Cardiac operative risk evaluation: The EuroSCORE II, does it make a real difference?

BACKGROUND: The EuroSCORE, worldwide used as a model for prediction of mortality after cardiac surgery, has recently been renewed. Since October 2011, the EuroSCORE II calculator is available at the EuroSCORE website and recommended for clinical use. The intention of this paper is to compare the use of the initial EuroSCORE and EuroSCORE II as a risk evaluation tool. METHODS: 100 consecutive patients who underwent combined mitral valve and coronary bypass surgery (MVR + CABG) and 100 consecutive patients undergoing combined aortic valve surgery and coronary bypass surgery (AVR + CABG) at the Radboud University Nijmegen Medical Center before 10 October 2011 were included. For both groups the initial EuroSCORE and the EuroSCORE II model were used for risk calculation and based on the calculated risks, cumulative sum charts (CUSUM) were constructed to evaluate the impact on performance monitoring. RESULTS: For the MVR + CABG group the calculated risk using the initial logistic EuroSCORE was 9.95 ± 8.47 (1.51-45.37) versus 5.08 ± 4.03 (0.67-19.76) for the EuroSCORE II. For the AVR + CABG group 9.50 ± 8.6 (1.51-69.5) versus 4.77 ± 6.6 (0.96-64.24), respectively. For both groups the calculated risk by the EuroSCORE II was statistically lower compared with the initial EuroSCORE (p < 0.001). This lower expected risk has influence on performance monitoring, using risk-adjusted CUSUM analysis. CONCLUSION: The EuroSCORE II, based on a recently updated database, reduces the overestimation of the calculated risk by the initial EuroSCORE. This difference is statistically significant and the EuroSCORE II may also reflect better current surgical performance.

Stroke after coronary artery bypass grafting. Is there place for a stroke-risk stratification model?

AIM: Preoperative carotid screening is common in the prevention of perioperative stroke. The authors describe our experience with selective screening of patients with a recent (<1 year) neurological event. Because many variables are related with the development of perioperative stroke we additionally evaluate the value of a stroke-risk stratification model. METHODS: Of 1 442 isolated myocardial revascularizations performed between January 2002 and December 2005, 118 patients had a history of preoperative stroke. Twenty-four patients had a recent stroke. In 5/24 patients duplex revealed significant stenosis of the internal carotid artery, which was treated prophylactically. RESULTS: Eleven patients (0.83%) developed a perioperative stroke. Three patients recovered completely during hospital stay, three died related to their stroke. Of the other 94 patients with a history of stroke, 5 had a stroke, none of them had a significant stenosis of the carotid artery. Of the 1,224 patients without a history of stroke, 6 developed a perioperative stroke. Three of them had a significant carotid artery stenosis, however in two patients stroke deficit was on the ipsilateral side and the third patient had a transient ischemic attack. All eleven patients had a calculated stroke risk of 3 or higher corresponding with a expected risk of at least 0.9%. CONCLUSIONS: With the used protocol, in the described patient population, perioperative stroke incidence is low. on the other hand, the complexity of the mechanism of perioperative stroke is confirmed and the use of a stroke-risk stratification model seems us justified for a better identification of patients at risk.

[Mediastinitis and cervical fasciitis necroticans post extraction of 2 molars]. / Mediastinitis en cervicale fasciitis necroticans na extractie van 2 molaren.

A 38-year-old man developed dysphagia, fever and marked trismus, resulting in an abcess of the parafaryngeal region, soon after the surgical extraction of 2 mandibular molars. Despite systemic antibiotics and surgical drainage, the abcess spread to the mediastinum. Within a short space of time, cervical fasciitis necroticans and descending necrotizing mediastinitis developed. Because of the life-threatening health condition, the patient was admitted to a hospital for further treatment. He underwent surgical exploration of the cervical and sternal region, thoracotomy for mediastinal drainage, debridement, and daily mediastinal rinsing with hydrogen peroxide and betadine iodine. After 5 weeks intensive treatment, the patient could be discharged from the hospital in a fairly good condition of health.

Cardiac surgery and operative mortality in 1992 and 2002: the St Antonius experience.

