Decreased physical activity is a predictor for a complicated recovery post cardiac surgery.

BACKGROUND: Physical activity (PA) reduces the risk of cardiovascular disease and physically active survivors of a cardiac event are at lower risk of recurrent events. We hypothesized that patients with a decreased PA, undergoing cardiac surgery, are at higher risk for a postoperative complicated recovery (PCR). METHODS: Three thousand three hundred eighty two patients undergoing elective cardiac surgery between January 2007 and December 2013 were included. The group was divided into three subgroups: group A, aged ≤ 65 years (N = 1329); group B, aged > 65 years and ≤ 75 years (N = 1250); and group C aged >75 years (N = 803). To assess PA, the criteria of the Corpus Christy Heart Project were used. A PCR consists of the occurrence of a major postoperative event, defined as any of the following complications: reoperation, deep sternal wound infection, renal failure, stroke, postoperative ventilation > 2 days, intensive care stay ≥ 5 days, hospital stay ≥ 10 days, or hospital mortality. RESULTS: One thousand three hundred sixty seven patients (40%) were considered as patients with a decreased PA. Both in group B (p = 0.001) and in group C (p = 0.003), patients with a decreased PA were significantly associated with an increased risk of a PCR, which was not the case in group A (p = 0.28). Logistic regression analysis identified a decreased PA as an independent predictor for PCR in groups B (p = 0.003, odds 1.71) and C (p = 0.033, odds 1.48), but not in group A (p = 0.11, odds 0.71). CONCLUSION: Decreased physical activity is an independent predictor for a PCR in patients aged 65 years or older undergoing elective cardiac surgery.

Surgical aortic valve replacement in patients older than 75 years: is there really a quality of life benefit?

BACKGROUND: To evaluate the results of elective isolated surgical aortic valve replacement (SAVR) on quality of life (QoL) in patients > 75 years. METHODS: 138 patients operated between January 2008 and December 2011 were included. The EuroQOL questionnaire (EQ-5D, EQ-VAS) was completed preoperatively, and 1- and 2-years postoperatively. The logistic EuroSCORE was used for risk stratification, the Corpus Christi Heart project criteria to assess physical activity. RESULTS: Mean age was 79.5 ± 2.8 years, mean risk 9.7 ± 5.4, hospital mortality 2.8 %. For 115 patients (83.3 %) the preoperative QoL information was complete. Fifty patients were classified as sedentary. In the first postoperative year 13 patients died, mostly sedentary patients (p = 0.046) with a low EQ-5D (p = 0.017). There was no QoL information on 32 survivors, mostly sedentary patients (p = 0.001). The 70 patients with QoL information showed an increased QoL (NS). Two years postoperatively, 16 patients died, significantly more sedentary patients (p = 0.015) with a low EQ-5D (p = 0.006). For 42 survivors, there was no QoL information; these were mostly sedentary patients (p = 0.021). The 57 patients with 2-year QoL information had an increased EQ-5D (NS) and EQ-VAS (p = 0.024). CONCLUSIONS: QoL increases after SAVR. However, the patients lost to follow-up were mostly sedentary or had a low preoperative QoL, which can lead to biased results.

Is quality of life post cardiac surgery overestimated?

BACKGROUND: Quality of Life (QoL) studies concerns the difference in QoL between the baseline and the post-surgical assessment. Many such studies, however, suffer from incomplete QoL-data with regard to patients with a proven survival--the drop-outs. Our hypothesis is that patients with a low preoperative QoL, high operative risk and older age are at higher risk for drop-out, which may result in a biased conclusion. METHODS: This study includes 1675 patients, all of whom were operated between July 1, 2009 and July 1,2012 and have a proven one-year survival, as well as a complete preoperative EuroQoL registration (EQ-5D and EQ-VAS). Based on the calculated 30 and 70 percentiles of age, EuroSCORE risk, and EQ-5D and EQ-VAS values, the group was split into three different subgroups. We studied whether (1) there was a correlation between age, risk, preoperative QoL and postoperative QoL and (2) if the drop-outs were correlated to age, risk and preoperative QoL. RESULTS: There is a statistically significant correlation between postoperative QoL and both age (p = 0.029) and risk (p = 0.002). Both relations have a negative Pearson's r. There is also a statistically significant (p = 0.0001) correlation between pre- and postoperative QoL, now with a positive Pearson's r. The percentage of drop-outs increases in a statistically significant manner with an increased risk (p = 0.001), older age (p = 0.001) and a low preoperative QoL (EQ-5D, p = 0.001 and EQ-VAS, p = 0.003). CONCLUSION: We conclude that QoL post cardiac surgery is overestimated, certainly for older, high risk patients and patients with a low preoperative QoL.

