Inflammatory Glycoprotein YKL-40 Is Elevated after Coronary Artery Bypass Surgery and Correlates with Leukocyte Chemotaxis and Myocardial Injury, a Pilot Study.

The aim of the present study was to investigate the levels of YKL-40 during and after coronary artery bypass grafting surgery (CABG) and to establish possible connections between YKL-40 and markers of oxidative stress, inflammation, and myocardial injury. Patients undergoing elective CABG utilizing cardiopulmonary bypass (CPB) were recruited into the study. Blood samples were collected at the onset of anesthesia, during surgery and post-operatively. Levels of YKL-40, 8-isoprostane, interleukin-8 (IL-8), monocyte chemotactic protein-1 (MCP-1) and troponin T (TnT) were measured by immunoassay. YKL-40 levels increased significantly 24 h after CPB. Positive correlation was seen between post-operative TnT and YKL-40 levels (r = 0.457, p = 0.016) and, interestingly, baseline YKL-40 predicted post-operative TnT increase (r = 0.374, p = 0.050). There was also a clear association between YKL-40 and the chemotactic factors MCP-1 (r = 0.440, p = 0.028) and IL-8 (r = 0.484, p = 0.011) linking YKL-40 to cardiac inflammation and fibrosis following CABG. The present results show, for the first time, that YKL-40 is associated with myocardial injury and leukocyte-activating factors following coronary artery bypass surgery. YKL-40 may be a factor and/or biomarker of myocardial inflammation and injury and subsequent fibrosis following heart surgery.

Pulmonary vascular resistance index during coronary artery bypass surgery with aprotinin.

Low pulmonary vascular resistance index (PVRI) reflects favorable redundant pulmonary circulation following coronary artery bypass grafting with cardiopulmonary bypass surgery (CPB). This randomized study investigated whether aprotinin given in different modalities impacts PVRI after coronary artery bypass grafting. A total of 40 patients undergoing coronary artery bypass grafting were randomized to four groups according to aprotinin dose: (1) high dose, (2) early low dose, (3) late low dose, and (4) without aprotinin. Oxygenation index, pulmonary shunt, alveolar-arterial oxygen gradient and PVRI were determined. PVRI was calculated as the transpulmonary pressure gradient divided by cardiac index multiplied by 80. The results showed that PVRI remained relative low in all patients provided aprotinin regardless of treatment dosage; PVRI increased at 4 h after restarting ventilation after CPB in patients without aprotinin as compared with aprotinin (266 ± 137, 266 ± 115, 244 ± 86 vs. 386 ± 121, dynes-s-cm-5, respectively, p = .047). Elevated postoperative PVRI was predictive for patients without aprotinin (AUC 0.668; SE 0.40; p < .0001; CI 0.590-0.746). There were no statistical differences in oxygenation index, pulmonary shunt or alveolar-arterial oxygen gradient between the groups. In conclusion, aprotinin maintains a low PVRI in elective patients with healthy lungs during CPB. We suggest that aprotinin maintains pulmonary arterial endothelial integrity.

Obesity paradox disappears in coronary artery bypass graft patients during 20-year follow-up.

AIMS: Although obesity is a risk factor for coronary heart disease (CHD), it might be associated with a favourable prognosis in patients with CHD. The aim of the study was to evaluate this so called 'obesity paradox' during a follow-up period of 20 years in patients who had undergone coronary artery bypass grafting (CABG). METHODS AND RESULTS: The study population consisted of 922 CHD patients who had undergone CABG between 1993 and 1994. Pre and perioperative data was collected from patient records and supplemented with patient questionnaires, telephone contacts and data from national archives. The 10-year postoperative prognosis of normal-weight patients (body mass index (BMI) 18.5-24.9 kg/m2) was inferior to that of overweight (BMI 25.0-29.9 kg/m2) and obese patients (BMI⩾30.0 kg/m2) and to the background population. Beyond 10 years the prognosis of obese patients deteriorated when compared with the overweight group. At the end of the 20-year follow-up, survival of the normal weight group was 0.68 (95% confidence interval (CI), 0.49-0.87; p<0.001), the overweight group 0.82 (95% CI, 0.71-0.92; p<0.001), and the obese group 0.67 (95% CI, 0.49-0.85; p<0.001), when compared with their background populations (=1.00). Obese patients developed diabetes more frequently and died more frequently of cardiovascular disease than patients in the two other study groups during the second postoperative decade ( p<0.01). CONCLUSION: During long-term follow-up the obesity paradox seems to disappear due to progression of cardiometabolic disease in patients who have undergone CABG.

