Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario / Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital

Objetivo. Este estudio analiza la frecuencia de las complicaciones postoperatorias tras la cirugía cardiaca, la incidencia del fracaso en el rescate (FR) y su relación con la supervivencia. Métodos. Desde enero del 2003 hasta diciembre del 2009, se intervinieron 2.750 pacientes adultos de cirugía cardiaca. Se analizaron 9 complicaciones postoperatorias. Para conocer las variables asociadas con alguna de estas complicaciones, se realizó análisis de regresión logística múltiple. La supervivencia se estimó mediante curvas de Kaplan-Meier y las complicaciones asociadas con la mortalidad se estimaron mediante regresión de Cox. Resultados. La mortalidad hospitalaria fue 1,4% (IC del 95%, 1,01%-1,9%). La frecuencia de complicaciones postoperatorias fue del 38,5% (36,7%-40,4%) y el FR, 3,6% (2,5%-4,9%). La cirugía urgente (OR = 2,03, IC del 95%, 1,52-2,72), la insuficiencia renal crónica (OR = 1,50, IC del 95%, 1,25-1,80) y la edad ≥70 años (OR = 1,42, IC del 95%, 1,20-1,68) fueron las variables que se asociaron con más fuerza con las complicaciones seleccionadas. La supervivencia a los 5 años fue del 93% en los pacientes sin complicaciones y el 83% en los pacientes con alguna de las complicaciones (p < 0,0001). Las complicaciones asociadas con la supervivencia a medio plazo fueron la neumonía (HR 2,6, IC del 95%, 1,275,50), el infarto agudo de miocardio (HR 1,9, IC del 95%, 1,10-2,30) y la insuficiencia renal aguda (HR 1,7, IC del 95%, 1,30-2,26). Conclusiones. La incidencia de complicaciones postoperatorias en cirugía cardiaca oscila alrededor del 40% y aumenta la mortalidad hospitalaria aunque el FR fue muy bajo (3,6%; IC del 95%, 2,5-4,9) (AU)

Objective. This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. Methods. The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. Results. Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). Conclusions. The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9) (AU)

[Mortality from postoperative complications (failure to rescue) after cardiac surgery in a university hospital]. / Mortalidad de las complicaciones postoperatorias (failure to rescue) tras cirugía cardiaca en un hospital universitario.

OBJECTIVE: This study analyses the rate of post-operative complications after cardiac surgery, the incidence of the failure to rescue (FR), and the relationship between complications and survival. METHODS: The study included a total of 2,750 adult patients operated of cardiac surgery between January 2003 and December 2009. An analysis was made of 9 post-operative complications. Multiple logistic regression analysis was used to find independent variables associated with any of the selected complications. Survival was analysed with Kaplan-Meyer survival estimates. A risk-adjusted Cox proportional regression model was used to find out which complications were associated with mid-term survival. RESULTS: Hospital mortality rate was 1.4% (95% CI: 1.0%-1.9%). Postoperative complications rate was 38.5% (36.7%-40.4%), and FR 3.6% (2.5%-4.9%). Urgent surgery (OR = 2.03; 1.52-2.72), chronic renal failure (OR = 1.50, 95%.CI: 1.25-1.80), and age ≥70 years (OR = 1.42; 1.20-1.68) were the variables that showed the highest strength of association with the selected complications. Survival at 5 years in the group of patients without complications was 93%, and in the group of patients with complications it was 83% (P<.0001). Postoperative complications associated with mid-term survival were pneumonia (HR = 2.6, 95% CI; 1.27-5.50), acute myocardial infarction (HR = 1.9; 1.10-2.30), and acute renal failure (HR = 1.7; 1.30-2.26). CONCLUSIONS: The incidence of complications after cardiac surgery is around 40%, and was associated with an increase in hospital mortality, although FR was very low (3.6%; 95% CI: 2.5-4.9).

Long-Term Mortality After Pneumonia in Cardiac Surgery Patients: A Propensity-Matched Analysis.