Male-female differences in aortic valve and combined aortic valve/coronary surgery: a national cohort study in the Netherlands.

Objective: The outcome of female patients after adult cardiac surgery has been reported to be less favourable compared with the outcome of male patients. This study compares men with women with respect to patient and procedural characteristics and early mortality in a contemporary national cohort of patients who underwent aortic valve (AV) and combined aortic valve/coronary (CABG/AV) surgery. Methods: All patients who underwent AV (n=8717, 56% male) or a combined CABG/AV surgery (n=5867, 67% male) in the Netherlands between January 2007 and December 2011 were included. Results: In both groups, women were generally older than men (p<0.001) and presented with higher logistic EuroSCORES. In isolated AV surgery, men and women had comparable in-hospital mortality (OR 1.20, 95% CI 0.90 to 1.61; p=0.220). In concomitant CABG/AV surgery, in-hospital mortality was higher in women compared with men (OR 2.00, 95% CI 1.44 to 2.79; p<0.001). The area under the curve for logistic EuroSCORE 1 was systematically higher for men versus women in isolated AV surgery 0.82 (95% CI 0.78 to 0.86) vs 0.75 (95% CI 0.69 to 0.80) and in concomitant CABG/AV surgery 0.78 (95% CI 0.73 to 0.82) vs 0.69 (95% CI 0.63 to 0.74). Finally, (the weight of) risk factors associated with in-hospital mortality differed between men and women. Conclusions: There are substantial male-female differences in patient presentation and procedural aspects in isolated AV and concomitant CABG/AV surgery in the Netherlands. Further studies are necessary to explore the mechanisms underlying the observed differences. In addition, the observation that standard risk scores perform worse in women warrants exploration of male-female specific risk models for patients undergoing cardiac surgery.Brief title.

The role of angina pectoris in chronic pain after coronary artery bypass graft surgery.

UNLABELLED: Visceral nociception readily sensitizes the central nervous system, causing referred somatic pain and hyperalgesia via somato-visceral convergence. Hyperalgesia in the perioperative period may increase vulnerability to subsequent development of chronic pain. The study aim is to investigate the role of angina pectoris, an ischemic visceral pain, in long-term pain after coronary artery bypass surgery (CABG). We sent questionnaires to 369 patients who underwent CABG surgery in 2003. Questions were asked about angina pectoris and other pain in the period before surgery, the first week postoperatively (= acute pain), and the period after 3 months after surgery (= chronic pain). We obtained results from 256 patients (response rate = 69%). The point prevalence of chronic pain after CABG was 27% after a mean follow-up of 16 months (SD +/- 3 months). Patients with chronic pain after CABG had more angina pectoris than those without chronic pain: Before surgery (P = .07), early on postoperatively (P = .004), and more than 3 months after surgery (P = .000004). We found cumulative prevalences of chronic pain after CABG at 3 months of 39%, and of 32% after 6 months. Other predictive factors for chronic pain after CABG were acute postoperative pain (P = .00002) and younger age (P = .002). Angina pectoris is associated with chronic pain after CABG surgery. Other predictive factors include acute postoperative pain and younger age. PERSPECTIVE: The influence of postoperative angina pectoris for chronic pain after CABG surgery has not been described in the literature to date. Visceral nociception may play an important role in the development of chronic pain after surgery and should be taken into account in future studies.

Autotransfusion management during and after cardiopulmonary bypass alters fibrin degradation and transfusion requirements.

