Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS).

INTRODUCTION: The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. METHODS: This is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis. RESULTS: The trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250). CONCLUSIONS: MiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Surgical aortic valve replacement in the era of transcatheter aortic valve implantation: a review of the UK national database.

OBJECTIVES: To date the reported outcomes of surgical aortic valve replacement (SAVR) are mainly in the settings of trials comparing it with evolving transcatheter aortic valve implantation. We set out to examine characteristics and outcomes in people who underwent SAVR reflecting a national cohort and therefore 'real-world' practice. DESIGN: Retrospective analysis of prospectively collected data of consecutive people who underwent SAVR with or without coronary artery bypass graft (CABG) surgery between April 2013 and March 2018 in the UK. This included elective, urgent and emergency operations. Participants' demographics, preoperative risk factors, operative data, in-hospital mortality, postoperative complications and effect of the addition of CABG to SAVR were analysed. SETTING: 27 (90%) tertiary cardiac surgical centres in the UK submitted their data for analysis. PARTICIPANTS: 31 277 people with AVR were identified. 19 670 (62.9%) had only SAVR and 11 607 (37.1%) had AVR+CABG. RESULTS: In-hospital mortality for isolated SAVR was 1.9% (95% CI 1.6% to 2.1%) and was 2.4% for AVR+CABG. Mortality by age category for SAVR only were: <60 years=2.0%, 60-75 years=1.5%, >75 years=2.2%. For SAVR+CABG these were; 2.2%, 1.8% and 3.1%. For different categories of EuroSCORE, mortality for SAVR in low risk people was 1.3%, in intermediate risk 1% and for high risk 3.9%. 74.3% of the operations were elective, 24% urgent and 1.7% emergency/salvage. The incidences of resternotomy for bleeding and stroke were 3.9% and 1.1%, respectively. Multivariable analyses provided no evidence that concomitant CABG influenced outcome. However, urgency of the operation, poor ventricular function, higher EuroSCORE and longer cross clamp and cardiopulmonary bypass times adversely affected outcomes. CONCLUSIONS: Surgical SAVR±CABG has low mortality risk and a low level of complications in the UK in people of all ages and risk factors. These results should inform consideration of treatment options in people with aortic valve disease.

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†.

OBJECTIVES: With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period. METHODS: Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes. RESULTS: There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk. CONCLUSIONS: The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.

Short- and long-term outcomes of pneumonectomy in a tertiary center.

BACKGROUND: Surgery is the most important therapeutic modality for lung cancer. Surgical outcomes are normally reported as 30-day or 90-day mortality or 5-year survival; 10-year survival is rarely mentioned in national data or international studies. METHODS: Three hundred and six patients (79% male) underwent pneumonectomy, mainly for lung cancer, from January 1998 to February 2013. Their short- and long-term outcomes up to September 2014 were analyzed retrospectively. The mean age was 64 years (range 22-82 years) and 24% were aged ≥70 years. Thoracoscore was used to calculate the risk of hospital mortality. RESULTS: Operative mortality was 4.5% whereas predicted mortality was 8%. The operative mortality for cancer patients was 3.3%; the national mortality for lung cancer is 6.5%. Only 2 patients died in hospital after a pneumonectomy in the last 5 years. Half of the patients who died in hospital were ≥70 years old; 29% (4 patients) died after urgent operations for nonmalignant disease. Overall 5- and 10-year survival was 32% and 20%. Median and mean survival was 26 and 57 months, respectively. Long-term survival was better in females aged <70 years, in left pneumonectomy patients, and in those with squamous cell lung cancer. CONCLUSION: Our mortality for pneumonectomy was 50% less than the national mortality rate and significantly lower than that predicted by the Thoracoscore for lung cancer. This confirms that pneumonectomy is still an effective modality for the treatment of lung cancer, with low operative mortality and good long-term survival, especially in younger patients.

WITHDRAWN: Is there life after the Mesothelioma and Radical Surgery trial? Does extrapleural pneumonectomy still have a role in the management of pleural mesothelioma? A 13-year, single-center experience.

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Could Thoracoscore predict postoperative mortality in patients undergoing pneumonectomy?