Symptoms of Sternal Nonunion Late after Cardiac Surgery.

Background A cohort of patients having symptoms of sternal nonunion late after sternotomy was studied to find out whether the complaints were related to true sternal nonunion or decreased bone density. Methods A survey was mailed to 2,053 cardiac surgical patients operated in our institution between July 2007 and June 2010. The patients were requested about symptoms referring to sternal instability. A group of symptomatic individuals as well as 1:1 age- and time-matched asymptomatic controls were examined with sternal palpation, ultrasound during standardized sternal pressure provocation, and computed tomography (CT). Results The number of patients replied in the survey was 1,918 (93.4%); 2.3% (44 patients) reported sensation of movement or clicking in sternum during body movements and during coughing. Symptomatic patients living within 200 km to the hospital (21) and their asymptomatic controls (21) were selected for further clinical and imaging studies. Mean period between the initial operation and the examinations was 36 (22-56) months. Sternal palpation pain was significantly associated with reported symptoms suggestive of sternal nonunion (odds ratio [OR] 22.0; 95% confidence interval [CI] 2.5-195); however, none of the patients had clinically unstable sternum or nonunion in the sternal imaging. The symptoms of sternal instability were more frequent in patients whose bone mineralization rate (as measured with T-scores) was higher. Conclusion Symptoms suggestive of sternal nonunion were experienced by 2.3%. However, their symptoms did not correlate with CT scans or provocation ultrasound although palpation pain was evident. Thus the pain is derived from nonmechanical etiologies. Higher bone mineralization rate correlated with abnormal symptoms of sternal wound.

Adipocytokine resistin correlates with oxidative stress and myocardial injury in patients undergoing cardiac surgery.

OBJECTIVES: Adipocytokines are hormones regulating energy metabolism and appetite and according to recent reports also inflammatory responses including ischaemia-reperfusion injury. Based on experimental data, we hypothesized that the levels of adipocytokines adiponectin, adipsin, leptin and/or resistin would correlate with myocardial injury, inflammation and oxidative stress during cardiac surgery. METHODS: Thirty-two patients undergoing an elective on-pump coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CPB) were recruited into the study. Blood samples were collected after the induction of anaesthesia, and at the onset of CPB, 1 and 15 min after the removal of aortic cross-clamp and 4 and 24 h after the onset of CPB. Samples were analysed for levels of four adipocytokines (adiponectin, adipsin, leptin and resistin) and markers of oxidative stress [myeloperoxidase (MPO) and 8-isoprostane], inflammation [interleukin-6 (IL-6)] and myocardial injury [troponin T (TnT)]. RESULTS: Adiponectin and adipsin concentrations declined, while leptin and resistin levels increased significantly by 24 h after the onset of the operation. Interestingly, basal levels of resistin (r = 0.41, P = 0.020) as well as the maximal increase occurring in resistin levels during the 24-h follow-up (r = 0.49, P = 0.005) correlated positively with TnT release. In addition, the reperfusion-induced elevation in resistin levels correlated positively with oxidative stress measured as increases in MPO concentrations. CONCLUSIONS: As an original finding, we report here that resistin levels correlate with oxidative stress and myocardial injury in patients undergoing cardiac surgery. In addition, leptin levels were increased on the first postoperative day, but only minor declines were found in adiponectin and adipsin levels. Resistin has been implicated in unfavourable metabolic, cardiovascular and inflammatory responses: it may thus serve as a useful biomarker or a drug target in conditions complicated by ischaemia-reperfusion injury.

Associations of metabolic syndrome and diabetes mellitus with 16-year survival after CABG.