UNLABELLED: The coagulation-fibrinolytic profile during cardiopulmonary bypass (CPB) has been widely documented. However, less information is available on the possible persistence of these alterations when autotransfusion is used in management of perioperative blood loss. This study was designed to explore the influence of autotransfusion management on intravascular fibrin degradation and postoperative transfusions. Thirty patients, undergoing elective primary isolated coronary bypass grafting, were randomly allocated either to a control group (group A; n=15) or an intervention group (group B; n=15) in which mediastinal and residual CPB blood was collected and processed by a continuous autotransfusion system before re-infusion. Intravascular fibrin degradation as indicated by D-dimer generation was measured at five specific intervals and corrected for hemodilution. In addition, chest tube drainage and need for homologous blood were monitored. D-dimer generation increased significantly during CPB in group A, from 312 to 633 vs. 291 to 356 ng/mL in group B (p = .001). The unprocessed residual blood (group A) revealed an unequivocal D-dimer elevation, 4131 +/- 1063 vs. 279 +/- 103 ng/mL for the processed residual in group B (p < .001). Consequently, in the first post-CPB period, the intravascular fibrin degradation was significantly elevated in group A compared with group B (p = .001). Twenty hours postoperatively, no significant difference in D-dimer levels was detected between both groups. However, a significant intra-group D-dimer elevation pre- vs. postoperative was noticed from 312 to 828 ng/mL in group A and from 291 to 588 ng/mL in group B (p < .01 for both). Postoperative chest tube drainage was higher in the patients from group A, which also had the highest postoperative D-dimer levels. Patients in group A perceived a higher need for transfusions of red cells suspensions postoperatively. These data clearly indicate that autotransfusion management during and after CPB suppresses early postoperative fibrin degradation. KEYWORDS: cardiopulmonary bypass, cardiotomy suction, coronary surgery, autotransfusion, fibrin degradation.

Development and implementation of a clinical pathway for cardiac surgery in the intensive care unit: Effects on protocol adherence.

RATIONALE, AIMS AND OBJECTIVES: Cardiac surgery (CS) is facilitated by multiple perioperative guidelines and protocols. Use of a clinical pathway (CP) may facilitate the care of these patients. METHODS: This is a pre-post design study in the ICU of a tertiary referral centre. A CP for CS patients in the ICU was developed by ICU-nurses and enabled them to execute proactively predefined actions in accordance with and within the preset boundaries which were part of a variance report. A tailored implementation strategy was used. Primary outcome measure was protocol adherence above 80% on the domains of blood pressure control, action on chest tube blood loss and electrolyte control within the CP. RESULTS: In a 4-month period, 84 consecutive CP patients were included and compared with 162 matched control patients admitted in the year before implementation; 3 patients were excluded. Propensity score was used as matching parameter. CP patients were more likely to receive early adequate treatment for derangements in electrolytes (96% vs 47%, P < .001), blood pressure (90% vs 49%, P < .001) and adequate treatment for chest tube blood loss (90% vs 10%, P < .001). We found no differences in hospital and ICU LOS, ICU readmission or mortality. CONCLUSION: Use of the CP improved postoperative ICU treatment for cardiac surgical patients. Implementation of a CP and the use of a special variance report could be a blueprint for the implementation and use of a CP in low-volume high complex surgery.

Estimated creatinine clearance instead of plasma creatinine level as prognostic test for postoperative renal function in patients undergoing coronary artery bypass surgery.

BACKGROUND: Preoperative renal failure is a risk factor for adverse events in cardiac surgery. Serum creatinine (SCr) is the most used test for renal failure. However, patients can have significantly decreased glomerular filtration rates with normal SCr levels. More accurate approximation of renal function can be obtained using the Cockroft-Gault equation to calculate an estimated creatinine clearance (CrCl) rate from SCr. METHODS: This study included 627 patients undergoing an isolated CABG between January 2003 and September 2004. CrCl was calculated using the Cockroft-Gault formula. Patients were divided in group A-SCr, 576 patients (91.1%) with a good renal function, SCr < or =1.20 mg/dL for women and < or =1.40 mg/dL for men, and a group B-SCr, with impaired renal function, 51 patients (8.1%). CrCl < or = 50 mL/min was chosen to reflect renal impairment. Group A-CrCl (555 patients, 88.5%) had a normal renal function and group B-CrCl (72 patients,11.5%) an impaired renal function. The studied outcomes were hospital mortality, hospital morbidity, and postoperative renal failure. RESULTS: There was no statistical significant difference between A-SCr and B-SCr group according to the studied outcomes. On the contrary, using the CrCl there was a statistical significant difference between A-CrCl and B-CrCl for the percentage of postoperative renal failure 10 patients (1.8%) versus 5 patients (6.9%) (p=0.00), hospital morbidity 75 patients (13.5%) versus 16 patients (22.2%) (p=0.04). Hospital mortality, 11 patients (2%) versus 4 patients (5.6%), was not significantly (p=0.06) different. Postoperative dialysis, four patients (0.7%) versus three patients (4.2%) (p=0.00), stroke, three patients (0.5%) versus three patients (4.2%) (p=0.00), and hospital stay (7.6 days vs 11.0 days) (p=0.01) were significantly different. CONCLUSION: This study documents that the association between preoperative renal failure and adverse outcomes after CABG is stronger with the estimated CrCl than with the routinely used SCr. Routine estimation or measurement of glomerular filtration rate should be preferred to SCr as screening method for the detection of higher risk patients undergoing CABG.