BACKGROUND: The role that intensive care unit (ICU)-acquired pneumonia plays in the long-term outcomes of cardiac surgery patients is not well known. This study examined the association of pneumonia with in-hospital mortality and long-term mortality after adult cardiac surgery. METHODS: A total of 2750 patients admitted to our ICU after cardiac surgery from January 2003 to December 2009 are the basis for this observational study. Patients who developed ICU-acquired pneumonia were matched with patients without it in a 1:2 ratio. The matching criteria were age, urgent or scheduled surgery, surgical procedure, and the propensity score for pneumonia. Multiple regression analysis was used to find predictors of hospital mortality. The relationship between pneumonia and long-term survival was analyzed with Kaplan-Meier survival estimates and a risk-adjusted Cox proportional regression model for patients discharged alive from hospital. RESULTS: Pneumonia was diagnosed in 32 (1.2%) patients and there were 19 cases per 1000 days of mechanical ventilation. Patients with pneumonia had a significantly higher hospital mortality rate (28% vs 6.2%, P = .003) and a higher mortality at the end of follow-up (53% vs 19%, P < .0001) than those without it. Regression analysis showed that pneumonia was a strong predictor of hospital mortality. Five-year survival was as follows: pneumonia, 62%; control, 81%; and cohort patients, 91%. The Cox model showed that, after adjusting for confounding factors, patients with pneumonia (hazard ratio = 3.96, 95% confidence interval [CI]: 1.41-11.14) had poorer long-term survival. CONCLUSION: Pneumonia remains a serious complication in patients operated for cardiac surgery and is associated with increased hospital mortality and reduced long-term survival.

Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada / Red cell transfusion and long-term survival in non-complicated heart surgery

OBJETIVO: Averiguar si existe asociación entre la transfusión perioperatoria de 1-2 unidades de hematíes y la morbilidad hospitalaria, la mortalidad a 30 días y la supervivencia a largo plazo en los pacientes operados en cirugía cardíaca. DISEÑO: Estudio de cohorte prospectivo. Ámbito: UCI de un hospital universitario. PACIENTES: Se valoró a todos los pacientes mayores de 17 años operados de cirugía cardíaca e ingresados en la UCI desde noviembre del 2002 hasta diciembre del 2009. Se analizó a los pacientes que no recibieron transfusión de hematíes (n = 703) y a los que recibieron transfusión perioperatoria de 1-2 unidades de hematíes (n = 959). Variables de interés: Se analizó el efecto de la transfusión sobre la morbilidad hospitalaria y la mortalidad a 30 días. El seguimiento de los enfermos dados de alta vivos del hospital finalizó el 31 de diciembre del 2011. La asociación de la transfusión con la supervivencia a largo plazo se evaluó con el método de Kaplan-Meier. La evaluación de los posibles factores predictivos de mortalidad a largo plazo se realizó mediante la construcción de modelos de regresión de Cox. RESULTADOS: La frecuencia de complicaciones postoperatorias cardíacas y no cardíacas fue mayor en los pacientes que recibieron transfusión. La mortalidad a 30 días de estos últimos fue mayor que en los pacientes no transfundidos (1% vs. 0,1%, p = 0,02). La presencia de anemia preoperatoria se asoció a un mayor uso de transfusión. La transfusión de hematíes no fue un factor de riesgo de mortalidad a largo plazo (Hazard ratio = 1,4; intervalo de confianza del 95%, 0,9-2,1). CONCLUSIONES: La transfusión perioperatoria de 1-2 unidades de hematíes en los pacientes operados de cirugía cardíaca se asocia a un incremento de la morbilidad hospitalaria y la mortalidad a 30 días, y no tiene efecto en la mortalidad a largo plazo

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n = 703) and those who did (n = 959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. Study endpoints: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P = .02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio = 1.4, 95% CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality

[Red cell transfusion and long-term survival in non-complicated heart surgery]. / Transfusión de hematíes y supervivencia a largo plazo en la cirugía cardíaca no complicada.

