The first Latin-American risk stratification system for cardiac surgery: can be used as a graphic pocket-card score.

This study aims to develop the first Latin-American risk model that can be used as a simple, pocket-card graphic score at bedside. The risk model was developed on 2903 patients who underwent cardiac surgery at the Spanish Hospital of Buenos Aires, Argentina, between June 1994 and December 1999. Internal validation was performed on 708 patients between January 2000 and June 2001 at the same center. External validation was performed on 1087 patients between February 2000 and January 2007 at three other centers in Argentina. In the development dataset the area under receiver operating characteristics (ROC) curve was 0.73 and the Hosmer-Lemeshow (HL) test was P=0.88. In the internal validation ROC curve was 0.77. In the external validation ROC curve was 0.81, but imperfect calibration was detected because the observed in-hospital mortality (3.96%) was significantly lower than the development dataset (8.20%) (P<0.0001). Recalibration was done in 2007, showing excellent level of agreement between the observed and predicted mortality rates on all patients (P=0.92). This is the first risk model for cardiac surgery developed in a population of Latin-America with both internal and external validation. A simple graphic pocket-card score allows an easy bedside application with acceptable statistic precision.

Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial.

The objective of this study is to evaluate the costs and health benefits of coronary artery bypass grafting (CABG) surgery with and without cardiopulmonary bypass (CPB). Randomized controlled clinical trial is used as the design. The setting is in a single tertiary cardiothoracic center in Middlesex, UK. Participants were 168 patients (27 females) requiring primary isolated CABG surgery. Patients were randomized to have the procedure performed by a single surgeon either with CPB (n = 84) or by an off-pump coronary artery bypass (OPCAB) surgery (n = 84). Health-related quality of life was assessed at baseline, 6 weeks, and 6 months using the World Health Organization Quality-of-Life (WHOQOL-100) questionnaire. Mean total costs of patient management by either technique were calculated using different available key sources. A utility measure, derived from WHOQOL-100, was used to calculate quality-adjusted life year (QALY) gained in each group, on basis of which a cost-effectiveness analysis was performed. The mean total costs of an OPCAB patient was 5859 pounds , whereas for a CPB patient it was 7431 pounds with a mean difference of 1572 pounds (standard error [SE] 674 pounds ; P = 0.02). Three patients died in the CPB group and two in the OPCAB group during the 6-month follow-up period. Mean QALYs over 6 months was 0.379 in the OPCAB group and 0.362 in the CPB group, but the difference was not significant (mean difference 0.017; SE 0.016; P = 0.305). OPCAB surgery offered patients in this randomized trial similar health benefits to CPB over a 6-month period, but at a significantly less cost.

Objective surgical skill assessment: the diagonal operating matrix.

There is an urgent need for structured surgical training and assessment due to the reduction in the training duration with the European Working Time Directive (EWTD). We propose a model for objective skill assessment, the PAR-Diagonal Operating Matrix (PAR-DOM) which breaks down the task of vascular anastomosis into clearly defined skills. The PAR-DOM is made up of a 3x5 table and progress is made along vectors defined on the x-axis as PAR and on the y-axis as four levels. PAR defines three skills at each level. Each skill is graded from 1-3 (this may be taken as below average, average, above average). The skills at various levels are: Level 0 - Posture, Address, Relaxation; Level 1 - Pick-up, Airtime, Rotation; Level 2 - Placing, Angles, Rhythm; Level 3 - Precision, Adaptability, Reproducibility; Level 4 - Pace, Awareness, Relations. The PAR-DOM matrix provides a graphic representation of the progress of trainees over their training period assigned for them to stay with the trainer and also help identify individual strengths and weaknesses.

Comparison of clinical and economic outcomes of two antibiotic prophylaxis regimens for sternal wound infection in high-risk patients following coronary artery bypass grafting surgery: a prospective randomised double-blind controlled trial.

OBJECTIVE: Prospective studies show a 10% incidence of sternal wound infection (SWI) after 90 days of follow-up, compared with infection rates of 5% reported by the National Nosocomial Infections Surveillance System after only 30 days of follow-up. This incidence increases 2-3 times in high-risk patients. DESIGN: Prospective randomised double-blind controlled clinical trial. SETTING: Cardiothoracic centre, UK. PATIENTS: Patients were eligible if they were undergoing median sternotomy for primary isolated coronary artery bypass grafting, with at least one internal thoracic artery used for coronary grafting and having one or more of the following three risk factors: (1) obesity, defined as body mass index 30 kg/m(2); (2) diabetes mellitus; or (3) bilateral internal thoracic artery grafts (ie, the use of the other internal thoracic artery). INTERVENTIONS: The study group received a single dose of gentamicin 2 mg/kg, rifampicin 600 mg and vancomycin 15 mg/kg, with three further doses of 7.5 mg/kg at 12-hour intervals. The control group received cefuroxime 1.5 g at induction and three further doses of 750 mg at 8-hour intervals. MAIN OUTCOME MEASURES: The primary end point was the incidence of SWI at 90 days. The secondary end point was the antibiotic and hospital costs. RESULTS: During the study period, 486 patients underwent isolated coronary artery bypass grafting with a 30-day SWI of 7.6%. 186 high-risk patients were recruited and analysed: 87 in the study group and 99 in the control group. 90-day SWI was significantly reduced in 8 patients in the study group (9.2%; 95% CI 3.5% to 15.3%) compared with 25 patients in the control group (25.2%; 95% CI 19.5% to 39.4%; p = 0.004). The study group had a significantly lower cost of antibiotics (21.2% reduction--US$96/patient; p<0.001), and a significantly lower hospital cost (20.4% reduction in cost--US$3800/patient; p = 0.04). CONCLUSIONS: Longer and broader-spectrum antibiotic prophylaxis significantly reduces the incidence of SWI in high-risk patients, with a significant economic benefit in costs of antibiotics as well as hospital costs.