Is gait speed improving performance of the EuroSCORE II for prediction of early mortality and major morbidity in the elderly?

BACKGROUND: The aim of this study was to verify if gait speed can be an incremental predictor for mortality and/or major morbidity in combination with EuroSCORE II. METHODS: A single center prospective study cohort of 150 patients aged 70 years or older and undergoing cardiac surgery between August 2012 and April 2013. Slow gait speed was defined as a time taken to walk 5 meters of ≥6 second. The logistic EuroSCORE and EuroSCORE II were used for risk stratification. RESULTS: The studied group had a mean age of 77.7±5.2 years and mean gait speed was 4.9±1.01 (3.0-8.6) seconds. Slow gait speed was recorded in 21 patients (14%), indicated as frail, the other 129 patients (86%) as active. The logistic EuroSCORE risk (P=0.528), was not significantly different between the two groups. The EuroSCORE II risk, however, was significantly higher (P=0.023) for the frail group. There was no mortality and no statistically significant difference in percentage of major morbidity between the frail (28.6%) versus 17.1% for the active group (P=0.209) and slow gait speed could not be identified as independent predictor. Nevertheless frailty demonstrated an incremental value to improve performance of the logistic EuroSCORE model to predict early mortality and/or major morbidity in this elderly patient population. This was not so for EuroSCORE II. CONCLUSIONS: We confirm the incremental value of frailty, evaluated by gait speed, to improve mortality and morbidity prediction of the logistic EuroSCORE model in elderly undergoing cardiac surgery. We could not confirm this for the new EuroSCORE II model.

Frailty is associated with delirium and mortality after transcatheter aortic valve implantation.

OBJECTIVE: We hypothesised that frailty assessment is of additional value to predict delirium and mortality after transcatheter aortic valve implantation (TAVI). METHODS: Observational study in 89 consecutive patients who underwent TAVI. Inclusion from November 2012 to February 2014, follow-up until April 2014. Measurement of the association of variables from frailty assessment and cardiological assessment with delirium and mortality after TAVI, respectively. RESULTS: Incidence of delirium after TAVI: 25/89 (28%). Variables from frailty assessment protectively associated with delirium were: Mini Mental State Examination, (OR 0.79; 95% CI 0.65 to 0.96; p=0.02), Instrumental Activities of Daily Living (OR 0.79; 95% CI 0.63 to 0.99; p=0.04) and gait speed (OR 0.05; 95% CI 0.01 to 0.50; p=0.01). Timed Up and Go was predictively associated with delirium (OR 1.14; 95% CI 1.03 to 1.26; p=0.01). From cardiological assessment, pulmonary hypertension was protectively associated with delirium (OR 0.34; 95% CI 0.12 to 0.98; p=0.05). Multivariate logistic analysis: Nagelkerke R2=0.359, Mini Mental State Examination was independently associated with delirium. Incidence of mortality: 11/89 (12%). Variables predictively associated with mortality were: the summary score Frailty Index (HR 1.66, 95% CI 1.06 to 2.60; p=0.03), European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (HR 1.14, 95% CI 1.06 to 1.22; p<0.001) and complications (HR 4.81, 95% CI 1.03 to 22.38; p=0.05). Multivariate Cox proportional hazards analysis: Nagelkerke R2=0.271, Frailty Index and EuroSCORE II were independently associated with mortality. CONCLUSIONS: Delirium frequently occurs after TAVI. Variables from frailty assessment are associated with delirium and mortality, independent of cardiological assessment. Thus, frailty assessment may have additional value in the prediction of delirium and mortality after TAVI.