OBJECTIVE: A study was made to explore the possible association between the perioperative transfusion of 1 - 2 red blood cell units and in-hospital morbidity, 30-day mortality, and long-term survival in patients undergoing heart surgery. DESIGN: A prospective observational study was carried out. SETTING: The ICU of a university hospital. PATIENTS: All patients over 17 years of age that underwent heart surgery and were admitted to the ICU between November 2002 and December 2009 were included. Those patients who did not (n=703) and those who did (n=959) receive the perioperative transfusion of 1 - 2 red blood cell units were assessed. STUDY ENDPOINTS: The endpoints were the effect of transfusion on both hospital morbidity and on 30-day mortality. In addition, all patients discharged alive from hospital until 31 December 2011 were subjected to follow-up. The association between transfusion and survival was assessed by means of the Kaplan-Meier method. Cox proportional hazards models were used to assess factors associated with long-term survival. RESULTS: The frequency of both cardiac and non-cardiac perioperative complications was higher in patients receiving transfusion. The 30-day mortality rate was higher in those who received transfusion (1% vs 0.1%, P=.02). Preoperative anemia was associated with a more intensive use of transfusion. Red blood cell transfusion was not found to be a risk factor for long-term mortality (hazar ratio=1.4, 95%CI 0.9-2.1). CONCLUSIONS: The perioperative transfusion of 1 - 2 red blood cell units in patients undergoing heart surgery increases both hospital morbidity and the 30-day mortality rate, but does not increase long-term mortality.

Respiratory tract infections after cardiac surgery: impact on hospital morbidity and mortality.

AIM: Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are associated with worse outcomes. The aim of this study was to identify risk factors associated with NP and tracheobronchitis after cardiac surgery and to determine the impact of these infections on hospital morbidity and mortality. METHODS: We evaluated 1600 adult patients undergoing cardiac surgery under standard cardiopulmonary bypass. Data were collected prospectively. All NP and tracheobronchitis episodes were confirmed by a semiquantitative culture of endotracheal aspirate. Logistic regression analysis was done to identify risk factors for respiratory tract infection and mortality. RESULTS: The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of mechanical ventilation). Significant independent risk factors for respiratory tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection fraction < 30% (P = 0.001), chronic renal failure (P < 0.0001) and urgent surgery (P < 0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%, P < 0.0001) than patients without respiratory tract infection. The median hospital length of stay was significantly longer in patients with pneumonia (42 days) and tracheobronchitis (28 days) than in patients without any respiratory tract infection (11 days, P < 0.0001). CONCLUSION: NP after cardiac surgery is associated with severe outcomes. Independent risk markers for respiratory tract infection were left ventricular ejection fraction < 30%, chronic renal failure and urgent surgery.

[Preoperative anemia in coronary surgery: a risk factor?]. / Anemia preoperatoria en la cirugía coronaria: ¿un factor de riesgo?

INTRODUCTION AND OBJECTIVES: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and in-hospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital. METHODS: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed. RESULTS: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore > or =4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2+/-2.5 days vs. 3.7+/-2.8, p=0.004; in-hospital: 17.5+/-11.3 days vs. 14.7+/-10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8). CONCLUSIONS: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not.

Anemia preoperatoria en la cirugia coronaria: un factor de riesgo? / Preoperative anemia in coronary surgery: A risk factor?

Objetivo: El papel de la anemia preoperatoria como factor de riesgo en la cirugía coronaria no está bien establecido. El objetivo de este estudio es analizar la asociación de la anemia preoperatoria con las complicaciones postoperatorias y la mortalidad hospitalaria en los enfermos operados de cirugía coronaria aislada en el Hospital de Son Dureta. Material y métodos: Se incluyeron en este estudio todos los pacientes operados de cirugía coronaria aislada con circulación extracorpórea desde noviembre de 2002 hasta junio de 2007. La anemia preoperatoria se definió según los criterios de la OMS como una hemoglobina inferior a 13g/dl en los hombres e inferior a 12g/dl en las mujeres. Los efectos adversos postoperatorios cardíacos y no cardíacos se analizaron en función de la presencia o ausencia de la anemia preoperatoria y de la estratificación del riesgo quirúrgico, sobre la base del valor del EuroSCORE logístico. Resultados: Se incluyeron 623 pacientes. La incidencia de anemia preoperatoria fue del 34,5%. Esta incidencia fue mayor en pacientes con EuroSCORE de 4 o más que con EuroSCORE inferior a 4 (el 41 y el 27%; p=0,0001). No hubo diferencias significativas entre la incidencia de complicaciones postoperatorias de los pacientes con anemia y sin anemia. La estancia media en la UCI y hospitalaria fue más larga en los pacientes con anemia preoperatoria que en los pacientes sin ella (UCI: 3,2±2,5 días y 3,7±2,8; p=0,004; hospitalaria: 17,5±11,3 días y 14,7±10,2; p=0,001). La mortalidad hospitalaria fue del 0,8% (intervalo de confianza del 95%: 0,3-1,9). No hubo diferencias en la mortalidad de los pacientes con anemia preoperatoria y sin anemia preoperatoria (el 0,9 y el 0,7%; p=0,8). Conclusiones: En este estudio, la anemia preoperatoria en los pacientes operados de cirugía coronaria aislada no se asoció con una mayor morbimortalidad hospitalaria, aunque la estancia hospitalaria fue más larga. La limitación del tamaño de la muestra impide confirmar que la anemia preoperatoria sea o no un factor de riesgo en la cirugía coronaria (AU)