OBJECTIVES: Thoracoscore is incorporated in the new British Thoracic Society and National Institute of Health and clinical Excellence guidelines to evaluate the operative mortality risk of patients undergoing thoracic surgery. This study examines the accuracy of Thoracoscore in predicting postoperative mortality in patients undergoing pneumonectomy. METHODS: All patients who underwent pneumonectomy from January 1998 to March 2008 were included. Thoracoscore was calculated based on the following variables: age, sex, American Society of Anaesthesiologists' class, performance status classification, dyspnoea score, priority of surgery, procedure class, Diagnosis group and comorbidities score. RESULTS: Two hundred and forty-three patients with a mean age of 63 ± 9 years were included and 81% were male. The predicted postoperative mortality based on Thoracoscore was 8 ± 2.6% (95% confidence interval (CI) 4.56-11.43), while actual in-hospital mortality was 4.5% (11/243) (95% CI 1.87-7.12). 54% (6/11) of in-hospital mortality was of those who were >70 years old and 73% (8/11) of patients who died in hospital were male. Nine of 11 (82%) patients had pneumonectomy for malignancy. Thoracoscore was divided into four risk groups: low (0-3), moderate (3.1-5), high (5.1-8) and very high (>8). It underestimated mortality in low-risk group while overestimated in high-risk groups. The 30-day, 1-year, 2-year and 3-year observed mortalities were 5.3, 29, 43 and 55%, respectively. CONCLUSIONS: Although advanced age, the male sex and malignancy proved to be strong predictors of in-hospital mortality in our study, Thoracoscore failed to predict accurate risk of in-hospital mortality in pneumonectomy patients in this study. Further studies are required to validate the Thoracoscore in different subgroups of thoracic surgery.

Research report: the effects of hyperbaric oxygen preconditioning on myocardial biomarkers of cardioprotection in patients having coronary artery bypass graft surgery.

We have previously conducted and reported on the primary endpoint of a clinical study which demonstrated that hyperbaric oxygen (HBO2) preconditioning consisting of two 30-minute intervals of 100% oxygen at 2.4 atmospheres absolute (ATA) prior to coronary artery bypass graft (CABG) surgery leads to an improvement in left ventricular stroke work (LVSW) 24 hours following CABG. In that study, 81 patients were randomized to treatment with HBO2 (HBO2; n = 41) or routine treatment (Control Group; n = 40) prior to surgery. The objective of this manuscript is to further report on the result of the exploratory secondary endpoints from that study, specifically the effects of HBO2 preconditioning on biomarkers of myocardial protection. Intraoperative right atrial biopsies were assessed, via an Enzyme Linked ImmunoSorbent Assay (ELISA), for the expression of eNOS and HSP72. In this study, no significant differences were observed between the groups with respect to the quantity of myocardial eNOS and HSP72. However, in the HBO2 Group, following ischemia and reperfusion, the quantities of myocardial eNOS and HSP72 were increased. This suggests that HBO2 preconditioning in this group of patients may be capable of inducing endogenous cardioprotection following ischemic reperfusion injury (IRI).

Hyperbaric oxygen preconditioning improves myocardial function, reduces length of intensive care stay, and limits complications post coronary artery bypass graft surgery.

OBJECTIVE: The objective of this study was to determine whether preconditioning coronary artery disease (CAD) patients with HBO(2) prior to first-time elective on-pump cardiopulmonary bypass (CPB) coronary artery bypass graft surgery (CABG) leads to improved myocardial left ventricular stroke work (LVSW) post CABG. The primary end point of this study was to demonstrate that preconditioning CAD patients with HBO(2) prior to on-pump CPB CABG leads to a statistically significant (P<.05) improvement in myocardial LVSW 24 h post CABG. METHODS: This randomised control study consisted of 81 (control group=40; HBO(2) group=41) patients who had CABG using CPB. Only the HBO(2) group received HBO(2) preconditioning for two 30-min intervals separated 5 min apart. HBO(2) treatment consisted of 100% oxygen at 2.4 ATA. Pulmonary artery catheters were used to obtain perioperative hemodynamic measurements. All routine perioperative clinical outcomes were recorded. Venous blood was taken pre HBO(2), post HBO(2) (HBO(2) group only), and during the perioperative period for analysis of troponin T. RESULTS: Prior to CPB, the HBO(2) group had significantly lower pulmonary vascular resistance (P=.03). Post CPB, the HBO(2) group had increased stroke volume (P=.01) and LVSW (P=.005). Following CABG, there was a smaller rise in troponin T in HBO(2) group suggesting that HBO(2) preconditioning prior to CABG leads to less postoperative myocardial injury. Post CABG, patients in the HBO(2) group had an 18% (P=.05) reduction in length of stay in the intensive care unit (ICU). Intraoperatively, the HBO(2) group had a 57% reduction in intraoperative blood loss (P=.02). Postoperatively, the HBO(2) group had a reduction in blood loss (11.6%), blood transfusion (34%), low cardiac output syndrome (10.4%), inotrope use (8%), atrial fibrillation (11%), pulmonary complications (12.7%), and wound infections (7.6%). Patients in the HBO(2) group saved US$116.49 per ICU hour. CONCLUSION: This study met its primary end point and demonstrated that preconditioning CAD patients with HBO(2) prior to on-pump CPB CABG was capable of improving LVSW. Additionally, this study also showed that HBO(2) preconditioning prior to CABG reduced myocardial injury, intraoperative blood loss, ICU length of stay, postoperative complications, and saved on cost, post CABG.

