The European Heart Rhythm Association symptom classification for atrial fibrillation: validation and improvement through a simple modification.

AIMS: To validate the European Heart Rhythm Association (EHRA) symptom classification in atrial fibrillation (AF) and test whether its discriminative ability could be improved by a simple modification. METHODS AND RESULTS: We compared the EHRA classification with three quality of life (QoL) measures: the AF-specific Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) questionnaire; two components of the EQ-5D instrument, a health-related utility which can be used to calculate cost-effectiveness, and the visual analogue scale (VAS) which demonstrates patients' own assessment of health status. We then proposed a simple modification [modified EHRA (mEHRA)] to improve discrimination at the point where major treatment decisions are made. quality of life data and clinician-allocated EHRA class were prospectively collected on 362 patients with AF. A step-wise, negative association was seen between the EHRA class and both the AFEQT and the VAS scores. Health-related utility was only significantly different between Classes 2 and 3 (P < 0.001). We developed and validated the mEHRA score separating Class 2 (symptomatic AF not limiting daily activities), based on whether the patients were 'troubled by their AF' (Class 2b) or not (Class 2a). This produced two distinct groups with lower AFEQT and VAS scores and, importantly, both clinically and statistically significant lower health utility (Δutility 0.9, P = 0.01) in Class 2b than Class 2a. CONCLUSION: Based on patients' own assessment of their health status and the disease-specific AFEQT, the EHRA score can be considered a useful semi-quantitative classification. The mEHRA score has a clearer separation in health utility to assess the cost efficacy of interventions such as ablation, where Class 2b symptoms appear to be the appropriate treatment threshold.

Thoracic epidural or paravertebral catheter for analgesia after lung resection: is the outcome different?

OBJECTIVE: The aim of this study was to determine whether thoracic epidural analgesia (TEA) or a paravertebral catheter block (PVB) with morphine patient-controlled analgesia influenced outcome in patients undergoing thoracotomy for lung resection. DESIGN: A retrospective analysis. SETTING: A tertiary referral center. PARTICIPANTS: The study population consisted of 1,592 patients who had undergone thoracotomy for lung resection between May 2000 and April 2008. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Patients who received PVBs were younger, had a higher forced expiratory volume in 1 second, had a higher body mass index, a higher incidence of cardiac comorbidity, fewer pneumonectomies, and more wedge resections. A multivariable logistic regression model was used to develop a propensity-matched score for the probability of patients receiving an epidural or a paravertebral catheter. Four patients with an epidural to one with a paravertebral catheter were matched, with 488 patients and 122 patients, respectively. Postmatching analysis now showed no difference between the groups for preoperative characteristics or operative extent. Postmatching analysis showed no significant difference in outcome between the two groups for the incidence of postoperative respiratory complication (p = 0.67), intensive therapy unit (ITU) stay (p = 0.51), ITU readmission (p = 0.66), or in-hospital mortality (p = 0.67). There was a significant reduction in the hospital length of stay in favor of the paravertebral group (6 v 7 days, p = 0.008). CONCLUSIONS: Paravertebral catheter analgesia with morphine patient-controlled analgesia seems as effective as thoracic epidural for reducing the risk of postoperative complications. The authors additionally found that paravertebral catheter use is associated with a shorter hospital stay and may be a better form of analgesia for fast-track thoracic surgery.

The impact of social deprivation on coronary revascularisation treatment outcomes within the National Health Service in England and Wales.

BACKGROUND: There is strong evidence to suggest that social deprivation is linked to health inequalities. In the UK, concerns have been raised regarding disparities in the outcomes of acute cardiac services within the National Health Service (NHS). This study explored whether differences exist in (a) elective hospital presentation time (b) indicators of severity and disease burden and (c) treatment outcomes (hospital stay and mortality) on the basis of the index of multiple deprivation (IMD) status. DESIGN: This study was a retrospective analysis of data from NHS databases for 13,758 patients that had undergone cardiac revascularisation interventions at the Liverpool Heart and Chest Hospital between April 2007-March 2012. METHODS: The data was analysed by descriptive, univariate and multivariate statistics to explore the association between the IMD quintiles (Q1-Q5) and revascularisation type, elective presentation time, hospital length of stay and mortality. RESULTS AND CONCLUSIONS: Univariate analysis indicated that there were significant differences between patients from the most deprived areas (Q5) compared with patients from the least deprived areas (Q1), these included admission volumes, time before presentation to hospital and proportion of non-elective cases. After risk-adjustments, percutaneous coronary intervention patients from Q5 compared with Q1 had significantly greater length of hospital stay and risk of in-hospital major acute cardiovascular events. After multivariate adjustment for baseline risk factors, patients from Q5 were associated with significantly worse five-year survival as compared with Q1 (hazard ratio (HR) 1.52, 95% confidence interval (CI): 1.36-1.71; p < 0.001). In conclusion, there is evidence to suggest that inequalities in cardiac revascularisation choices and outcomes in the UK may be associated with social deprivation.