OBJECTIVE: Comparing the changes in open-heart surgical procedures and hospital mortality in 1992 with 2002. DESIGN AND SETTING: Retrospective investigation at St Antonius Hospital in Nieuwegein. METHOD: A comparison of the open-heart surgical procedures, hospital mortality and age distribution of the operated patients was made, using the database of the Department of Cardiothoracic Surgery. RESULTS: The total number of open-heart surgical procedures increased. There were more combined procedures, aortic valve replacements and reconstructions of the thoracic aorta. The total number of reoperations decreased. In 2002 the use of an arterial conduit for coronary bypass procedures reached 94%, and the radial artery was used for the first time. The mean patient age and the hospital mortality were higher in 2002. CONCLUSION: Comparing cardiovascular surgery in 1992 to 2002 showed an increase in complicated procedures and older age groups of patients. This may be the reason for higher overall mortality. The mean patient age increased considerably from 1992 to 2002, together with the number of combined procedures and aortic valve replacements with biological valve prostheses. These trends give cardiovascular surgery a challenging future, to treat the patient adequately and keeping the mortality and complication rates low.

Effect of dipyridamole on myocardial reperfusion injury: A double-blind randomized controlled trial in patients undergoing elective coronary artery bypass surgery.

Dipyridamole reduces reperfusion-injury in preclinical trials and may be beneficial in patients undergoing coronary angioplasty, but its effect on patients undergoing coronary artery bypass grafting (CABG) is unknown. We hypothesized that dipyridamole limits myocardial reperfusion-injury in patients undergoing CABG. The trial design was a double-blind trial randomizing between pretreatment with dipyridamole or placebo. In all, 94 patients undergoing elective on-pump CABG were recruited between February 2010 and June 2012. The primary endpoint was plasma high-sensitive (hs-) troponin-I at 6, 12, and 24 hours after reperfusion. Secondary endpoints were the occurrence of bleeding, arrhythmias, need for inotropic support, and intensive care unit length of stay. Finally, 79 patients (33 dipyridamole) were included in the per-protocol analysis. Dipyridamole did not significantly affect postoperative hs-troponin-I (change in plasma hs-troponin I -3% [95% confidence interval -23% to 36%]; P > 0.1). Secondary endpoints did not differ between groups. Dipyridamole prior to CABG does not significantly reduce postoperative hs-troponin release.

Sex differences in patient and procedural characteristics and early outcomes following cardiac surgery.

AIM: The purpose of this study was to evaluate whether women undergoing cardiac surgery are more likely to suffer postoperative complications and mortality than men with respect to baseline and procedural characteristics. METHODS: Data of 4030 adult patients undergoing cardiac surgery between January 2007 and June 2012 were retrospectively analyzed; 3075 isolated CABGs (CABG-group) and 955 aortic valve replacements (AVR) whether or not in combination with CABG (VALVE-group) The total study population, had a mean age 69.6 ±10.3 years, and there were 1073/4030 women (26.6%). RESULTS: Female patients were older (P=0.001), at higher EuroSCORE risk (P=0.001) and have a higher BMI (P=0.001). In the CABG-group female patients receive fewer distal anastomoses (P=0.001) and arterial grafts were less frequently used (P=0.002). In the combined procedures in women less distal anastomoses were applied (P=0.029). Postoperative female CABG patients have a higher hospital mortality (P=0.031) and early mortality (P=0.019). In the VALVE group there is no difference in hospital or early mortality between both genders. Binary logistic regression did not identify female gender as an independent risk factor for hospital- or early mortality in both patient groups. CONCLUSION: Although female patients undergoing cardiac surgery are older and at higher risk, female gender is not an independent risk factor. The operative procedure and gender related differences in treatment may be important and affect the outcome.

Comparison of transthoracic and transesophageal echocardiography with surgical findings in mitral regurgitation. The ESMIR Research Group.

