Atrial fibrillation in elderly patients after coronary artery bypass grafting; gender differences in outcome.

OBJECTIVES: To evaluate gender-related differences in preoperative risk factors, hospital events, especially atrial fibrillation (AF), and length of stay in elderly patients undergoing isolated coronary artery bypass grafting (CABG). DESIGN: Prospectively collected data from consecutive patients undergoing isolated CABG in Tampere University Hospital between May 1999 and November 2000, in total 1131 patients. RESULT: We analysed 621 patients 65 years and older of whom 401 (65%) were male. When evaluating gender differences we found that the women were older (73 vs. 71 yrs, p<0.001) and significantly more often had hypertension (66% vs. 49%, p<0.001) and chronic heart insufficiency (11% vs. 4%, p=0.001). The NYHA classification of the women was worse (3.4 vs. 3.1, p<0.001) and in the angiographic data they had left main stenosis more often (31% vs. 21%, p=0.005) than the men. The women needed longer hospitalisation (19 vs. 15 days, p<0.001). There was no difference in the prevalence of postoperative AF between the genders, but in spite of that women had more postoperative strokes (6% vs. 3%, p=0.028) and also other major complications (29% vs. 19%, p=0.004) than the men. The 30-day mortality was higher in the female group (8% vs. 5%, p=0.06). We analysed preoperative risk factors and found that the females had a 1.6-fold risk for postoperative major complication after adjustment for age and other risk factors. In a logistic regression analysis age and the number of anastomoses emerged as independent predictors of AF in males, but in females we could not find any predictor for postoperative AF. CONCLUSIONS: The women are older and have more comorbidities and risk factors at the time of CABG. They also have more postoperative complications, but not a significantly higher mortality. Importantly, the excess of morbidity remains after adjustment for age and underlying risk factors. There is no gender difference in the incidence of postoperative AF in the elderly population. However, it seems to occur independent of age in the women only.

Bowel preparation for colonoscopy in very old patients: a randomized prospective trial comparing oral sodium phosphate and polyethylene glycol electrolyte lavage solution.

BACKGROUND: Colonoscopic preparations are defectively tolerated among many very old patients and the quality of preparation is often inadequate. METHODS: Seventy-two patients aged 80 years or more were randomized to receive either NaP (37) or PEG (35) preparation. Patients' and endoscopists' opinions of the preparation and colonoscopy were ascertained, the adverse effects were recorded, clinical indicators of dehydration such as tongue dryness, upper body muscle weakness and confusion were assessed and laboratory tests were taken before and after the preparation. RESULTS: Patients' evaluations showed no significant difference regarding the tolerance of preparations. Only the frequency of nausea was higher in the NaP group (16%/9%, P = 0.01). Assessment of the indicators of dehydration showed a difference only in tongue dryness in the NaP group (P = 0.02). The quality of preparation was evaluated by endoscopists as good or excellent in 81% of cases in the NaP group and in 77% of cases in the PEG group. The median values of potassium decreased from 4.0 mmol/L to 3.7 mmol/L (P < 0.05) and of sodium increased from 142 mmol/L to 145 mmol/L (P < 0.05) after NaP preparation. CONCLUSION: Sodium phosphate and PEG preparations are almost equally tolerated and effective in very old inpatients. NaP preparations cause more changes in the levels of potassium and sodium. For those elderly patients who are vulnerable to complications caused by electrolyte disturbances we recommend PEG preparation.

Ischemic preconditioning protects right ventricular function in coronary artery bypass grafting patients experiencing angina within 48-72 hours.

BACKGROUND: To test whether ischemic preconditioning (IP) is able to protect the myocardium in recently unstable CABG patients. EXPERIMENTAL DESIGN: prospective, randomised, controlled clinical study. SETTING: University Hospital. PATIENTS: Forty CABG patients with recent unstable angina were randomised into an IP group (n=20) and a control group (n=20). Subgroup was divided based on the time of the most recent ischemia onset before the operation. INTERVENTION: The IP group was preconditioned with 2 cycles of 2-min ischemia followed by 3-min reperfusion before cross clamping. MEASURES: Hemodynamic data were monitored till the 1st POD. Biochemical markers were measured till the 2nd POD. RESULTS: There were no differences in cardiac index (Cl) and right ventricular ejection fraction (RVEF) in patients experiencing angina within 48 hours prior to operation. The percentage changes in CI and RVEF at 1 hour after declamping were significantly better in the IP group in patients experienced angina within 48-72 hours (106% vs 88% of baseline, p=0.027 and 103% vs 81% of baseline, p=0.023). No difference in postoperative cardiac troponin I (CTnI) and CK-MB was found between the IP and controls in either subgroup. CONCLUSIONS: IP has a beneficial effect on global and right ventricular hemodynamic functional recovery in unstable CABG patients experiencing angina within 48-72 hours prior to the operation. However, IP has no additional protective effects in unstable CABG patients who experience angina within 48 hours.

The protective effects of preconditioning decline in aged patients undergoing coronary artery bypass grafting.