Alcohol Septal Ablation for Hypertrophic Obstructive Cardiomyopathy: Safe and Apparently Efficacious But Does Reporting of Aggregate Outcomes Hide Less-Favorable Results, Experienced by a Substantial Proportion of Patients?

AIMS: To describe individual and aggregate outcomes for patients undergoing alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM). METHODS: Retrospective case series reviewing all patients undergoing ASA at a United Kingdom tertiary referral center from 2000-2012. Aggregate and individual outcomes are described in terms of symptomatic and hemodynamic response. RESULTS: Eighty-eight patients were reviewed. Alcohol was delivered in 84, with clinical status data available in 82 and hemodynamic data available in 74. All patients had resting or exercise stress left ventricular outflow tract (LVOT) gradient >50 mm Hg. Mean age was 60.3 ± 14.3 years. Follow-up period was 4.2 ± 3.3 years. Twenty-four patients (27%) required ≥2 procedures. Complete heart block was observed in 17%. New York Heart Association (NYHA) class pre ASA was 2.80 ± 0.46, improving to 1.92 ± 0.84 post ASA (P<.001). Fifty-eight out of 82 patients (71%) had improved NYHA class. Resting peak gradient was 99.80 ± 45.86 mm Hg. Post-ASA peak gradient fell to 23.77 ± 41.87 mm Hg (P<.001). Sixty-one out of 74 patients (82%) had successful treatment of LVOT gradient. A successful outcome in both symptomatic and gradient treatment was seen in 66% of patients. No patient who received alcohol suffered sudden cardiac death. Fifteen patients had implantable cardioverter defibrillator implantation; no appropriate therapy was delivered. CONCLUSIONS: ASA is safe, with few major complications. Aggregate outcomes are good, but can hide individual failure. There is a need to refine case selection, procedure planning, and performance to secure more uniform favorable outcomes.

Should obese patients undergo on- or off-pump coronary artery bypass grafting?

OBJECTIVES: To determine if on- or off-pump coronary artery bypass grafting (CABG) makes a difference to in-hospital mortality and long-term survival in obese patients. METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Obesity was defined as a body mass index (BMI) >30 kg/m(2). Uni- and multivariate analyses were performed for in-hospital mortality and long-term survival. A propensity analysis was also performed. RESULTS: The overall mortality rate was 2.1% (N = 284) for all cases, N = 13 369. The mortality rate for obese patients (N = 4289) was 2.3%, and for non-obese patients (N = 9080) it was 2.0%; P = 0.4. The median follow-up was 7.0 (interquartile range 4.1-10.1) years. Univariate analysis identified that in-hospital mortality was significantly lower in obese patients undergoing off-pump CABG; P = 0.01. No significant difference existed with regard to non-obese patients; P = 0.55. Kaplan-Meier survival analysis identified that off-pump CABG was associated with improved survival in obese patients; P = 0.01. Multivariate analysis of non-obese patients did not identify on- or off-pump CABG as a significant factor determining in-hospital mortality or long-term survival. Multivariate analysis of obese patients identified off-pump CABG as being associated with significantly reduced in-hospital mortality (odds ratio [OR] 0.56, 95% confidence interval [CI] 0.34-0.93, P = 0.03), and significantly improved long-term survival (hazard ratio 0.81, 95% CI 0.67-0.98, P = 0.03). In-hospital mortality and long-term survival were significantly affected by the era of surgery, regardless of patients' BMI. Propensity matching of non-obese patients (N = 6088, 1:1 matching) did not identify on- or off-pump CABG as a significant factor determining in-hospital mortality or long-term survival. Propensity matching of obese patients (N = 2980, 1:1 matching) identified on-pump CABG as a significant factor determining in-hospital mortality (OR 0.50, 95% CI 0.26-0.98, P = 0.04), but having no effect on long-term survival. CONCLUSIONS: Univariate, multivariate and propensity matching suggest that obese patients undergoing CABG have reduced in-hospital mortality if they undergo revascularization with the off-pump technique.