BACKGROUND: The associations of metabolic syndrome (MetS) or diabetes mellitus (DM) on long-term survival after coronary artery bypass grafting (CABG) have not been extensively evaluated. The aim of the present study was to assess the impact of MetS and DM on the 16-year survival after CABG. METHODS: Diabetic and metabolic status together with relevant cardiovascular data was established in 910 CABG patients operated in 1993-94. They were divided in three groups as follows: neither DM nor MetS (375 patients), MetS alone (279 patients) and DM with or without MetS (256 patients). The 16-year follow-up of patient survival was carried out using national health databases. The relative survival rates were analyzed using the Life Table method comparing the observed survival rates of three patient groups to the rates based on age-, sex- and time-specific life tables for the whole population in Finland. To study the independent significance of MetS and DM for clinical outcome, multivariate analysis was made using an optimizing stepwise procedure based on the Bayesian approach. RESULTS: Bayesian multivariate analysis revealed together six variables to predict clinical outcome (2 months to 16 years) in relation to the national background population, i.e. age, diabetes, left ventricular ejection fraction, BMI, perfusion time during the CABG and peripheral arterial disease. Our principal finding was that after postoperative period the 16-year prognosis of patients with neither DM nor MetS was better than that of the age-, sex-and time-matched background population (relative survival against background population 1.037, p < 0.0001). The overall survival of MetS patients resembled that of the matched background population (relative survival 0.998, NS). DM was associated with significantly increased mortality (relative survival 0.86, p < 0.0001). Additionally, mortality was even higher in patients receiving insulin treatment than in those without. Excess death rate of DM patients was predominantly caused by cardiovascular causes. CONCLUSION: In this long-term follow-up study patient groups without diabetes had at least equal 16 years' survival after CABG than their matched background populations. Survival of DM patients started to deteriorate already few years after the operation.

A 12-year follow-up on the changes in health-related quality of life after coronary artery bypass graft surgery.

OBJECTIVES: Improvement in quality of life (QoL) and survival benefit are the primary objectives of coronary artery bypass graft (CABG) surgery. The profile of patients undergoing isolated CABG has altered towards higher age with more preoperative comorbidities. Thus, the importance of QoL over the quantity of life among elderly patients is getting more emphasized. In this study, our main goal was to evaluate the long-term changes in QoL, overall performance status and symptomatic status after the CABG. METHODS: Comprehensive data of 508 patients who underwent isolated CABG in a single institution were prospectively collected. The RAND-36 Health Survey (RAND-36) was used as an indicator of QoL. Karnofsky dependency category was used to evaluate overall performance status, and symptomatic status was assessed using New York Heart Association (NYHA) class. All assessment were made preoperatively and repeated 1 year and 12 years later. The follow-up of the study cohort was complete in 95 and 84% of the alive patients at 1 year and 12 years, respectively. Analysis was based mainly on three age groups: ≤64 years (282 patients), 65-74 years (175 patients) and ≥75 years (51 patients). RESULTS: Thirty-day, 1-year and 10-year survival rates were 98, 97 and 79%, respectively. Twelve years after the surgery significant improvement (P<0.05) was seen in all but one RAND-36 dimensions of the QoL (general health, P=0.76) as well as in functional capacity (P<0.001) and NYHA class. All age groups showed improvements in RAND-36 physical component summary (PCS) and mental component summary (MCS) scores compared with the preoperative values. The youngest subgroup maintained their physical and mental health status best, whereas older subgroups had more pronounced decreases in their PCS and MCS scores. CONCLUSIONS: Despite an ongoing deterioration 12 years after the CABG, there was significant improvement in most dimensions of the QoL and functional capacity in comparison with the preoperative values. The elderly gain less long-term benefit from CABG regarding the QoL and survival.

Cardiopulmonary bypass decreases pulmonary vascular resistance index after coronary artery bypass surgery.