This prospective study was conducted to ascertain whether echocardiographic evaluation could provide more insight into the genesis of mitral regurgitation (MR) before surgery. All patients underwent preoperative transthoracic and transesophageal echocardiography. Nine centers participated in the ESMIR (Echocardiographic Selection of patients for MItral valve Reconstruction) study and 350 patients were included. Compared with surgical findings, the percentage of functional abnormalities correctly predicted by both echo modalities was highest in patients with increased leaflet mobility (83% for transthoracic and 86% transesophageal echocardiography). In contrast, in normal leaflet mobility, the prediction was better by transthoracic than by transesophageal echocardiography (75% vs 64%). In patients with restricted leaflet mobility, the predictive value of both techniques was similar. The diagnostic yield of anatomic abnormalities of both echo techniques was similar, except for chordal rupture; a sensitivity by transesophageal echocardiography of 79% and by transthoracic echocardiography of 57% (p < 0.001). In general, the sensitivity of each echo technique for detecting anatomic abnormalities was <70%, except for annular dilatation, leaflet thickening, and chordal rupture. At surgery, the prevailing functional condition was increased leaflet mobility (42%). The conclusion is that both echo techniques provide adequate information regarding the functional condition of the mitral valve apparatus, not withstanding limitations in assessing anatomic details. Transthoracic echocardiography appears to be sufficient for preoperative evaluation of MR.

Pulmonary resection after pneumonectomy in patients with bronchogenic carcinoma.

Eight patients with a previous pneumonectomy for bronchogenic carcinoma underwent an additional resection because of a second primary carcinoma in the remaining lung. One patient died of pulmonary embolism in the postoperative period. The postoperative course was otherwise uneventful except for prolonged air leak. Two patients died after 3 months (bone metastasis) and 5 months (recurrent small-cell carcinoma). Two patients were alive at the time this article was written but had evidence of recurrence after 18 months (distant metastasis) and 21 months (local recurrence at the site of positive resection margins). Three patients were alive and doing well without evidence of disease after 16, 17, and 40 months. After careful selection, even patients with a previous pneumonectomy may be good candidates for additional resection of a second primary bronchogenic carcinoma.

Second primary lung cancer after bronchial sleeve resection. Treatment and results in eleven patients.

During the years 1960 to 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Follow-up was complete except for one patient, who was no longer available for follow-up 4 years after operation. Eleven patients (7.6%) had a second primary cancer in the lung; 10 of these patients (90.9%) were men. Mean age at sleeve operation was 61.2 +/- 11.6 years. Mean interval between sleeve operation and development of second primary cancer was 53.8 months (range, 6 to 197 months). All second primary cancers occurred on the contralateral side. In five cases there was squamous cell carcinoma, in two there was adenocarcinoma, in one there was adenosquamous carcinoma, in two there was small cell carcinoma, and in one patient no definite histologic type could be established. Five patients had different histologic type from the initial, resected primary tumor. Seven patients (64%) were operated on: five underwent lobectomy and two underwent segmentectomy. In one patient the tumor was judged to be unresectable. Chemotherapy was given to the two patients with small cell carcinoma and radiotherapy was given to one patient with bone metastases. Follow-up was complete for these 11 patients. Data were calculated from detection of second primary cancer. There was one postoperative death from myocardial infarction. Eight other patients died during follow-up: five died of recurrent tumor or metastases, two died of acute cardiac failure, and one died of a perforated ulcer. The 1- and 4-year actuarial survivals were 41% and 30%, respectively. For the patients operated on, 1- and 4-year survivals were 57% and 43%, respectively. There were no survivors at 5 years. Sleeve resection is a valuable method of preserving functional lung tissue. It offers a chance of subsequent resection in patients who have second primary cancer, with acceptable results.

Survival in synchronous vs. single lung cancer: upstaging better reflects prognosis.

OBJECTIVE: To define prognostic parameters for patients with synchronous non-small cell lung cancer (NSCLC). DESIGN: Retrospective study of period from 1970 through 1997. PATIENTS: Patients with a single (n = 2,764) and synchronous NSCLC (n = 85) who underwent pulmonary resection. METHODS: All tumors were classified postsurgically, and the tumors of the patients with synchronous lung cancer were staged separately. The most advanced tumor was used for comparison. Actuarial survival time was estimated, and risk factors influencing survival were evaluated. Patients who died within 30 days of surgery were excluded. MEASUREMENT AND RESULTS: Five-year survival for single NSCLC was 41% and for synchronous lung cancer it was 19%. The relative risk of death for patients with synchronous lung cancer was 1.75, compared to that for patients with single lung cancer. The most advanced tumor in synchronous cancer was a significant predictor of survival (p<0.005). The survival of patients with synchronous lung cancer in which the most advanced tumors were stage I (n = 40) and stage II (n = 27) was not different from that of patients with stage II (n = 834) and stage IIIA (n = 405) single lung cancer, respectively. CONCLUSION: The poorer survival of patients with synchronous NSCLC is confirmed and quantified. The stage of the most advanced tumor was the best predictor of prognosis. The prognosis of patients with synchronous NSCLC resembles the prognosis of patients with a single lung cancer of a higher stage. Upstaging in synchronous lung cancer is recommended on the basis of these observations.