The effect of patient sex on survival in patients undergoing isolated coronary artery bypass surgery receiving a radial artery.

OBJECTIVES: To determine whether patient sex makes a difference to in-hospital mortality and survival in patients undergoing isolated coronary artery bypass graft surgery (CABG) receiving a radial artery graft. METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Uni- and multivariate analyses were performed for in-hospital mortality and long-term survival. A propensity analysis was also performed. RESULTS: Overall mortality was 2.1% (n = 284) for all cases, n = 13 369. Median follow-up was 7.0 (interquartile range 4.1-10.1) years. Of the cases 28.2% of males (n = 384) and 29.7% of females (n = 764) had a radial artery utilized. Univariate analysis demonstrated that in-hospital mortality was significantly lower in male patients, P < 0.001, and radial artery use was associated with increased survival in males, P < 0.0001, but not in females, P = 0.82. In male patients, multivariate analysis failed to identify the radial artery as a risk factor for in-hospital death. The radial artery was identified as a significant prognostic factor, associated with improved long-term survival (hazard ratio [HR] 0.78, 95% confidence interval [CI] 0.69-0.88, P = 0.0001). Propensity analysis confirmed this finding (HR 0.76, 95% CI 0.67-0.86, P < 0.0001). In female patients, multivariate analysis failed to identify the radial artery as a significant factor determining in-hospital mortality or long-term survival. Propensity analysis confirmed these findings. CONCLUSION: Males derive a significant survival advantage if they receive a radial artery graft when undergoing isolated CABG. The radial artery makes no difference to long-term survival in female patients. Radial artery use does not affect in-hospital mortality regardless of patient sex.

Virchow's triad and intestinal ischemia post cardiac surgery.

BACKGROUND: Intestinal ischemia is associated with a very high mortality rate. We combined the principles of Virchow's triad to produce preoperative and postoperative models for the development of intestinal ischemia. METHODS: A single institutional study was undertaken involving 18,325 consecutive patients from April 1997 to March 2012. Univariate and multivariate analysis was performed. RESULTS: Mortality was 87% in 91 patients who developed bowel ischemia. Multivariate logistic regression demonstrated that age, peripheral vascular disease, intraaortic balloon pump support, female sex, and preexisting renal failure were significant determinates of intestinal ischemia preoperatively. Logistic regression demonstrated that age, peripheral vascular disease, creatine kinase-MB level, reoperation for bleeding, and blood product usage were significant determinates of intestinal ischemia postoperatively. CONCLUSIONS: Potentially remedial causes of intestinal ischemia include blood product usage, reoperation for bleeding, and creatine kinase-MB release. Age, female sex, peripheral vascular disease, intraaortic balloon pump usage, and preexisting renal failure are fixed risk factors. Despite the continuing trend of reduced blood product usage in the field of cardiac surgery, the increase in patients' risk factors will mean that incidences of intestinal ischemia may increase in the future.

Pneumonectomy: risk factor or innocent bystander?

BACKGROUND: Pneumonectomy is associated with a higher operative mortality rate and worse 5-year survival after resection for non-small-cell lung cancer, compared to lobectomy. We investigated whether pneumonectomy is an independent risk factor for hospital mortality and poor long-term survival, after risk factor adjustment. METHODS: We analyzed a prospectively validated thoracic surgery database. Kaplan-Meier survival curves were constructed for patients who had undergone lobectomy (n = 1484) or pneumonectomy (n = 266). Logistic and Cox multivariate regression analysis and propensity matching were performed on hospital mortality and long-term survival data. RESULTS: Univariate analysis demonstrated that pneumonectomy was a significant risk factor for hospital death (p = 0.02) and long-term survival (p < 0.001). Logistic regression failed to demonstrate pneumonectomy as a risk factor for hospital mortality. Cox regression analysis failed to identify pneumonectomy as a statistically significant risk factor. Propensity analysis (n = 266 in each group with 1:1 matching) demonstrated that pneumonectomy was not associated with hospital mortality (p = 0.37) or poorer long-term survival (p = 0.19) compared to lobectomy. CONCLUSION: Pneumonectomy is not an independent risk factor for hospital mortality or long-term survival, after adjustment for confounding factors.

Preoperative red cell distribution width in patients undergoing pulmonary resections for non-small-cell lung cancer.