BACKGROUND: Decreased pulmonary vascular resistance index (PVRI) reflects favorable postoperative pulmonary circulation after coronary artery bypass grafting. This randomized study investigated whether cardiopulmonary bypass (CPB) impacts PVRI after coronary artery bypass grafting. MATERIAL AND METHODS: A total of 47 patients undergoing coronary artery bypass grafting were randomized into four groups according to the ventilation and surgical technique: (1) No ventilation group, with intubation tube detached from the ventilator, (2) low tidal volume group, with continuous low tidal volume ventilation, (3) continuous 10 cm H2O positive airway pressure (CPAP) group, and (4) randomly selected patients undergoing surgery without CPB. Oxygenation index, pulmonary shunt, alveolar-arterial oxygen gradient and PVRI were determined. PVRI was calculated as the transpulmonary pressure gradient divided by cardiac index multiplied by 80. RESULTS: During the first postoperative morning there were no statistical differences in oxygenation index, pulmonary shunt or alveolar-arterial oxygen gradient between the groups, while PVRI remained elevated in patients without CPB as compared with patients with CPB (263 ± 98 vs. 122 ± 84, dyne-s-cm(-5), respectively, p < 0.001). PVRI decreased in all patients with CPB regardless of ventilation technique. In contrast, elevated postoperative PVRI values were predictive for patients without CPB (AUC 0.786; SE 0.043; p < 0.001; 95% CI. 0.701-0.870). CONCLUSIONS: Modified ventilation does not affect PVRI in elective patients with healthy lungs during CPB. Instead, CPB per se may have an important role on diminished PVRI. We suggest that CPB preserves pulmonary arterial endothelial integrity.

Immunoglobulin G4-positive ascending thoracic aortitis may be prone to dissection.

OBJECTIVE: Immunoglobulin (Ig) G4-positive aortitis may determine outcome after surgery for ascending aorta. We evaluated IgG4 expression of dilated ascending aortic wall. METHODS: The study consisted of 91 patients who underwent ascending aortic surgery. For histology, hematoxylin-eosin, elastase-van Gieson, and periodic acid-Schiff stainings were performed. The amount of T and B lymphocytes, plasma cells, macrophages, cell proliferation, and IgG4 positivity were determined by immunohistochemistry. RESULTS: The aortic wall in 12 patients had IgG4 positivity that was always confined to the adventitia. Adventitial plasma cells were numerous in all but 2 of these patients (P < .0001). Aortitis was revealed in 2 patients (17%) with IgG4-positive staining of the aorta and in 6 patients (8%) with IgG4 negativity. IgG4 staining was significantly associated with total aortic wall inflammation (area under the curve, 0.865; standard error, 0.043; P = .000; 95% confidence interval, 0.779-0.950). The mean diameter of the ascending aorta was 69 ± 4.7 mm and 56 ± 1.1 mm in patients with IgG4 positivity and negativity, respectively (P < .004). Approximately half of the patients with IgG4 positivity had dissection (42%), compared with only 15 of 79 (19%) of the remaining patients (P = not significant). Two patients with IgG4 positivity had to undergo reoperation because of immediate postoperative dissection. Seven patients died, including 4 patients (33%) with IgG4 positivity; the remaining 3 patients (4%) were IgG4 negative (P < .005). CONCLUSIONS: IgG4-positive ascending aortic wall was frequent in our study cohort (13%) and revealed aortic inflammation associated with dilatation.

Diazoxide may protect endothelial glycocalyx integrity during coronary artery bypass grafting.

OBJECTIVES: Plasma hyaluronan and syndecan-1 levels represent shedding of the endothelium glycocalyx during ischemia and edema. Diazoxide, a K(ATP)-channel opener, has been shown to decrease myocardial edema during coronary artery bypass grafting (CABG). We evaluated whether diazoxide exerts an impact on plasma hyaluronan and syndecan-1 levels during CABG. DESIGN: Representative blood samples for hyaluronan and syndecan-1, before, during and after surgery, were obtained in 13 out of 16 patients that had a history of stable coronary artery disease undergoing CABG with or without diazoxide. Electron microscopy from biopsies procured from the right atrium in 9 patients was performed to confirm ultrastructural differences among patients before and during CABG. RESULTS: Ultrastructural differences were apparent between individual patients already before operation at base line reflecting differences in the severity of myocardial ischemia and edema. A significant decrease of hyaluronan and syndecan-1 values was observed in patients with diazoxide after surgery (p < 0.04). Significant correlation of plasma hyaluronan and syndecan-1 levels was observed in patients with diazoxide but not in controls (p < 0.005, Spearman rank rho). CONCLUSION: Diazoxide may have an impact on levels of peripheral plasma hyaluronan and syndecan-1 after CABG, suggesting decreased shedding of the endothelial glycocalyx layer.