Pharmacological preconditioning with hyperbaric oxygen: can this therapy attenuate myocardial ischemic reperfusion injury and induce myocardial protection via nitric oxide?

Ischemic reperfusion injury (IRI) is an inevitable part cardiac surgery such as coronary artery bypass graft (CABG). While ischemic hypoxia and the ensuing normoxic or hyperoxic reperfusion are critical to the initiation and propagation of IRI, conditioning myocardial cells to an oxidative stress prior to IRI may limit the consequences of this injury. Hyperbaric oxygen (HBO2) is a modality of treatment that is known to generate an oxidative stress. Studies have shown that treatment with HBO2 postischemia and reperfusion is useful in ameliorating myocardial IRI. Moreover, preconditioning the myocardium with HBO2 before reperfusion has demonstrated a myocardial protective effect by limiting the infarct size post ischemia and reperfusion. Current evidence suggests that HBO2 preconditioning may partly attenuate IRI by stimulating the endogenous production of nitric oxide (NO). As NO has the capacity to reduce neutrophil sequestration, adhesion and associated injury, and improve vascular flow, HBO2 preconditioning induced NO may play a role in providing myocardial protection during interventions that involve an inevitable episode of IRI. This current opinion review article attempts to suggest that HBO2 may be used to pharmacologically precondition and protect the myocardium from the effects of IRI that is known to occur during cardiac surgery.

Can hyperbaric oxygen be used as adjunctive heart failure therapy through the induction of endogenous heat shock proteins?

Heart failure (HF) is a chronic condition that is expected to increase in incidence along with increased life expectancy and an aging population. As the incidence of HF increases, the cost to national healthcare budgets is expected to run into the billions. The costs of lost productivity and increased social reliance on state support must also be considered. Recently, acute myocardial infarction (AMI) has come to be seen as the major contributing factor to HF. Although thrombolysis may restore coronary perfusion after an AMI, it may also introduce ischemic reperfusion injury (IRI). In an attempt to ameliorate sustained protein damage caused by IRI, endogenous chaperone proteins known as heat shock proteins (HSPs) are induced as a consequence of the stress of IRI. Recently, hyperbaric oxygen has been shown to induce the production of HSPs in noncardiac tissue, with a resultant protective effect. This current opinion review article suggests a possible role for hyperbaric oxygen, as a technologically modern drug, in augmenting the induction of endogenous HSPs to repair and improve the function of failing hearts that have been damaged by AMI and IRI. In addition, this simple, safe, noninvasive drug may prove useful in easing the economic burden of HF on already overextended health resources.

Hyperbaric oxygen: a novel technology for modulating myocardial schemia-reperfusion via a single drug.

Over the years, the anecdotal medical use of oxygen has demonstrated, in a non-evidence-based manner, that it may have wide-ranging clinical consequences. Although oxygen is a critical substrate in the alleviation of hypoxia, anoxia, and ischemia, paradoxically, it also functions as a deleterious metabolite during the reperfusion of previously ischemic tissues. In adding to this controversy, a spate of new pioneering work has identified hyperoxygenation (hyperoxia) and its metabolites as solely and purposefully demonstrating cellular and clinical benefit,particularly in the field of ischemic reperfusion injury (IRI). Furthermore, the beneficial effects of oxygen have been technologically augmented by administration at doses above atmospheric pressure and at higher concentrations. The novel technology that involves oxygen treatment at supra-atmospheric pressures in high concentrations is known as hyperbaric oxygen (HBO). Although the concept of hyperbaric oxygen has been around since the mid 20th century, it is only during the past decade or so that its therapeutic potential as a new technology-based drug has been exploited for the purposes of cellular tolerance and protection. HBO has recently been shown to be a useful adjunct in several models of IRI, including myocardial infarction. How it does this remains to be elucidated. This article attempts to bring into the spotlight some pertinent developments regarding HBO and myocardial IRI, while simultaneously stimulating intellect, thought, and discussion as to whether this novel technology--HBO--which consists of only a singular drug--oxygen--is a therapy that warrants further laboratory and clinical investigation as a therapeutic modality that may be safe and cost-effective, without producing significant adverse effects.

Hyperbaric oxygen: a new drug in myocardial revascularization and protection?