Introduction and objectives: Preoperative anemia as a risk factor of adverse outcomes after coronary surgery has not been well-established. This study has aimed to analyze the association between preoperative anemia and postoperative adverse events and inhospital mortality in the patients undergoing isolated coronary artery bypass graft surgery in the Son Dureta hospital. Methods: All the patients undergoing isolated coronary artery bypass graft surgery with extracorporeal circulation from November 2002 to June 2007 were included. Preoperative anemia was defined as hemoglobin (Hb)<13g/dL in men and Hb<12g/dL in women. The association between postoperative cardiac and noncardiac adverse events and the presence or absence of preoperative anemia and concomitant surgical risk, assessed by logistic EuroScore, were analyzed. Results: A total of 623 patients were included. The rate of preoperative anemia was 34.5%. Patients with Euroscore >4 had higher incidence of preoperative anemia than patients with Euroscore<4 (41% vs. 27%; p=0.0001). There were no statistically significant differences in the rate of postoperative adverse events related to the presence or absence of preoperative anemia. Median ICU and hospital length of stay were longer in patients with preoperative anemia than in patients without preoperative anemia (ICU: 3.2±2.5 days vs. 3.7±2.8, p=0.004; inhospital: 17.5±11.3 days vs. 14.7±10.2, p=0.001). Hospital mortality rate was 0.8% (95% CI 0.3-1.9). There were no differences in the mortality rate of the patients with and without preoperative anemia (0.9% vs 0.7%, p=0.8). Conclusions: In this study, preoperative anemia in patients undergoing coronary artery bypass graft surgery was not associated with increased hospital morbidity-mortality. However, ICU and hospital length of stay were longer in patients with preoperative anemia. The limitation of the sample size prevents us from confirming whether preoperative anemia is a risk factor after coronary surgery or not (AU)

[Predictive value of the EuroSCORE model in cardiac surgery in our site]. / Valor predictivo del modelo EuroSCORE en la cirugía cardíaca de nuestro centro.

OBJECTIVE: The use of risk prediction models in cardiac surgery makes it possible to compare and evaluate health care quality between different institutions in countries. This study aimed to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model in estimating the risk of mortality of cardiac surgery patients of our hospital. PATIENTS AND METHODS: The additive and logistic EuroSCORE models were applied to all patients who underwent cardiac surgery with extracorporeal circulation from the time the cardiac surgery unit was opened in our center in November 2002 until February 2006. All data were obtained prospectively when the patients were admitted to the Intensive Care Unit. Mortality observed was compared with that estimated in the following subgroups: global cardiac surgery, isolated coronary surgery, isolated valvular surgery, combined valvular and coronary surgery and thoracic aorta surgery. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. RESULTS: We studied 1,053 patients who had several differences with the EuroScore model population. Overall observed mortality was 2.2% (95% CI 1.2 - 3.1). The EuroSCORE models overestimated mortality (additive predicted 5%, logistic predicted 4.6%). Mortality of coronary bypass graft surgery was 1.2% and both EuroSCORE models overestimated it. Discriminative power of both models was good with an Area under ROC curve for both models of 0.78 and 0.79. CONCLUSIONS: The use of both EuroSCORE models overestimated overall observed mortality and that of the different surgical subgroups of cardiac surgery performed in our institution.