Triple sequential grafts using the internal mammary artery. An angiographic and short-term follow-up study.

Between December 1984 and December 1988, coronary artery bypass operations, involving the use of 119 sequential internal mammary artery grafts with three or more anastomoses per conduit, were performed in 116 patients. Patients included 14 women and 102 men, with a mean age of 60 years. They received a total of 629 anastomoses; 373 anastomoses were used in multiple sequential arterial bypass grafts; 116 sequential left and three right internal mammary artery jump grafts were performed. There were 27 patients with bilateral internal mammary artery grafts, but only 17 had completely arterial revascularizations. Perioperative infarction occurred in 3.4% of the patients; 1.7% of infarctions were related to sequential internal mammary artery grafts. There were no hospital deaths. Control angiography was performed within a month of the operation in 72 patients (with 371 anastomoses, of which 229 were in sequential arterial bypass grafts). The overall patency rate was 94.6%, and for the internal mammary artery sequential graft with three or more anastomoses it was 96.1%. The mean follow-up period was 13 months; 110 patients were in New York Heart Association class I; there was one non-cardiac-related death, and three patients (2.6%) had a late myocardial infarction. One was related to the area revascularized by the sequential internal mammary artery graft. Multiple sequential internal mammary artery bypass grafts in coronary artery disease are feasible, with a high short-term patency and a low perioperative morbidity and mortality.

TNM staging and long-term follow-up after sleeve resection for bronchogenic tumors.

From 1960 to 1989, 145 patients (132 men and 13 women) with a mean age of 60.3 years underwent sleeve lobectomy or sleeve resection of a main bronchus for a bronchogenic tumor. Squamous cell carcinoma was predominantly found (116 patients, 80.0%), followed by carcinoid tumor in 13 patients (9.0%). Postoperative staging was: stage I, 61 patients (42.1%); stage II, 47 (32.4%); stage IIIA, 33 (22.8%); and stage IIIB, 4 (2.7%). Thirty-day mortality was 4.8% (7 patients). Follow-up was complete except for 1 patient who was lost to follow-up 4 years after operation. For the whole group, 5-, 10-, and 15-year survival rates were 49%, 37%, and 18%, respectively. Better survival was noted in patients with carcinoid tumor and squamous cell carcinoma. Considering 112 patients with T2 and T3 squamous cell carcinoma, 5- and 10-year survival rates for N0 disease (52 patients) were 59% and 47%, for N1 disease (51 patients) 21% and 0%, and for N2 disease (9 patients) 44% and 0%. Differences between N1 and N2 disease were not statistically significant. Survival after sleeve resection is best for carcinoid tumors and squamous cell carcinoma with negative nodes. Presence of N1 or N2 disease significantly worsens prognosis, with no 10-year survivors and no difference between N1 and N2 status.

Current management of postoperative chylothorax.

BACKGROUND: This study was performed to review our experience with postoperative chylothorax and describe our current approach. In addition, we wanted to estimate the impact of video-assisted thoracoscopic surgery (VATS) on our current management policy. METHODS: From January 1991 to December 1999, 12 patients developed chylothorax after various thoracic procedures. Their mean age was 61.5 (range 31 to 80 years). The procedures were cardiac, aortic, and pulmonary operations. RESULTS: All patients were initially treated conservatively. In addition, 7 patients needed surgical intervention, including one thoracotomy and six VATS. The site of thoracic duct laceration was identified and treated with VATS in 4 patients. In 2 patients, the leak could not be localized by VATS, and fibrin glue or talcage were applied in the pleural space. All patients were discharged without recurrent chylothorax. CONCLUSIONS: VATS is an effective tool in the management of persisting postoperative chylothorax. Its easy use, low cost, and low morbidity rate suggest an earlier use of VATS in the treatment of postoperative chylothorax.