Improved Prediction by Dynamic Modeling: An Exploratory Study in the Adult Cardiac Surgery Database of the Netherlands Association for Cardio-Thoracic Surgery.

BACKGROUND: The predictive performance of static risk prediction models such as EuroSCORE deteriorates over time. We aimed to explore different methods for continuous updating of EuroSCORE (dynamic modeling) to improve risk prediction. METHODS AND RESULTS: Data on adult cardiac surgery from 2007 to 2012 (n=95 240) were extracted from the Netherlands Association for Cardio-Thoracic Surgery database. The logistic EuroSCORE predicting in-hospital death was updated using 6 methods: recalibrating the intercept of the logistic regression model; recalibrating the intercept and joint effects of the prognostic factors; re-estimating all prognostic factor effects, re-estimating all prognostic factor effects, and applying shrinkage of the estimates; applying a test procedure to select either of these; and a Bayesian learning strategy. Models were updated with 1 or 3 years of data, in all cardiac surgery or within operation subgroups. Performance was tested in the subsequent year according to discrimination (area under the receiver operating curve, area under the curve) and calibration (calibration slope and calibration-in-the-large). Compared with the original EuroSCORE, all updating methods resulted in improved calibration-in-the-large (range -0.17 to 0.04 versus -1.13 to -0.97, ideally 0.0). Calibration slope (range 0.92-1.15) and discrimination (area under the curve range 0.83-0.87) were similar across methods. In small subgroups, such as aortic valve replacement and aortic valve replacement+coronary artery bypass grafting, extensive updating using 1 year of data led to poorer performance than using the original EuroSCORE. The choice of updating method had little effect on benchmarking results of all cardiac surgery. CONCLUSIONS: Several methods for dynamic modeling may result in good discrimination and superior calibration compared with the original EuroSCORE. For large populations, all methods are appropriate. For smaller subgroups, it is recommended to use data from multiple years or a Bayesian approach.

Male-female differences and survival in patients undergoing isolated mitral valve surgery: a nationwide cohort study in the Netherlands.

OBJECTIVES: The objective of this study was to compare male-female differences with respect to baseline characteristics and short-term outcome in a contemporary nationwide cohort of patients who underwent isolated mitral valve (MV) surgery. METHODS: All patients [N = 3411; 58% males (N = 1977)] who underwent isolated MV surgery (replacement: N = 1048, 31%; reconstruction: N = 2364, 69%) in the Netherlands between January 2007 and December 2011 were included in this study. Differences in patient and procedural characteristics and in-hospital outcome were compared between male and female patients. RESULTS: Female patients were generally older (mean age, 64 vs 61 years, P < 0.001), presented more often with pulmonary hypertension (P = 0.03) and had higher logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) I (P < 0.001). Male patients presented more often with prior coronary artery bypass graft surgery (P < 0.001) and active endocarditis (P = 0.002). Female patients underwent MV replacement more often (P < 0.001) and, in case of replacement, received stented bioprostheses more often (P < 0.001). In-hospital mortality rates after MV replacement were 7% (n = 33) and 7% (n = 40) in male and female patients, respectively (OR 1.08, 95% CI 0.67-1.75; P = 0.75). In-hospital mortality rates after MV reconstruction were 1.4% (n = 21) and 1.3% (n = 11) in male and female patients, respectively (OR 0.88, 95% CI 0.42-1.84; P = 0.74). CONCLUSIONS: There are substantial male-female differences in patient presentation and procedural aspects in isolated MV surgery in the Netherlands. Female patients are older, have more severe disease at the time of surgery and undergo valve repair less often. Future studies are needed to identify potentially modifiable patient factors to improve the outcome of female patients with MV disease.

Anticoagulation therapy after bioprosthetic aortic valve replacement in Dutch cardiothoracic centres: acceptance of guidelines does not lead to overall implementation†.