Postoperative sternal stability assessed by vibration: a preliminary study.

PURPOSE: Mechanical stability of the postoperative sternum was assessed using novel analysis based on vibration response. DESCRIPTION: The response to controlled vibration in the 50 Hz to 1,500 Hz range was studied in 22 elective cardiac surgical patients with an accelerometer, recorded, and processed on a personal computer. Each patient had four measurement sessions. The mechanical transfer function of the sternum was estimated, and several descriptive factors were extracted from it to determine how they reflect changes occurring in the bone during the recovery from sternotomy. EVALUATION: Complete datasets were obtained from 14 patients. The most informative variable for the sternal healing was the P(600-1500) index, which reflects transmittance in the wide frequency band between 600 Hz and 1500 Hz. The index dropped after surgery, indicating a decrease in transmission. The postoperative measurements revealed a reverse trend in the same variable, which can be attributed to healing. CONCLUSIONS: Significant changes caused by the sternotomy and subsequent healing processes were observed using vibration measurement.

Lack of C4d deposition may reveal susceptibility for ascending aortic dissection.

OBJECTIVES: Complement activation as evidenced by C4d deposition indicates immunological tissue reactivity. We sought to study the vascular reactivity of the aortic wall by characterizing C4d deposits. DESIGN: Aortic wall histology and immunohistochemistry for C4d, leukocytes, T- and B-lymphocytes, plasma cells, macrophages, endothelial cells, smooth muscle cells, cell proliferation, elastase, and Van-Gieson-staining were performed to 91 consecutive patients that underwent surgery for ascending aorta, and the samples were grouped according to presence of C4d deposits. RESULTS: Fifty-three out of 91 patients had C4d deposits mainly within the adventitia (C4d +), whereas 38 patients lacked C4d deposits (C4d-) including decreased staining of intra-aortic vessels (p < 0.005). Intimal thickness and cellularity, together with inflammation consisting of plasma cells were increased in C4d- as compared with C4d + (p < 0.05). Receiver operating characteristic curve (ROC) analysis showed that C4d was associated with stabile nondissecting ascending aorta (AUC 0.792; SE 0.053; p = 0.000; 95% CI 0.688-0.895), but not with presence of aortitis per se (AUC 0.523; SE 0.069; p = 0.752; 95 % CI 0.388-0.658). CONCLUSIONS: Lack of C4d may indicate active remodeling of the aortic wall leading to aortic dissection (AD). Immunologic complement factors may be amenable to diagnosis of instability after aortic surgery.

A disintegrin and metalloprotease -8 and -15 and susceptibility for ascending aortic dissection.

BACKGROUND. Dilatation of the ascending aorta (AA) is affected by extra-cellular matrix modifications and inflammation. A disintegrin and metalloproteases (ADAMs) may reveal differences between AA and ascending aortic dissection (AD). We characterized the inflammatory histology of AD and AA and examined the role of ADAM8 and -15 in these diseases. MATERIAL AND METHODS. Aortic wall histology and immunohistochemistry for leukocytes, T- and B-lymphocytes, plasma cells, macrophages, endothelial cells, smooth muscle cells, cell proliferation, elastase and Van-Gieson-staining were performed to 40 consecutive patients that underwent surgery for AA or AD. The expressions of ADAM8 and -15 mRNA and proteins were evaluated using QRT-PCR and immunohistochemistry. RESULTS. Thirty-four patients were enrolled, of which 29 had AA and five had AD of the ascending aorta. B-cells throughout the aortic wall and intimal plasma cells were more numerous during AD as compared with AA (p < 0.05). The gene expressions for ADAM8 and -15 were notably lower in AA as compared with AD. The median for down-regulation of ADAM8 and -15 in AA was -2.7 and -1.8, respectively. ADAM8 and -15 were mainly found in the media layer in patients with AD. Two of the patients with AA and increased ADAMs developed AD of the remaining aorta. CONCLUSIONS. The involvement of ADAM8 and -15 together with inflammation consisting of B-cells may indicate active remodelling of the aortic wall leading to AD.