OBJECTIVES: Red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with cardiac disease. We sought to investigate the association of RDW in patients undergoing lung resections for non-small-cell lung cancer with respect to in-hospital morbidity, mortality and long-term survival. METHODS: Analysis of consecutive patients on a validated prospective thoracic surgery database was performed for those undergoing potentially curative resections at a single institution. Univariate and multivariate analyses were performed for postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. RESULTS: Overall mortality was 1.9% for all cases (n = 917). The median follow-up was 6.8 years. Univariate analysis demonstrated that RDW has a significant effect on hospital length of stay (P < 0.001), in-hospital mortality rates (P < 0.001), postoperative invasive and non-invasive ventilation (P < 0.001), superficial wound infections (P = 0.06) and long-term survival (P < 0.0001). Multivariate analysis revealed that RDW is a significant factor determining postoperative invasive and non-invasive ventilation, superficial wound infections, length of hospital stay, in-hospital mortality and long-term survival. Confounding factor analysis revealed that in the absence of anaemia, RDW was still a significant factor in the above analysis. CONCLUSIONS: RDW is a significant factor after risk adjustment, determining in-hospital morbidity, mortality and long-term survival in patients post-potentially curative resections for non-small-cell lung cancer. Further work is needed to elucidate the exact mechanism of RDW impact on in-hospital morbidity, mortality and long-term survival. We speculate that subtle bone marrow dysfunction may be an issue.

Long-term survival of non-smokers undergoing coronary artery bypass surgery.

OBJECTIVES: We sought to investigate long-term survival of non-smokers undergoing coronary artery bypass surgery (CABG). METHODS: A prospective database of consecutive patients was retrospectively analysed and cross correlated with the UK strategic tracking service to evaluate survival after primary CABG. Univariate, multivariate and a propensity analyses were performed. RESULTS: We analysed 13 337 primary CABG procedures. Median follow-up was 7 years. Kaplan-Meier survival curves demonstrate that non-smokers have a significantly improved long-term survival compared with ex- and current smokers, P < 0.0001. Cox regression analysis identified smoking status, age, diabetes, ejection fraction (EF), body mass index, cerebrovascular disease, dialysis, left internal mammary artery (LIMA) non-usage, postoperative creatinine kinase muscle-brain isoenzyme (CKMB), radial artery usage, preoperative rhythm, forced vital capacity (FVC) and logistic EuroSCORE as significant risk factors determining long-term survival. Propensity matching resulted in 3575 non-smokers being matched 1:1, with ex-smokers. After matching, univariate analysis demonstrated the significantly worse long-term survival of ex-smokers compared with non-smokers, P < 0.0001. Cox regression analysis identified smoking status, age, postoperative CKMB, cerebrovascular disease, dialysis, diabetes, EF, FVC, LIMA non-usage, radial artery used, sinus rhythm and logistic EuroSCORE as significant risk factors determining long-term survival. Survival by smoking status plotted at the mean of the covariates, prepropensity matching, demonstrated that non-smokers had a significantly better long-term survival than ex-smokers, P < 0.0001; however, after propensity matching, non-smokers under 65 years of age had a significantly worse long-term survival compared with ex-smokers, P < 0.0001. CONCLUSIONS: Non-smokers under the age of 65 years of age have significantly worse long-term survival compared with ex-smokers after risk factor adjustment. We speculate that this is because ex-smokers have had the causative factor, smoking, removed, but non-smokers have not.

Statins and long-term survival after isolated valve surgery: the importance of valve type, position and procedure.