In 2012, the Netherlands Association of Cardiothoracic Surgery accepted the new guidelines of the European Association for Cardio-Thoracic Surgery on antiplatelet and anticoagulation management in cardiac surgery. The aim of our study was to evaluate knowledge and implementation of these guidelines in Dutch cardiothoracic centres 8 months later, specifically after biological aortic valve replacement. One month prior to and 8 months after acceptance of the new guidelines, a questionnaire was sent to all 16 Dutch cardiothoracic centres about their current anticoagulation management after biological aortic valve replacement, their knowledge and implementation of the guidelines. All centres returned the questionnaire. Fifteen centres declared knowledge of the guidelines of which two adjusted their anticoagulation therapy. Four declared they did not follow the guidelines. However, of the remaining 11 centres, only 7 followed the guidelines. Between the centres, current anticoagulation therapy varied from aspirin to coumarin with different dosages and durations. Despite acceptance of the guidelines, only 7 of 16 centres followed them, and there remains great variability in the postoperative anticoagulation management after biological aortic valve replacement in Netherlands.

Effect of metformin pretreatment on myocardial injury during coronary artery bypass surgery in patients without diabetes (MetCAB): a double-blind, randomised controlled trial.

BACKGROUND: During coronary artery bypass graft (CABG) surgery, ischaemia and reperfusion damage myocardial tissue, and increased postoperative plasma troponin concentration is associated with a worse outcome. We investigated whether metformin pretreatment limits cardiac injury, assessed by troponin concentrations, during CABG surgery in patients without diabetes. METHODS: We did a placebo-controlled, double-blind, single-centre study in an academic hospital in Nijmegen (Netherlands) in adult patients without diabetes undergoing an elective on-pump CABG procedure. We randomly assigned patients (1:1) in blocks of ten via a computer-generated randomisation sequence to either metformin hydrochloride (500 mg three times per day) or placebo (three times per day) for 3 days before surgery. The last dose was given roughly 3 h before surgery. Patients, investigators, trial staff, and the statistician were all masked to treatment allocation. The primary endpoint was the plasma concentration of high-sensitive troponin I at 6, 12, and 24 h postreperfusion after surgery, analysed in the per-protocol population with a mixed-model analysis using all these timepoints. Secondary endpoints included the occurrence of clinically relevant arrhythmias within 24 hours after reperfusion, the need for inotropic support, time to detubation, duration of stay in the intensive-care unit, and postoperative use of insulin. This study is registered with ClinicalTrials.gov, number NCT01438723. FINDINGS: Between Nov 8, 2011, and Nov 22, 2013, we randomly assigned 111 patients to treatment (57 to metformin and 54 to placebo). Five patients dropped out from the metformin group, and six from the placebo group. 52 patients in the metformin group and 48 patients in the placebo group were included in the per-protocol analysis. Geometric mean high-sensitivity troponin I increased from 0 µg/L to 3·67 µg/L (95% CI 3·06-4·41) with metformin and to 3·32 µg/L (2·75-4·01) with placebo at 6 h after reperfusion; 2·84 µg/L (2·37-3·41) and 2·45 µg/L (2·02-2·96), respectively, at 12 h; and to 1·77 µg/L (1·47-2·12) and 1·60 µg/L (1·32-1·94) at 24 h. The concentrations did not differ significantly between the groups (difference 12·3% for all timepoints [95% CI -12·4 to 44·1] p=0·35). Occurrence of arrhythmias did not differ between groups (three [5·8%] of 52 patients who received metformin vs three [6·3%] of 48 patients who received placebo; p=1·00). There was no difference between groups in the need for inotropic support, time to detubation, duration of stay in the intensive-care unit, or postoperative use of insulin. No patients died within 30 days after surgery. Occurrence of gastrointestinal discomfort (mostly diarrhoea) was significantly higher with metformin than with placebo (11 [21·2%] of 52 vs two [4·2%] of 48 patients; p=0·01). INTERPRETATION: Short-term metformin pretreatment, although safe, does not seem to be an effective strategy to reduce periprocedural myocardial injury in patients without diabetes undergoing CABG surgery. FUNDING: Netherlands Organisation for Health Research and Development and Netherlands Heart Foundation.