Common variation in the ADAM8 gene affects serum sADAM8 concentrations and the risk of myocardial infarction in two independent cohorts.

OBJECTIVE: The single nucleotide polymorphism (SNP) rs2995300 in the metalloproteinase-disintegrin gene ADAM8 has been shown to affect the areas of complicated coronary plaques and the risk of fatal myocardial infarction (MI) in men. This study was set up to further investigate the role of ADAM8 in MI. AIM: To investigate the possible association of the ADAM8 SNPs rs2995300 and rs2275725 with ADAM8 mRNA levels, serum soluble ADAM8 (sADAM8) concentrations, and MI risk. METHODS: Samples from the Finnish cardiovascular study (FINCAVAS, N=2156) and the angiography and genes study (ANGES, N=1000) were genotyped. Serum sADAM8 concentrations were determined with ELISA (N=443). ADAM8 mRNA levels in atherosclerotic plaques were analysed from the tampere vascular study (TVS, N=53) samples. RESULTS: A significantly increased MI risk for carriers of the rs2995300C allele and the rs2275725 A allele was revealed in the meta-analysis of the ANGES and FINCAVAS patient data (OR=1.42, P<0.001 and OR=1.43, P<0.001). The risk increase was comparable to that caused by smoking in these cohorts. The risk allele carriers also had higher sADAM8 serum concentrations. CONCLUSIONS: The risk alleles of the investigated ADAM8 SNPs were associated with elevated sADAM8 serum levels and MI risk. The present results implicate ADAM8 in the development of CVDs and suggest its prognostic and therapeutic potential.

The human heart releases cardiotrophin-1 after coronary artery bypass grafting with cardiopulmonary bypass.

OBJECTIVES: Cardiotrophin-1 (CT-1) is closely linked to many cardiovascular diseases, such as myocardial infarction and heart failure, and exhibits cardioprotective effect in ischemia-reperfusion injury. The present study was designed to investigate the course of CT-1 in patients undergoing on-pump coronary artery bypass grafting (CABG), and to evaluate the relationship between plasma CT-1 levels and postoperative cardiac function. METHODS: Twenty-four patients undergoing elective CABG were studied. Radial artery blood samples were collected before cardiopulmonary bypass (CPB), 5 min and 20 min after reperfusion, and 1 h, 6 h, 12 h and 24 h after CPB. Coronary sinus blood samples were collected before CPB, 5 min and 20 min after reperfusion. Plasma CT-1 levels were measured using the ELISA method. Hemodynamic data were collected. RESULTS: Peripheral CT-1 levels did not change significantly postoperatively. Trans-myocardial CT-1 levels increased significantly 5 min and 20 minutes after reperfusion as compared to baseline. A weak positive correlation (r = 0.408, p = 0.048) was found between trans-myocardial CT-1 levels at 20 min after reperfusion and CI at 12 h after CPB. CONCLUSIONS: The heart secretes CT-1 after ischemic injury. The precise effect of CT-1 in CABG needs further investigation.

Aquaporin-7 expression during coronary artery bypass grafting with diazoxide.