Valor predictivo del modelo EuroSCORE en la cirugía cardíaca de nuestro centro / Predictive value of the EuroSCORE model in cardiac surgery in our site

Objetivo. El uso de modelos de predicción del riesgo de cirugía cardíaca permite comparar y evaluar la calidad asistencial entre distintos centros y países. El objetivo de este estudio fue valorar la eficacia del modelo EuroSCORE (European system for cardiac operative risk evaluation) en estimar el riesgo de mortalidad en la cirugía cardíaca de nuestro hospital. Pacientes y métodos. Se aplicaron los modelos EuroSCORE aditivo y logístico a todos los pacientes sometidos a cirugía cardíaca con circulación extracorpórea desde el inicio de la actividad, en noviembre de 2002, hasta febrero de 2006. Todos los datos se obtuvieron de una base de datos cumplimentada de forma prospectiva cuando los pacientes ingresaban en la Unidad de Cuidados Intensivos. Se comparó la mortalidad observada con la estimada en los siguientes subgrupos: cirugía cardíaca global, cirugía coronaria aislada, cirugía valvular aislada, cirugía valvular y coronaria combinada y cirugía de la aorta torácica. La discriminación del modelo se comprobó midiendo el área bajo la curva ROC (receiver operating characteristics curve). Resultados. Estudiamos a 1.053 pacientes que presentaron varias diferencias con la población del modelo EuroSCORE. La mortalidad global observada fue de 2,2% (IC 95%: 1,2-3,1). Los modelos EuroSCORE sobrevaloraron la mortalidad observada (aditivo 5% y logístico 4,6%). La mortalidad observada en la cirugía coronaria aislada fue del 1,2% y ambos modelos EuroSCORE la sobrevaloraron. El poder discriminante de ambos modelos fue bueno con un área bajo la curva ROC de 0,78 (score aditivo) y 0,79 (score logístico). Conclusiones. El uso de ambos modelos EuroSCORE sobrevalora la mortalidad global observada y la de los distintos subgrupos quirúrgicos de la cirugía cardíaca practicada en nuestro centro

Objective. The use of risk prediction models in cardiac surgery makes it possible to compare and evaluate health care quality between different institutions in countries. This study aimed to assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) model in estimating the risk of mortality of cardiac surgery patients of our hospital. Patients and methods. The additive and logistic EuroSCORE models were applied to all patients who underwent cardiac surgery with extracorporeal circulation from the time the cardiac surgery unit was opened in our center in November 2002 until February 2006. All data were obtained prospectively when the patients were admitted to the Intensive Care Unit. Mortality observed was compared with that estimated in the following subgroups: global cardiac surgery, isolated coronary surgery, isolated valvular surgery, combined valvular and coronary surgery and thoracic aorta surgery. Model discrimination was tested by determining the area under the receiver operating characteristic (ROC) curve. Results. We studied 1,053 patients who had several differences with the EuroScore model population. Overall observed mortality was 2.2% (95% CI 1.2 - 3.1). The EuroSCORE models overestimated mortality (additive predicted 5%, logistic predicted 4.6%). Mortality of coronary bypass graft surgery was 1.2% and both EuroSCORE models overestimated it. Discriminative power of both models was good with an Area under ROC curve for both models of 0.78 and 0.79. Conclusions. The use of both EuroSCORE models overestimated overall observed mortality and that of the different surgical subgroups of cardiac surgery performed in our institution

[Spontaneous rupture of the papillary muscle with angiographically normal coronary vessels]. / Rotura espontánea de músculo papilar con coronarias angiográficamente normales.

Papillary muscle rupture is an unusual pathology, commonly being a mechanical complication of an acute myocardial infarction or a blunt chest trauma. In this case report we describe a patient with a spontaneous complete posteromedial papillary muscle rupture, secondary to an isolated papillary muscle infarction, in the absence of coronary artery disease, resulting in severe mitral regurgitation, cardiogenic shock and uneventful urgent mitral valve replacement. The clinical and histopathologic literature, and mechanisms to explain this kind of rupture, are reviewed.

Intermittent electromechanical dissociation as an unusual sign of prosthetic valve thrombosis in a patient with prosthetic fibrous ingrowth.