OBJECTIVES: To investigate whether valve position, type and procedure are important factors in determining the beneficial effects of statin therapy with regard to long-term survival in patients undergoing isolated single valve surgery. METHODS: A prospective single-institution cardiac surgery database was analysed. Univariate, multivariate stepwise linear, logistic and Cox regression analysis and propensity matching were performed to identify if statins were associated with increased survival post-valve surgery. RESULTS: Overall mortality was 3.4% (n = 172) for all cases, n = 5013. The median follow-up was 5.8 years. Kaplan-Meier survival analysis indicated that statin therapy was beneficial for all patients undergoing isolated valve surgery, n = 5013, P = 0.03 and isolated aortic valve surgery, n = 3220, P = 0.03, but not isolated mitral valve surgery n = 1793, P = 0.4. Cox regression analysis of the study cohort revealed that statin therapy was a significant factors determining long-term survival in the study cohort, postisolated aortic valve replacement and postisolated biological aortic valve replacement. Statins therapy was not associated with an increased long-term survival post-mitral valve replacement or repair. Propensity matching resulted in 1555 patients receiving statins being matched 1:1 with those not receiving statins. The results after propensity matching concurred with that of the Cox regression analyses, demonstrating that statin therapy was significantly associated with reduced in-hospital mortality, hospital length of stay and postoperative creatinine kinase, muscle-brain isoenzyme release. CONCLUSIONS: Previous publications have not distinguished valve type, position and repair as possible factors influencing statin-therapy outcomes. Statin therapy is associated with increased long-term survival postaortic valve replacement with a biological valve only. Statin therapy had no survival benefit in patients undergoing mitral valve repair or a mechanical valve replacement. A randomized trial is necessary to confirm or refute our findings.

Survival of patients with or without symptoms undergoing potentially curative resections for primary lung cancer.

BACKGROUND: Numerous historical screening programs to detect lung cancer have been undertaken. With technologic advances, complimentary diagnostic tests have been developed; however, only the National Lung Cancer Trial has demonstrated increased survival. Following the success of this study, screening programs are being trialled in several countries. Screening should, in theory, reduce lung cancer deaths by identifying asymptomatic patients with earlier tumors. This study asked whether lung cancer patients who are asymptomatic at presentation have a better survival than those who present with symptoms. METHODS: This was a retrospective analysis of a validated prospective thoracic surgery database from a tertiary center in the Northwest of England. Included were 1,546 consecutive patients (826 men, 720 women) who received operative intervention for non-small cell lung cancer. The main outcome measures included 5-year survival and univariate and multivariate Cox regression analysis. RESULTS: Cancer stage, age, and operation type were confirmed as being of prognostic importance, validating previous studies. Survival between asymptomatic or symptomatic patients did not differ significantly (p = 0.489), regardless of stage. The hazard ratios (with 95% confidence intervals) for variables associated with poorer outcome identified by Cox's regression analysis were male sex, 1.34 (1.15 to 1.56); advancing age, 1.03 (1.02 to 1.04); advancing stage, 3.30 (2.69 to 4.04); and pneumonectomy, 1.24 (1.01 to 1.52). Symptoms were not a significant variable affecting survival on multivariate analysis. CONCLUSIONS: This retrospective study from the Northwest of England showed that in our subset of lung cancer patients undergoing resection, asymptomatic patients with non-small cell lung cancer do not have improved survival, implying it is a systemic disease in many at diagnosis. Care should be taken when generalizing the results of the National Lung Screening Trial to all populations until further validation has been performed.

Prediction of in-hospital mortality following pulmonary resections: improving on current risk models.

OBJECTIVES: Using a large, prospectively collected and independently validated thoracic database, we created a risk-prediction tool for in-hospital mortality with the aim of improving on the accuracy of Thoracoscore. METHODS: A prospectively collected and independently validated database containing lung resections was utilized, N = 2574. Logistic regression analysis with bootstrapping, and by the use of a random training and test set was utilized. Comparisons against the Thoracoscore, ESOS.01 and the Society of Thoracic Surgeons (STS) models were performed. RESULTS: A logistic model identified age [odds ratio (OR) 1.1, 95% confidence interval (CI) 1.0-1.2, P = 0.0002], sex (OR 0.34, 95% CI 0.14-0.83, P = 0.02), predicted postoperative FEV1 (OR 0.96, 95% CI 0.94-0.99, P = 0.002), emphysema (OR 3.2, 95% CI 1.0-9.9, P = 0.04), excess alcohol consumption (OR 1.0, 95% CI 1.0-1.0, P = 0.04), pre-existing renal disease (OR 4.3, 95% CI 1.1-17.1, P = 0.04), predicted in-hospital mortality with an receiver operating curve (ROC) of 0.81 and a Hosmer-Lemeshow test of 0.9. Bootstrap analysis confirmed the above risk factors (ROC 0.82 and Hosmer-Lemeshow 0.2). Comparisons between Thoracoscore, ESOS.01 and the STS risk models demonstrated that none was very accurate, as all had low ROC values of 0.69, 0.70 and 0.61, respectively. The STS risk model does not apply to our population (ROC 0.61, Hosmer-Lemeshow, P = 0.004), and the ESOS.01 has poor predictive power (Hosmer-Lemeshow, P < 0.0001). CONCLUSIONS: Logistic regression based on age, sex, predicted postoperative FEV1, alcohol consumption and pre-existing renal disease predicts in-hospital mortality with improved accuracy compared with the use of Thoracoscore, ESOS.01 and the STS risk model.