OBJECTIVES: Aquaporin-7 is a water-channel protein that controls tissue glycerol supply after ischemia. A burden of experimental studies suggests that diazoxide, a mitochondrial K(ATP)-channel opener, may decrease myocardial edema during coronary artery bypass grafting (CABG). We evaluated whether diazoxide has an impact on atrial aquaporin-7 expression during CABG. DESIGN: Sixteen patients with a history of stable coronary artery disease were enrolled in the study. Eight patients were treated during cardiopulmonary bypass with diazoxide, while the rest eight patients remained as controls. Histopathology was evaluated from biopsies procured before and during CABG from the right atrium. From fresh atrial tissue biopsies, Aquaporin-7 was quantified by RT-PCR. RESULTS: Histological differences were apparent between individual patients already before operation at base line reflecting differences in severity of myocardial ischemia. As compared with fold change values before operation, Aquaporin-7 expression after operation was positive in all but one control, whereas aquaporin-7 expression was positive in only two patients receiving diazoxide. The relative aquaporin-7 expression was significantly lower in patients treated with diazoxide as compared with controls (p < 0.05). CONCLUSIONS: Diazoxide may have an impact on myocardial water balance and glycerol energy supply by decreasing relative aquaporin-7 expression during CABG.

Electrocardiographic presentation of left main disease in patients undergoing urgent or emergent coronary artery bypass grafting.

BACKGROUND: Widespread ST-segment depression with inverted T waves maximally in leads V4-V5 (ie, the global ischemia electrocardiogram [ECG] pattern) is a marker of adverse outcome in patients with non-ST-segment elevation acute coronary syndrome (ACS), perhaps because this pattern is indicative of left main stem stenosis. However, the prognostic value of this ECG pattern has not yet been established. OBJECTIVE: We studied the predictive value of a prespecified ECG pattern in patients who underwent urgent or emergent coronary artery bypass grafting (CABG). METHODS: We studied the sensitivity, specificity, and predictive values for the global ischemia ECG to predict angiographic left main coronary artery disease. Patients with a 12-lead ECG recorded during anginal symptoms before CABG were included. RESULTS: The global ischemia ECG pattern was found in 61 (76%) of 80 patients with and 12 (19%) of 65 patients without left main disease. The sensitivity, specificity, and positive and negative predictive values for left main coronary artery disease in patients with the global ischemia ECG pattern were 76%, 81%, 84%, and 74%, respectively. In multivariate analysis, the global ischemia ECG pattern was strongly associated with angiographic left main coronary artery disease after adjusting for age, gender, diabetes, hypertension, and smoking (hazard ratio, 16.0; 95% confidence interval, 6.5-39.5; P < 0.001). CONCLUSION: The global ischemia ECG pattern was strongly associated with angiographic left main coronary artery disease in patients who underwent urgent or emergent CABG.

European multicenter study with the Soprano valve for aortic valve replacement: one-year clinical experience and hemodynamic data.

BACKGROUND AND AIM OF THE STUDY: During recent years, pericardial bioprostheses have gained widespread acceptance as cardiac valve substitutes. The study aim was to evaluate the early clinical and hemodynamic performance of the Sorin SopranoTM supra-annular aortic bioprosthesis, as used for aortic valve replacement (AVR). METHODS: Between January 2004 and August 2006, a total of 501 patients (55% males; mean age 75 +/- 6.4 years) was prospectively enrolled into the study, which involved 10 European institutions. The indications for AVR were aortic stenosis in 91% of patients, aortic incompetence in 8%, and redo surgery in 1%. Preoperatively, 62% of the patients were in NYHA class III, and 12% in class IV. The mean prosthesis size was 21.4 +/- 1.8 mm. A non-everting technique was used in 88% of patients. Concomitant procedures were performed in 52% of cases (mainly coronary artery bypass grafts; 41%). The mean cross-clamp and cardiopulmonary bypass times were 70 +/- 27.2 min and 99 +/- 39.7 min, respectively. Doppler echocardiography performed at one and 12 months after surgery was evaluated by an independent core laboratory. RESULTS: Postoperatively, there were 25 early deaths (5%) and 13 late deaths, with an overall survival at one year of 92.9% (95% CI: 90.2-94.8) and freedom from valve-related death of 98.6% (95% CI: 97.5-99.6). After 12 months, most patients (87%) were in NYHA classes I-II. Actuarial freedoms from thromboembolism, bleeding, endocarditis and paraprosthetic leak at one year were 97.1% (CI: 95.1-98.2), 98.9% (CI: 97.4-99.5), 99.1% (CI: 97.7-99.7), and 99.6% (CI: 98.3-99.9), respectively. No events of thrombosis and structural valve deterioration (SVD) were observed. Subsequent echocardiographic evaluation showed low mean (11.1 +/- 5.1 mmHg at one year) and peak (19.5 +/- 8.9 mmHg at one year) transvalvular gradients, and a significant reduction in left ventricular mass, from 211 +/- 78.5 g at one month to 185 +/- 64.7 g at 12 months (p <0.0001). CONCLUSION: After 12 months, the clinical outcome with the Soprano bioprosthesis, when used for AVR, was excellent. The bioprosthesis also showed good hemodynamic performance, with a significant reduction of left ventricular hypertrophy.