Sunitinib does not attenuate contractile force following a period of ischemia in isolated human cardiac muscle.

Concerns have been raised about the development of heart failure in patients treated for cancer with angiogenesis inhibitors, such as the tyrosine kinase inhibitor sunitinib. Patients with previous coronary artery disease and hypertension have an increased risk of developing heart failure. Therefore, we studied the effect of sunitinib on the contractility of isolated human atrial trabeculae and the effect on recovery after ischemic stimulation. After informed consent, the atrial appendage of patients undergoing cardiac surgery was harvested and isolated trabeculae were placed in an organ bath with a force transducer. During electrical stimulation, contractile force was measured during normal pacing or after simulated ischemia. Of each patient, one trabecula was perfused with control and one with sunitinib. Contractile force (expressed as percentage of baseline force) declined over time to 57 ± 8 and 73 ± 20% after 150 min of stimulation for solvent- and sunitinib-treated trabeculae, respectively (mean ± SE; n = 8; p > 0.1). After simulated ischemia and reperfusion, contractile force was 40 ± 6% in the control compared to 39 ± 6% in the sunitinib-treated trabeculae during the last final 5 min of reperfusion (n = 12; p > 0.1). Sunitinib at low, but clinically relevant, concentrations does not have a direct effect on function of human atrial cardiomyocytes nor does it attenuate the recovery in contractile force of atrial cardiomyocytes after a period of ischemia. A direct and acute toxic effect on cardiomyocytes does not explain the development of heart failure in patients treated with sunitinib.

Analysis of mortality within the first six months after coronary reoperation.

BACKGROUND: Identify risk factors associated with mortality following repeat coronary revascularization (redoCABG) within the first 6 months following surgery. METHODS: Five hundred forty-one redoCABG patients (1987 to 1998) were studied by univariant and multivariant analysis. Mortality was assessed at three different points: hospital mortality (A) (36/541, 6.7%); mortality at 6 months (C) (75/541, 13.9%); and outpatient perioperative mortality, which is a death occurring from the time of hospital discharge to 6 months postoperatively (B) (39/541, 7.2%). RESULTS: Diabetes, hypertension, peripheral vascular disease, renal insufficiency, lung disease, myocardial infarction (MI) before the first operation, MI between the first and redoCABG, lack of sinus rhythm, no IMA graft, acute/emergency operation, perfusion time, and perioperative MI were all identified as risk factors related to early mortality. MI before the first operation, antegrade cardioplegia, and the time period 1987 to 1992 all influenced hospital mortality (A). Diabetes, hypertension, renal insufficiency, lung disease, and valvular heart disease all influenced the outpatient mortality up to 6 months. Independent predictive factors for early mortality were: age more than 69 years; diabetes; vascular insufficiency; chronic lung disease; MI between first and redoCABG; no IMA-graft; acute preoperative MI; emergency operation; perfusion time; perioperative MI; and the time period 1987 to 1992. Risk factors for in-hospital death included MI between the first and redoCABG, cardiopulmonary bypass time, and the time period 1987 to 1992. Diabetes is an important risk factor during the outpatient perioperative phase. Emergency surgery and perioperative MI predict mortality regardless of the time period (A, B, or C). CONCLUSIONS: Early mortality after redoCABG is influenced by many variables during the first 6 months following surgery. Understanding these factors and their time course may better help to assess the true risk associated with reoperation for recurrent coronary insufficiency.

Is no news good news? Organized follow-up, an absolute necessity for the evaluation of myocardial revascularization.

OBJECTIVE: The objective of this study is to find out whether follow-up information is registered by a non-organized follow-up representative for mortality and morbidity after myocardial revascularization. METHODS: The follow-up information registered by an organized (OFU) and a non-organized (NOFU) follow-up method is compared. The organized follow-up consists of an annual survey directly to the patient. The non-organized follow-up contains information provided by cardiologists and general practitioners. 1722 patients undergoing a CABG between 1999 and 2002 were included in this study. Completeness of the follow-up was registered as well as mortality and events, defined as return of angina, myocardial infarction, rhythm disturbances, heart failure, stroke and PTCA. RESULTS: The OFU was 98% complete and the NOFU 51.8% (P<0.05). The NOFU registered only 10 deaths; however, in the OFU another 21 patients who died during the first year postoperative were registered (P<0.05). In the OFU, 137 patients were registered with an event and in the NOFU 53 (P<0.05). In NOFU, the mean was 108+/-91 days and median was 78 days. CONCLUSION: OFU improves the completeness of the follow-up, as expected, but informs superior about mortality and events. That in the NOFU, for 50% of the patients, the information is at the most 78 days postoperative old, let us suppose that a lot of early (6 months) postoperative information is even missed by an NOFU. The establishment of an organized follow-up and feedback of mortality and events after myocardial revascularization becomes indispensable.