Red cell distribution width and coronary artery bypass surgery.

OBJECTIVES: The red cell distribution width (RDW) has been identified as an independent risk factor with regard to prognosis in patients with coronary artery disease with or without heart failure. We sought to investigate the role of RDW in patients undergoing isolated coronary artery bypass graft surgery (CABG). METHODS: Analysis of consecutive patients on a validated prospective cardiac surgery database was performed for patients undergoing isolated CABG. Univariate and multivariate analysis was performed for in hospital mortality, long-term survival, length of hospital stay, length of intensive care unit stay and creatinine kinase muscle-brain (CKMB) release. RESULTS: Overall mortality was 2.1% for all cases, N = 8615. Median follow up was 5.8 years. Univariate analysis demonstrated that the RDW has a significant effect on CKMB release, P = 0.001, in-hospital mortality, P < 0.0001, and long-term survival, P < 0.0001, but no significant effect on the ITU length of stay, P = 0.9, or hospital length of stay, P = 0.2. Multivariate analysis revealed that the RDW was a significant factor determining in-hospital mortality and long-term survival, but had no significant effect on CKMB release, ITU or hospital length of stay. Confounding factor analysis revealed that in the absence of anaemia, the RDW was still a significant factor determining in-hospital mortality and long-term survival. CONCLUSIONS: The RDW is a significant factor determining in-hospital mortality and long-term survival in patients undergoing isolated CABG. The mechanism of association requires further study.

Is single-unit blood transfusion bad post-coronary artery bypass surgery?

OBJECTIVES: Publications in the surgical literature are very consistent in their conclusions that blood is dangerous with regard to in-hospital mortality, morbidity and long-term survival. Blood is frequently used as a volume expander while simultaneously increasing the haematocrit. We investigated the effects of a single-unit blood transfusion on long-term survival post-cardiac surgery in isolated coronary artery bypass grafting patients. METHODS: A prospective single-institution cardiac surgery database was analysed involving 4615 patients. Univariate, multivariate stepwise Cox regression analysis and propensity matching were performed to identify whether a single-unit blood transfusion was detrimental to long-term survival. RESULTS: Univariate analysis revealed that blood was significantly associated with a reduced long-term survival even with a single-unit transfused, P = 0.0001. Cox multivariate regression analysis identified age, ejection fraction, preoperative dialysis, logistic EuroSCORE, postoperative CKMB, blood transfusion, urgent operative status and atrial fibrillation as significant factors determining long-term survival. When the Cox regression was repeated with patients who received no blood or only one unit of blood, transfusion was not a risk factor for long-term survival. An interaction analysis revealed that blood transfusion was significantly interacting with preoperative haemoglobin levels, P = 0.02. Propensity analysis demonstrated that a single-unit transfusion is not associated with a detrimental long-term survival, P = 0.3. CONCLUSIONS: Cox regression and propensity matching both indicate that a single-unit transfusion is not a significant cause of reduced long-term survival. Preoperative anaemia is a significant confounding factor. Despite demonstrating the negligible risks of a single-unit blood transfusion, we are not advocating liberal transfusion and would recommend changing from a double-unit to a single-unit transfusion policy. We speculate that blood is not bad, but that the underlying reason that it is given might be.

Female sex and long-term survival post curative resection for non-small-cell lung cancer.