We describe the echocardiographic features of an unusual hemodynamic phenomenon of intermittent electromechanical dissociation during regular sinus tachycardia in a patient with prosthetic mitral valve thrombosis. Thrombolysis with a solution of recombinant tissue-type plasminogen activator resulted in the disappearance of electromechanical dissociation and was effective in stabilizing the patient's condition. The later discovery of panus covering the valve ring after the lysis of clots confirmed surgery as the definitive treatment.

Identification of rpaP1-5 and rpaP2-6 genes encoding two additional variants of the 60S acidic ribosomal proteins of Schizosaccharomyces pombe.

In the fission yeast, four genes (rpaP1-1, rpaP1-3, rpaP2-2, and rpaP2-4) encoding two variants of the RpaP1 and RpaP2 ribosomal proteins (rp) have been characterized. We have identified cDNA for additional variants called RpaP1.5 and RpaP2.6. Sequence comparison suggests that RpaP1.5 diverged before RpaP1.1 and RpaP1.3 and that RpaP2.6 is closer to RpaP2.2 than to RpaP2.4. The corresponding genes, rpaP1-5 and rpaP2-6, are transcribed coordinately with other rp genes.

An unusual tethering of the bridging leaflets in atrioventricular septal defect producing a communication from left atrium to right ventricle.

We describe a 39-year-old woman who was diagnosed as having an unusual atrioventricular septal defect with a communication from left atrium to right ventricle. A common atrioventricular junction, with partially separated right and left atrioventricular orifices, was found at transoesophageal ultrasonic examination. Both bridging leaflets were attached to the underside of the atrial septum, which was grossly malaligned relative to the ventricular septum. The shunt was exclusively from left atrium to right ventricle because of the overriding of the left atrioventricular valve, with the left component of the inferior bridging leaflet firmly fused to the ventricular septal crest.

Cloning of the human IL-13R alpha1 chain and reconstitution with the IL4R alpha of a functional IL-4/IL-13 receptor complex.

The human homologue of the recently cloned murine IL-13 binding protein (IL-13R alpha1) was cloned from a cDNA library derived from the carcinoma cell line CAKI-1. The cloned cDNA encodes a 427 amino acid protein with two consensus patterns characteristic of the hematopoietic cytokine receptor family and a short cytoplasmic tail. The human protein is 74% identical to the murine IL-13R alpha1, and 27% identical to the human IL-13R alpha2. CHO cells expressing recombinant hIL-13R alpha1 specifically bind IL-13 (Kd approximately 4 nM) but not IL-4. Co-expression of the cloned cDNA with that of IL-4R alpha resulted in a receptor complex that displayed high affinity for IL-13 (Kd approximately 30 pM), and that allowed cross-competition of IL-13 and IL-4. Electrophoretic mobility shift assay showed that IL-13 and IL-4 were able to activate Stat6 in cells expressing both IL-4R alpha and IL-13R alpha1, while no activation was observed in cells expressing either one or the other alone.

Prostacyclin and thromboxane production by autogenous femoral veins grafted into the arterial circulation of the dog.

Vascular prostacyclin (PGI2) production is different in the arteries and veins of the dog. Experiments were performed to determine whether chronic grafting of the femoral vein into the arterial circulation would alter the normal PGI2 and thromboxane (TxA2) synthesis of the "arterialized" veins. Spontaneous and arachidonic acid (AA) stimulated PGI2 and TxA2 production (measured by radioimmunoassay of 6-keto PGF1 alpha and TxB2 respectively) were analysed in full thickness punch biopsies of the middle part of the grafts after 3 and 16 months and compared with unoperated veins and arteries. PGI2 production was significantly higher in arteries than in veins but no significant difference in TxB2 production was found. Middle "arterialized" venous graft produced significantly lower amounts of PGI2 and higher amounts of TxB2 than unoperated vessels. PGI2 production was more reduced in the distal than in the middle or the proximal parts of the venous grafts especially when stimulated with AA. These findings do not support the concept that the venous graft was biochemically adapted or "arterialized" in terms of PGI2 production when implanted for 3 months or longer. Rather, the markedly decreased PGI2/TxB2 ratio in the middle of the graft may be a contributory cause of thrombogenicity and may be implicated in the pathogenesis of neointimal hyperplasia.