Ischemia-reperfusion injury (IRI) occurs following coronary artery revascularization. Reactive oxygen species (ROS) were initially thought to play a role in the pathogenesis of this injury. However, the evidence for this is inconclusive. Recent studies involving ischemic preconditioning have identified ROS as potential mediators for the cardioprotective effects observed following this technique. Furthermore, cardiac studies involving IRI and the use of hyperbaric oxygen (HBO) have demonstrated the ability of HBO to induce cardioprotection and to attenuate IRI. This review suggests the possible role for HBO as a new drug in the arena of myocardial revascularization and cellular protection. While there is mounting clinical evidence for this, a methodological understanding of HBO's cellular mechanisms of actions appears to be lacking. As such, this article attempts to draw the similarity between HBO and other protective oxidative stress mechanisms and then to speculate in an evidence-based manner its possible cellular mechanistic role as a drug via the generation of ROS.

Pretreatment with hyperbaric oxygen and its effect on neuropsychometric dysfunction and systemic inflammatory response after cardiopulmonary bypass: a prospective randomized double-blind trial.

OBJECTIVE: Animal studies have shown that pretreatment with hyperbaric oxygen can induce central nervous system ischemic tolerance and also modulate the inflammatory response. We evaluated this therapy in patients undergoing cardiopulmonary bypass. METHODS: Sixty-four patients were prospectively randomized to group A (n = 31; atmospheric air, 1.5 atmospheres absolute) or group B (n = 33; hyperbaric oxygen, 2.4 atmospheres absolute) before on-pump coronary artery bypass grafting. Age, sex, body mass index, diabetes, hypertension, smoking, coronary disease severity, left ventricular function, Parsonnet score, Euroscore, bypass time, myocardial ischemia time, and number of grafts were comparable in both groups. Canadian Cardiovascular Society angina, New York Heart Association dyspnea, and previous myocardial infarction were significantly higher in group B. Inflammatory markers were analyzed before surgery and 2 and 24 hours after bypass. Neuropsychometric testing was performed 48 hours before surgery and 4 months after surgery and included trail making A and B, the Rey auditory verbal learning test, grooved peg board, information processing table A, and digit span forward and backward. Neuropsychometric dysfunction was defined as more than 1 SD deterioration in more than 2 neuropsychometric tests. Chi-square tests, Fisher tests, t tests, and analysis of variance were used as appropriate for statistical analysis. RESULTS: Group A had a significant postoperative increase in the inflammatory markers soluble E-selectin, CD18, and heat shock protein 70. This was not observed in group B. Neuropsychometric dysfunction was also significantly higher in group A compared with group B. There was no difference in any other early postoperative clinical outcome. CONCLUSIONS: Our results seem to indicate that pretreatment with hyperbaric oxygen can reduce neuropsychometric dysfunction and also modulate the inflammatory response after cardiopulmonary bypass. However, further multicenter randomized trials are needed to clinically evaluate this form of therapy.

Surgical nurse assistants in cardiac surgery: a UK trainee's perspective.

OBJECTIVE: To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS: Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS: Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS: Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.

Chronic pain due to talc pleurodesis for spontaneous pneumothorax.

Spontaneous pneumothorax is a common condition that usually affects young adults. Talc insufflation, either as a poudrage or by using slurry, is recognized as an effective treatment. We report a case of talc that resulted in chronic debilitating pain and necessitated further surgery.

Off-Pump Coronary Artery Bypass (OPCAB) surgery reduces risk-stratified morbidity and mortality: a United Kingdom Multi-Center Comparative Analysis of Early Clinical Outcome.

OBJECTIVE: Off-Pump Coronary Artery Bypass (OPCAB) surgery is gaining more popularity worldwide. The aim of this United Kingdom (UK) multi-center study was to assess the early clinical outcome of the OPCAB technique and perform a risk-stratified comparison with the conventional Coronary Artery Bypass Grafting (CABG) using the Cardio-Pulmonary Bypass (CPB) technique. METHODS: Data were collected on 5,163 CPB patients from the database of the National Heart and Lung institute, Imperial College, University of London, and on 2,223 OPCAB patients from eight UK cardiac surgical centers, which run established OPCAB surgery programs. All patients had undergone primary isolated CABG for multi-vessel disease through a midline sternotomy approach, between January 1997 and April 2001. Postoperative morbidity and mortality were compared between the CPB and OPCAB patients after adjusting for case-mix. The mortality of the OPCAB patients was also compared, using risk stratification, to the mortality figures reported by the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) based on 28,018 patients in the national database who were operated on between January 1996 and December 1999. RESULTS: Morbidity and mortality were significantly lower in the OPCAB patients compared with the CPB patients and the UK national database of CABG patients, over the same period of time, after adjusting for case-mix. CONCLUSIONS: This study demonstrates that risk stratified morbidity and mortality are significantly lower in OPCAB patients than CPB patients and patients in the UK national database.

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade-retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation.

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.