Combined off-pump coronary surgery and right lung resections through midline sternotomy.

Concomitant severe coronary artery disease and lung malignancies are uncommon. Combining conventional coronary surgery with cardiopulmonary bypass with lung resection is still a controversial issue. Conversely, combining off-pump coronary surgery with right lung resections through a midline sternotomy can be an attractive approach. Off-pump coronary surgery avoids the risks of cardiopulmonary bypass, reduces systemic inflammatory response and does not affect the immune system. We report a series of three patients successfully operated using this approach.

Survival after resection of metachronous non-small cell lung cancer in 127 patients.

BACKGROUND: In a number of patients with treated primary non-small cell lung cancer (NSCLC) a second primary tumor will be diagnosed. Our experience with surgery in these patients was analyzed and possible prognostic parameters were defined. METHODS: Patients with metachronous NSCLC (n = 127) who underwent resection from 1970 through 1997 were analyzed. All tumors were classified postsurgically. Median interval between the tumors was 3.7 years. Actuarial survival time was estimated and risk factors influencing survival were evaluated. RESULTS: Overall 5-year survival after the first resection was 70% and after the second resection was 26%. Patients with stage IA of the second primary tumor did have a significantly better survival (p < 0.005) as compared with patients with higher staged second primaries. Stage of second primary tumor and age were significant predictors of survival, whereas stage of first tumor, interval between resections, histology, and type of resection were not. CONCLUSIONS: Survival of patients with metachronous NSCLC and resection of both tumors is high, but poorer than after resection of the first tumor. Irrespective of the interval, patients with stage IA second primary tumor may benefit more from pulmonary resection.

Transsternal closure of bronchopleural fistula after pneumonectomy.

BACKGROUND: Bronchopeural fistula after pneumonectomy, with associated empyema, has no standard therapy. The transsternal, transpericardial approach was used in all patients presenting with a large fistula. METHODS: From 1974 through 1995, 55 patients underwent transsternal, transpericardial closure of a bronchopleural fistula. Mean age was 62.7 years (range, 33 to 78 years). Malignant disease had been the indication for pneumonectomy in 50 patients and benign lesions in 5 patients. The fistula was right-sided in 41 patients (74.5%), and the bronchial stump was less than 2 cm in 25 (45.5%). Treatment of the concomitant empyema was by closed drainage in 2 patients, by repeated needle aspiration in 17, and by open thoracostomy in 36 patients. Reamputation and closure of the stump was possible in 51 patients; in 4 a primary carinal resection was done. RESULTS: Three patients died within 30 days after operation (5.4%, 70% confidence interval 2.4%-10.7%). Ten patients died late during hospitalization, total hospital mortality, 23.6% (70% confidence interval 17.3% to 31.0%). Recurrent fistula symptoms were caused by a large recurrency in 6 patients (all died), by a small one in 7 (one death due to pulmonary embolism). Mean duration of hospital stay was 56 days (range, 2 to 174 days). At follow-up of 42 patients, there were no recurrent fistulas. All patients with benign lesions are alive and well. Of 37 cancer patients, 29 died, more than half due to malignancy. Risk factors for death included recurrent fistula, short interval between pneumonectomy and onset of fistula, and closing technique. Risk factors for recurrent fistula were a short bronchial stump and the nonuse of an open thoracostomy. CONCLUSIONS: Long-term results of transsternal closure are good, but hospital mortality is high. The present treatment of patients with large postpneumonectomy bronchopleural fistula includes early open thoracostomy, improvement of nutritional status, transsternal closure using resorbable sutures, and closure of the pleural space 3 weeks later.

Completion pneumonectomy after bronchial sleeve resection: incidence, indications, and results.

