutive patients were scored preoperatively using additive and logistic EuroSCORE as well as EuroSCORE II. The discriminative power of the EuroSCORE models was tested by calculating the area under the receiver operating characteristic curve (AUC). The calibration of the models was assessed by Hosmer-Lemeshow statistics and with observed-to-expected mortality ratio. MEASUREMENTS AND MAIN RESULTS: The in-hospital overall mortality was 3.65%, with predicted mortalities according to additive EuroSCORE, logistic EuroSCORE, and EuroSCORE II of 5.14%, 6.60%, and 3.51%, respectively. The observed-to-expected (O/E) mortality ratio confirmed good calibration for the entire cohort only for EuroSCORE II (1.05, 95% confidence interval 0.81 - 1.29). Hosmer-Lemeshow test confirmed overall good calibration only for additive EuroSCORE (p = 0.129). The EuroSCORE II confirmed very good discriminatory power for a prolonged intensive care unit (ICU) stay of>2 days and>5 days (AUCs>0.75). Acceptable discriminatory power was confirmed for a prolonged postoperative stay of>7 days and>12 days (AUCs>0.70). CONCLUSION: EuroSCORE II confirmed very good discriminatory capacity, good calibration ability (O/E mortality ratio), and good capability to predict prolonged ICU and postoperative stays in a contemporary patient cohort undergoing cardiac surgery.

Coronary artery surgery in a patient with grossly emphysematous lung.

The pedicled left internal thoracic artery graft is the mandatory conduit in coronary artery bypass surgery. A grossly emphysematous lung may sometimes present a significant problem for positioning of the pedicled left internal thoracic artery conduit. An inverted pedicled left internal thoracic artery graft (internal thoracic artery transected near its origin, thus supplied by retrograde flow from superior epigastric and musculophrenic arteries) might occasionally be the conduit of choice for those patients.

Procalcitonin-based therapeutic strategy to reduce antibiotic use in patients after cardiac surgery: a randomized controlled trial.

INTRODUCTION: Procalcitonin (PCT) is a thyroid gland prohormone, and its serum concentration is elevated in systemic bacterial infections. The diagnostic cut-off value of PCT in patients early after cardiac surgery remains unclear. OBJECTIVE: We investigated whether procalcitonin-guidance could reduce antibiotic usage safely. METHODS: The prospective study included 205 patients who underwent open heart surgery. The patients were randomly assigned for procalcitonin-guided antibiotic treatment (PCT-group; n = 102) or standard care (standard group; n = 103). On the basis of serum procalcitonin concentrations, usage of antibiotics was encouraged (PCT > or = 0.5 ng/mL) or discouraged. RESULTS: A relative risk of antibiotic exposure in the standard group compared with the PCT-group was 3.81 (95% CI = 2.03-7.17; p < 0.0001). The mean cost of antibiotics per patient in procalcitonin group was Euro 193.3 +/- 636.6 vs. Euro 372.1 +/- 841.1 (p = 0.206) in the standard group, while the mean cost per hospital day was Euro 8.0 +/- 18.4 vs. Euro 17.8 +/- 36.3 (p = 0.028). We found that non-infectious complications occurred in 40/102 vs. 41/103 (p = 0.592) while infections appeared in 5/102 vs. 22/103 (p = 0.001) cases. A statistically significant difference was observed in the treatment of urinary infections between PCT-group and standard group; 1/102 vs. 9/103 (p = 0.016). In the PCT-group, the ICU stay was 5.74 +/- 11.49 days and in the standard group 6.97 +/- 11.61 (p = 0.812). The hospital stay was 12.08 +/- 11.28 vs. 12.93 +/- 10.73 (p > 0.05) days, respectively. Mortality rates were equal in both groups of patients (p = 0.537). CONCLUSION: Procalcitonin-guided antibiotic treatment is safe and can significantly reduce the cost of postoperative care. Additionally, the antibiotic use during immediate postoperative course should be timely controlled and limited to documented bacterial infections.

Preconditioning with glucose-insulin-potassium solution and restoration of myocardial function during coronary surgery.