OBJECTIVES: To determine whether patient sex has a significant effect on long-term outcomes post curative resection of non-small-cell lung cancer. METHODS: We retrospectively analysed a prospectively validated thoracic surgery database (n = 4212), from a single institution, from September 2001 to October 2012. Univariate, Cox multivariate and propensity analysis was performed. Long-term follow-up was carried out via the National Strategic Tracing Service that operates in the United Kingdom. RESULTS: One hundred per cent follow-up was achieved. Overall institutional in-hospital mortality was 2.0% for all thoracic resections. Median survival was 2.78 years (range 0-13 years). Two thousand two hundred and thirty-three males and 1979 females were included. Kaplan-Meier survival of all the patients demonstrated superior survival of females for all stages, P = 0.0003, and stage I, P = 0.0006. Female sex conferred no survival advantage in stage II, P = 0.7, and IIIa, P = 0.1. Sub-analysis by histological type demonstrated that females had superior survival with adenocarcinoma compared with males, P < 0.001, but no sex difference existed with squamous carcinomas, P = 0.2. Cox analyses demonstrated that female sex was an advantageous prognostic factor for the entire study group [hazard ratio (HR) 0.82, 95% confidence interval (CI) 0.69-0.96] and Stage I only (HR 0.70, 95% CI 0.57-0.63). Sex was of no significance in Stage II and IIIa disease with regard to survival. Sub-analysis demonstrated that female sex was not a significant factor determining survival in patients with squamous carcinoma; however, it was significantly associated with increased survival in patients with adenocarcinoma (HR 0.63, 95% CI 0.51-0.78). A 1:1 propensity analysis confirmed the above findings. CONCLUSION: Propensity matching and Cox multivariate regression analysis confirmed the univariate finding that female sex is only associated with improved survival in patients with Stage I adenocarcinoma. Patient sex does not affect survival of patients with squamous carcinoma.

The long-term effects of developing renal failure post-coronary artery bypass surgery, in patients with normal preoperative renal function.

OBJECTIVES: Renal failure post-cardiac surgery is associated with an increased in hospital morbidity and mortality. We investigated the effect of new onset renal risk, injury or failure [risk, injury, failure, loss and end-stage kidney disease (RIFLE)] post-coronary artery bypass graft (CABG) on long-term survival, in patients with normal preoperative renal function. METHODS: The effect of developing postoperative renal risk, injury or failure as defined by the RIFLE criteria on the long-term survival of patients undergoing isolated CABG with a normal renal function was studied. Two separate multivariate analyses were performed based on preoperative serum creatinine or glomerular filtration rate (GFR). Univariate, multivariate, interaction and confounding factor analyses were performed. RESULTS: A total of 4029 isolated CABG patients were included in the study. 46.5% of patients had chronic kidney disease (CKD) stage 1 (GFR ≥90 ml/min/1.73 m(2)), 50.4% had CKD stage 2 (GFR 60-89 ml/min/1.73 m(2)) and 3.1% had CKD stage 3 (GFR 30-59 ml/min/1.73 m(2)) on admission, despite having a normal serum creatinine. The study group had a median follow-up of 3.6 years (95% CI 0-13.7). Renal risk, injury and failure were associated with a significantly reduced long-term survival (P < 0.001). In patients with normal preoperative serum creatinine, Cox regression analysis revealed that age (P = 0.026), preoperative creatinine (P =0.006) and logistic EuroSCORE (P < 0.0001) were significant factors in addition to the development of postoperative renal risk, injury or failure (P < 0.0001), with regard to determining long-term survival. A confounding factor analysis revealed that discharge creatinine (P = 0.0001) and discharge GFR (P = 0.0006) were significant determinants of long-term survival. In patients with a preoperative GFR >90 ml/min, Cox regression analysis revealed that diabetes (P = 0.004) sex (P = 0.019) and logistic EuroSCORE (P < 0.0001), were also significant factors in addition to the development of postoperative renal risk, injury or failure (P = 0.0001) with regard to determining long-term survival. A significant interaction between diabetes and the development of renal risk, injury or failure exists (P = 0.04). A confounding factor analysis revealed that discharge creatinine was a significant determinant (P = 0.0001) of long-term survival, and discharge GFR was not. CONCLUSIONS: Despite being a biochemically reversible process, the development of renal risk, injury and failure as defined by the RIFLE criteria post-cardiac surgery in patients with a normal preoperative renal function is associated with a significantly worse long-term outcome.

In-hospital mortality and long-term survival after coronary artery bypass surgery in young patients.