During the years 1960 through 1989, 145 patients underwent sleeve lobectomy or sleeve resection of a main bronchus. Completion pneumonectomy was performed in 19 patients (13.1%). Indications were bronchostenosis without malignancy in 10 patients, positive resection margins in 3, recurrent tumor in 5, and anastomotic dehiscence in 1. Mean age at sleeve operation was 59.3 years. In 18 patients the histology was squamous cell carcinoma and in 1 patient, carcinoid tumor. The mean interval between sleeve resection and completion pneumonectomy was 5.7 months (range, 3 to 16 months) for the patients with stenosis and 6.6 months (range, 1 to 17 months) for the others. There were 3 operative deaths (15.8%). The mean follow-up was 53.2 months. Five-year and 10-year survival rates after completion pneumonectomy for the patients with stenosis were 54% and 41%, respectively, and for the others, 52% and 52%.

Completion pneumonectomy: analysis of operative mortality and survival.

BACKGROUND: A single-institution experience with completion pneumonectomy was analyzed to assess operative mortality and late outcome. METHODS: A consecutive series of 138 completion pneumonectomies from 1975 to 1995 was reviewed, and compared with single-stage pneumonectomies performed during the same period. RESULTS: Hospital mortality was 13.8%, including 4 intraoperative and 15 postoperative deaths. Hospital mortality was the same for lung cancer (13.2%) as for benign disease (15.5%). It was 37.5% if an early complication of the primary operation was the indication (p = 0.01). If infection of the pleural space was the indication for completion pneumonectomy, hospital mortality was 23.3% (p > 0.05). In 760 single-stage pneumonectomies hospital mortality was 8.7% (p > 0.05). Five-year actuarial survival after completion pneumonectomy was 42.5% for all patients, 32.3% for those with lung cancer, and 58.8% for those with benign disease. CONCLUSIONS: Hospital mortality for completion pneumonectomy was the same for malignant as for benign indications. It was significantly higher if completion pneumonectomy was done for an early complication of the primary operation. Results at long term of lung cancer patients were the same for single-stage pneumonectomy and completion pneumonectomy.

Early mortality after surgical repair of postinfarction ventricular septal rupture: importance of rupture location.

BACKGROUND: The aim of this study was to identify factors influencing early outcome after surgical treatment of postinfarction ventricular septal rupture. We investigated the influence of proximal or distal rupture location. METHODS: Between 1980 and 1992 109 patients were treated surgically for ventricular septal rupture using a standardized technique. A division in time periods was made. The rupture was categorized according to its anterior or posterior site and proximal or distal location. RESULTS: The 30-day mortality rate was 27.5%. Multivariate logistic regression analysis identified preoperative shock (p = 0.0007) and right atrial oxygen saturation less than 60% (p = 0.021) as predictors for early death; the risk for early death declined over the time periods from 50% to 12.8% (p = 0.0007). Proximal ventricular septal rupture location (p = 0.0092) and interval between infarction and ventricular septal rupture less then 1 day (p = 0.034) were risk factors for the occurrence of preoperative shock. CONCLUSIONS: Proximal ventricular septal rupture location was the main determinant of preoperative cardiogenic shock, which in turn was the strongest predictor of early mortality. Over the time periods a decrease in early mortality was reached.

Long-term survival after bronchial sleeve resection: univariate and multivariate analyses.

BACKGROUND: Long-term results after bronchial sleeve resection remain controversial, especially in relation to nodal involvement. In a previous report, there were no 10-year survivors among patients with N1 or N2 disease. METHODS: From 1960 to 1989, 145 patients underwent bronchial sleeve resection for a bronchogenic tumor. Follow-up was updated until the end of 1994, so the minimum follow-up was 5 years for surviving patients. A univariate analysis and a multivariate analysis were performed. RESULTS: For the whole group, 5-year, 10-year, and 15-year survival rates were 46%, 33%, and 22%, respectively. The median survival time was 53 months. Five-year and 10-year survival rates for the 71 patients with no disease were 62% and 51%, respectively; for the 58 patients with N1 disease, 31% and 10%; and for the 16 patients with N2 disease, 5-year and 7-year survival rates were 31% and 13%. There was a highly significant difference in survival between patients with no and N1 or N2 disease but not between those with N1 and N2 disease. Multivariate analysis showed only nodal stage and patient age to be significant factors in relation to survival. CONCLUSIONS: Long-term results after bronchial sleeve resection are influenced chiefly by nodal stage. A significantly lower survival is found in patients with N1 and N2 disease, and most of these patients die of distant metastases.