The administration of glucose-insulin-potassium (GIK) solution has beeen shown to exert cardioprotective and immunomodulatory properties in coronary disease. 49 patients (pts.) for coronary surgery were randomly assigned to receive high-dose GIK treatment (30% glucose, insulin 2 IU.kg(-1).l(-1) and K(+) 80 mmo/l solution; 1 ml/kg/h); low-dose GIK treatment (10% glucose, insulin 32 IU l(-1) and K(+) 80 mmol/l solution; 1 ml/kg/h) or control treatment (Ringer solution 1 ml/kg/h). Haemodynamic measurements were done for four time points: T1 - after induction of anaesthesia; T2 - after the operation; T3 - 6 h after the operation and T4 - 24 h after the operation. Significant recovery of cardiac function was evident in high-dose GIK (H-GIK) and low-dose GIK (L-GIK) groups after 24 h (cardiac index improved considerably (p = 0.0002)), with a statistically significant difference between the groups (p = 0.005). LVSWI covariated with PCWP, improved over time in group H-GIK (p = 0.0008) and between the groups (p = 0.046). Oxygen supply-consumption ratio evidently improved in the GIK groups, while inotropic drug support was used in 5.5% pts. in group H-GIK vs. 13% in group L-GIK and 31% pts. in control (C) group. Glucose-insulin treatment has a potential cardioprotective effect in coronary surgery. The effect is independent of the glucose-insulin concentration and amount.

[Hemodynamic effects of intravenous administration of ACE inhibitor in prevention of heart failure following coronary artery bypass surgery].

INTRODUCTION: Our study was designed to explore the hemodynamic effects of intravenous administration of ACE-inhibitor quinaprilat in comparison with standard inotropic-vasodilator therapy. Patients with poor left ventricular function following coronary artery bypass (CABG) surgery were examined. MATERIALS AND METHODS: Thirty patients with poor left ventricular function (EF<30%) following CABG surgery with use of cardiopulmonaly bypass were examined. Fourty patients were control group. All patients had complete invasive hemodynamic monitoring. The ACE-inhibitor quinaprilat 0.5 mg/h was administered intravenously via infusion pump. The following parameters were analyzed: arterial blood pressure, systemic vascular resistance, pulmonary vascular resistance, heart rate, cardiac output, cardiac index, left ventricular stroke work index and the level of mixed venous oxygen saturation. RESULTS: The results of our study were as follows: Cardiac output, cardiac index and left ventricular stroke work index were significantly increased in comparison to the control group. Systemic arterial systolic pressure and pulmonary vascular resistance were decreased and there was no significant difference in systemic vascular resistance, mixed venous oxygen saturation, heart rate and diastolic blood pressure in comparison to the control group. DISCUSSION: Our results pointed at very satisfactory hemodynamic effects of quinaprilat on "stunned myocardium", after CABG surgery. The ACE inhibitors greatly reduce mortality in patients in all stages of heart failure, from asymptomatic dysfunction of the left ventricle to severe symptomatic stages. CONCLUSION: In prevention of heart failure in patients with impaired left ventricle function (LVEF<30%), who had undergone CABG surgery with use of cardiopulmonaly bypass, we achieved the best effects on the hemodynamics with parenteral administration of quinaprilat.

[Strategy and perspective of myocardial protection during ischaemia and reperfusion, and the role of volatile anaesthetics].

Surgical coronary revascularization is based on effectiveness of cardioplegia directed to protect myocardial functional integrity during periods of ischaemia and reperfusion. The aim of cardioplegia is to protect numerous intracellular processes: to spare the intracellular energy stores, to reduce free oxygen radical synthesis, to protect the function of the endothelium and myocardial oxygen balance as well as ionic balance. Crystalloid or blood cardioplegia, with anterograde or retrograde infusion, is a basic procedure of the intraoperative cardiac protection. Glucose-insulin-potassium (GIK) solution was primarily used in myocardial infarction. After the first promising results, some surgical teams started using a high glucose-insulin-potassium solution, as a metabolic modulation approach, during coronary surgery in addition to cardioplegia.The improvement of the left ventricular performances, rare rhythm disturbances and reduced need for inotropic support during the period of reperfusion justified the GIK beneficial effect. Further improvement in metabolic modulation during coronary surgery was made with fluorine ion halogenated volatile aneasthetics used for anaesthesia. Results of some experimental and first clinical studies have induced a new approach to modulation of the intracellular metabolic mechanisms and announced the new concept of anaesthetic preconditioning in coronary surgery. Large, randomized studies are needed to evaluate anaesthetic preconditioning and dependence of its efficiency on the type and dose of volatile anaesthetics.