OBJECTIVES: Coronary artery bypass graft (CABG) is performed for symptomatic and prognostic reasons. We aimed to determine the factors that contribute to in-hospital mortality and long-term survival in young patients (aged less than 65) undergoing CABG. METHODS: A prospective database was retrospectively analysed and cross-correlated with the United Kingdom's Strategic Tracing Service to evaluate survival in patients under the age of 65, following isolated primary CABG. Univariate-, multivariate logistic with Cox regression- and neural network analyses were performed. RESULTS: Patients under the age of 65, who had undergone isolated CABG between April 1997 and March 2010 were studied;n = 5967. In-hospital mortality was 1.1% and long-term mortality was 13.5%; median follow-up 7.9 years. Multivariate analysis demonstrated that atrial fibrillation, 'urgent' operation status, postoperative creatinine kinase (CKMB), moderate or poor left ventricular (LV) function, and female sex were significant factors predicting in-hospital mortality. Cox regression demonstrated that age, diabetes (oral and insulin controlled), moderate and poor LV function, cerebrovascular disease, dialysis, left internal mammary artery (LIMA) usage, postoperative CKMB, atrial fibrillation, 'urgent' operation status, and peripheral vascular disease were significant factors determining long-term survival. Radial artery use, off-pump surgery, composite arterial grating and graft number had no effect on in-hospital mortality or long-term survival. Neural network analysis confirmed the factors identified by logistic and Cox multivariate analysis. CONCLUSIONS: The risk factors for in-hospital mortality in patients under the age of 65 include postoperative CKMB, urgent operation status, LV function, female sex and atrial fibrillation. Significant factors determining long-term survival in the under-65 age group include age, atrial fibrillation, diabetes (diet and insulin controlled), LV function, cerebrovascular disease, dialysis, LIMA usage, 'urgent' operation status, CKMB and peripheral vascular disease.

Routine endoscopy to detect anastomotic leakage after esophagectomy.

BACKGROUND: This study evaluated the safety and efficacy of endoscopy in diagnosing anastomotic leaks after esophagectomy. METHODS: One hundred consecutive postesophagectomy patients, all having reconstruction using the stomach, underwent endoscopy in the first week after operation. The anastomosis and gastric mucosa were examined for evidence of ischemia, necrosis, and leak. RESULTS: There was no evidence that the procedure caused damage to the anastomosis or gastric conduit. The results of 79 examinations were normal, 15 showed gastric ischemia, 2 showed a leak, and 4 showed ischemia plus leakage. The 15 patients with ischemia alone were monitored with a repeat endoscopy after a further week: a late leak developed in 1 patient that was diagnosed at the second examination. No further leaks developed subsequently, making endoscopy 100% accurate in the diagnosis of leaks after esophagectomy. CONCLUSIONS: Esophagoscopy within 1 week of esophagectomy is a safe and highly accurate method of diagnosing leaks and provides unique information on the condition of the stomach. We believe it allows a more targeted approach to patient care in the context of anastomotic healing and in the treatment of leaks.

Smoking status at diagnosis and histology type as determinants of long-term outcomes of lung cancer patients.

OBJECTIVES: The study aimed to determine the importance of smoking status at operation and histology type with regard to long-term survival after potential curative surgery for lung cancer. METHODS: We analysed a prospectively validated thoracic surgery database (n = 2485). We benchmarked our 5-year survival against the International Association for the Study of Lung Cancer (IALSC) results. Univariate and Cox multivariate analyses were performed for the study group and for isolated adenocarcinoma and squamous carcinoma histological subtypes. RESULTS: Benchmarking failed to reveal any differences in survival of our study cohort compared with the IALSC results, P = 0.16. Univariate analysis revealed that non-smokers have a statistically better long-term outcome, P < 0.0001, than ever smokers. Patients with adenocarcinoma, n = 1216, had a worse outcome in ever smokers, P = 0.006. In patients with squamous carcinoma, n = 1065, smoking status made no difference, P = 0.4. Long-term survival was not significantly different for adenocarcinoma or squamous carcinoma, P = 0.87. Cox multivariate analysis revealed that patients with adenocarcinoma who were current smokers had a significantly worse long-term survival compared with ex-smokers and non-smokers (hazard ratio: 1.26, 95 confidence interval: 1.01-1.56), P = 0.04. Age, body mass index, sex, T stage, N stage, predicted postoperative forced expiratory volume in one second (FEV1), residual disease, alcohol consumption and oral diabetes were additional significant factors affecting long-term survival. Pneumonectomy, pack years, bronchial resection margin, New York Heart Association class, hypertension, previous cerebrovascular event, diet or insulin-controlled diabetes and previous myocardial infarction were excluded by the analysis as significant risk factors. Smoking status did not affect long-term survival in patients with squamous cell carcinoma. CONCLUSIONS: Smoking status at time of surgery does not effect long-term survival in patients with squamous cell carcinoma. Smoking status makes a significant difference to the long-term outcomes of patients with adenocarcinoma even after adjustment for their risk factors. This implies that a histological classification of adenocarcinoma may incorporate genetically diverse adenocarcinomas with regard to prognosis.