Long-term cardiac survival after reoperative coronary artery bypass grafting.

OBJECTIVE: Despite advances in cardiac surgery, the risk of reoperative coronary artery bypass surgery (RECABG) still exceeds those of a primary myocardial revascularization and also the late results are not so favourable. In this study, long-term cardiac survival is analyzed. METHODS: We analyzed long-term cardiac survival of 466 patients who survived the first 6 months after a RECABG between January 1987 and December 1998. Actuarial survival estimates were calculated and pre- and peroperative variables were analyzed to identify predictors of long-term cardiac related mortality. RESULTS: Mean follow-up was 7.7 +/- 3.8 years (1-17 years), and follow-up was 95.6% complete. One-year cardiac survival was 98.2%, 5-year: 91.0%, 10-year: 78.7% and 14-year survival 60.2%. Cardiac survival was only significantly superior for patients under 65 years of age at the moment of the RECABG. Impaired left ventricular function was identified as the only independent predictor of late cardiac-related mortality. CONCLUSION: The long-term survival in patients undergoing RECABG is acceptable. Once patients survived the first 6 postoperative months, advanced age (>65 years) is affecting long-term cardiac survival and impaired left ventricular function is the only independent predictor of late cardiac mortality.

Influence of obesity on in-hospital and early mortality and morbidity after myocardial revascularization.

OBJECTIVE: Obese patients are thought to have an increased risk for complications in coronary artery bypass surgery. Several risk stratification systems do not identify obesity as a variable for risk adjustment. The aim of this study is to evaluate the in-hospital and early (one year) mortality and morbidity in obese and non-obese patients after a CABG in the UMC St Radboud. METHODS: The data of 1130 patients undergoing a myocardial revascularization from January 2000 to August 2002 were analyzed. Obesity was measured by the body mass index (BMI). A BMI>or=30 kg/m2 was defined as obese. We compared 206 obese patients with 924 non-obese patients. Uni- and multivariate analysis were used to analyze the results. The 1-year survival was analyzed using Kaplan-Meier methods. RESULTS: There were no significant differences between obese and non-obese patients according to postoperative myocardial infarction, re-operation for bleeding, in-hospital mortality, renal complications, neurological complications, pulmonary complications, gastrointestinal complications, re-intubation, re-admission on intensive care, ventilation time, days on intensive care, days in hospital and late mortality. Only the incidence of postoperative wound infections was increased in obese patients, 8.3% in the obese versus 4.4% in the non-obese (P=0.02). Multivariate analysis identified obesity only as risk factor for postoperative for wound infections (P=0.04, odds ratio: 1.97). CONCLUSIONS: Obese patients do not have an increased risk of in-hospital and early (1 year) mortality after CABG. However, obese patients have an increased risk of postoperative wound infections compared to non-obese patients.

Preoperative prediction of prolonged stay in the intensive care unit for coronary bypass surgery.

OBJECTIVES: To construct a predictive model for a prolonged stay in the intensive care unit (ICU) for coronary artery bypass graft surgery (CABG). METHODS: Eight hundred and eighty-eight patients undergoing CABG were studied by univariate and multivariate analysis. Prolonged stay in the ICU was defined as >/=3 days stay. Stepwise selective procedure (P/=0.40 was used as cut-off point for the prognostic test. The specificity of this test for prolonged stay in the ICU was 99%; sensitivity 9%; positive predictive value 60%; and negative predictive value 89%. CONCLUSIONS: The results show that individual patients presented for CABG, can be stratified according to their risk for prolonged stay >/=3 days in the ICU.