External validation of modified EuroSCORE.

BACKGROUND: EuroSCORE is an adult cardiac surgery risk scoring method that is used worldwide, which has been shown to significantly overestimate the operative risk. We derived a new risk scoring method by modifying some of the risk factors included in the EuroSCORE algorithm and we validated it in an external database. METHODS: This study included 4,014 patients who underwent adult cardiac surgery at the Heart Centre, Tampere University Hospital, Finland. Operative risk was estimated by EuroSCORE and its modified version. RESULTS: In-hospital postoperative mortality rate was 3.2%. EuroSCORE (AUC for logistic EuroSCORE 0.82; 95% confidence interval (CI), 0.79-0.85) and modified score (AUC for logistic modified score 0.79; 95% CI, 0.75-0.83) performed well in predicting in-hospital mortality in this series. The mean logistic EuroSCORE was 8%, and the mean logistic modified score was 2.2%. Thus, the observed to expected ratio for in-hospital mortality was 0.4 for logistic EuroSCORE and 1.5 for logistic modified score. The difference between observed and predicted mortality rate matched correctly for increasing additive modified score, but not for EuroSCORE. The observed to predicted ratio in high-risk patients (within the 90th percentile of each risk algorithm) was 0.36 (13.2%/36.2% in 402 patients) for logistic EuroSCORE and 0.99 (14.7%/14.9% in 395 patients) for logistic modified score. CONCLUSIONS: This modified and simplified score, which includes most of EuroSCORE variables, seems to provide a more realistic estimation of postoperative mortality risk of patients undergoing any adult cardiac surgery.

Coronary artery bypass surgery in octogenarians: long-term outcome can be better than expected.

BACKGROUND: We have reviewed our experience with octogenarians undergoing coronary artery bypass grafting. METHODS: A consecutive series of 274 patients age 80 years or greater out of 3,474 patients who underwent isolated coronary artery bypass grafting. We have assessed the intrinsic risk aged 80 years or greater by comparing them with a propensity score-matched cohort of younger patients with similar operative risk (other than age). RESULTS: Thirty-day mortality (4.7% vs 1.3%, p<0.0001), combined adverse event rates (13.1% vs 6.6%, p<0.0001), and five-year survival (76.6% vs 90.4%, p<0.0001) were significantly poorer among patients aged 80 years or greater as compared with younger patients. These figures were, however, better than estimates of a recent systematic review by McKellar and colleagues (McKellar SH, Brown ML, Frye RL, Schaff HV, Sundt TM III. Comparison of coronary revascularization procedures in octogenarians: a systematic review and meta-analysis. Nat Clin Pract Cardiovasc Med 2008;5:738-46) (30-day mortality 7.2%, and five-year survival, 68%). When octogenarians were compared with 273 propensity score-matched patients aged less than 80 years, the 30-day mortality (4.8% vs 2.6%, p=0.17) and combined adverse event rates (13.2% vs 10.6%, p=0.36) did not significantly differ. Five-year survival, despite statistical significance, was not remarkably lower than that of propensity-matched patients aged less than 80 years (77.0% vs 81.3%, p=0.009). The decrease in survival of octogenarians was evident only during the first few months after surgery, but not later on. CONCLUSIONS: The results of this study suggest that immediate and five-year survival of octogenarians undergoing coronary artery bypass grafting may be even better than previously estimated. Survival of octogenarians may be suboptimal only during the first few months after surgery, whereas at five years may not differ remarkably from younger patients with otherwise similar operative risk.