OBJECTIVE: We sought to investigate the effects of myocardial ischemic preconditioning in adult and aged patients undergoing coronary artery bypass grafting. METHODS: Eighty patients with 3-vessel disease undergoing coronary artery bypass grafting were randomized into one of the following groups: adult ischemic preconditioning, adult control, aged ischemic preconditioning, and aged control. Hemodynamic data and cardiac troponin I values were compared between the groups. The ischemic preconditioning groups received 2 periods of 2 minutes of ischemia, followed by 3 minutes of reperfusion. The Student t test, chi(2) test, and analysis of variance for repeated measures were used for the statistical analysis. RESULTS: The baseline for right ventricular ejection fraction and cardiac index was similar. Right ventricular ejection fraction was depressed after the operation in all groups. Ischemic preconditioning significantly improved the recovery of right ventricular ejection fraction and cardiac index after the operation in adult patients (P =.013 and.001, respectively), but in the aged group there was no difference in the changes of ejection fraction and cardiac index (P =.232 and.889, respectively). The cardiac troponin I value in the adult patients subjected to ischemic preconditioning was lower than that in the adult control subjects (P =.046), but in aged patients undergoing ischemic preconditioning, the value was similar to that in aged control subjects (P =.897). Ischemic preconditioning also resulted in a shorter postoperative mechanical ventilation time and in less inotropic use in the adult group. CONCLUSION: Ischemic preconditioning protects the heart from ischemic reperfusion injury in adult patients undergoing coronary artery bypass grafting. The beneficial effects of ischemic preconditioning are manifested as a better recovery of right ventricular and global hemodynamic function, cellular viability, and surgical outcome. The protective effect of ischemic preconditioning is diminished in aged patients undergoing coronary bypass.

Inflammatory cytokines and soluble receptors after coronary artery bypass grafting.

Much interest has been focused on the overexpression of proinflammatory cytokines, but studies on their soluble receptors are rare. For a comprehensive picture of cytokine activation in cardiac surgery, a combination of cytokines and the corresponding soluble receptor concentration should be determined. Blood samples were collected from the radial artery and coronary sinus perioperatively in ten patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. TNF-alpha, IL-6, sTNFRI, sTNFRII, and sIL-6R levels in the plasma were determined. Systemic TNFRI, TNFRII and IL-6 increased significantly after reperfusion to the myocardium, while perioperative systemic sIL-6r levels were similar. Arterial and sinus levels of TNFRI, TNFRII and sIL-6r were similar before cardiopulmonary bypass. Five minutes after reperfusion to the myocardium, higher sinus TNFRI and TNFRII and lower sinus sIL-6R levels were observed as compared to the arterial levels. The myocardium release of sTNFRI (r=0.57, P=0.089) and sTNFRII (r=0.64, P=0.047) positively correlated with the change of cardiac index after cardiopulmonary bypass. Myocardium releases sTNFRI and sTNFRII after ischaemic-reperfusion injury, and this may be of benefit to cardiac performance. sIL-6R is constantly being produced in areas other than the myocardium, while sIL-6R levels are reduced by consumption in the myocardium after ischaemic-reperfusion injury.

Myocardial lactate production is not involved in the ischemic preconditioning mechanism in coronary artery bypass graft surgery patients.

OBJECTIVE: To study the relationship between ischemic preconditioning (IP) and lactate production and their impact on coronary artery bypass graft surgery patients. DESIGN: Prospective, randomized, controlled study. SETTING: University hospital. PARTICIPANTS: Eighty 3-vessel disease coronary artery bypass graft surgery patients with stable and unstable angina pectoris. INTERVENTIONS: The IP patients were preconditioned with 2 periods of 2-minute ischemia followed by 3-minute reperfusion before aortic cross-clamping. MEASUREMENTS AND MAIN RESULTS: The cardiac index (CI) after surgery was significantly higher in the IP group than in controls among stable patients (p = 0.013). IP was not effective in CI recovery in unstable patients. The baseline values of lactate production were 11.6%, 20.3%, -7.0%, and -2.9% in stable IP, stable control, unstable IP, and unstable control patients. Compared with baseline, lactate production increased significantly after the IP protocol (39.0% and 47.5% in the stable and unstable patients), and operation (47.5%, 31.7%, 35.4%, and 35.6% in stable IP, stable control, unstable IP, and unstable control patients) but not after 10 minutes of cardiopulmonary bypass (29.7% and 19.0% in the stable and unstable patients). There were no differences among the groups in lactate production after the operation. Lactate production after the IP protocol was negatively associated with CI recovery after surgery in the IP patients (p = 0.026). CONCLUSION: The IP effects do not include modulation of lactate production. IP induces lactate production, but it seems not to be involved in the triggering process.

Anti-inflammatory effects of 17beta-estradiol pretreatment in men after coronary artery surgery.

OBJECTIVE: To investigate the anti-inflammatory and hemodynamic effects of 17beta-estradiol in men undergoing elective coronary artery bypass graft surgery (CABG). DESIGN: Prospective, randomized, controlled. SETTING: Operating room and intensive care unit in a university hospital. PARTICIPANTS: Twenty-one men undergoing primary, elective CABG surgery. INTERVENTION: 17beta-estradiol, 2mg, was given orally twice in 14 hours before the operation. MEASUREMENTS AND MAIN RESULTS: Leukocyte counts, plasma myeloperoxidase, tumor necrosis factor-alpha, interleukin (IL)-6, IL-8, and IL-10 were measured perioperatively. Leukocyte counts were lower in the 17beta-estradiol group than in controls at 6 hours (11.4 +/- 2.0 hours v 15.5 +/- 4.7 hours x 10(9)/L) and 20 hours (11.6 +/- 1.9 hours v 13.6 +/- 2.5 hours x 10(9)/L) after reperfusion (p = 0.03). The release of myeloperoxidase was lower in the 17beta-estradiol group than in controls (5 minutes; 634.4 +/- 213.1 microg/mL v 773.1 +/- 209.3 microg/mL; 4 hours, 305.0 +/- 108.0 microg/mL v 441.3 +/- 191.6 microg/mL; p = 0.02). Systemic vascular resistance index was lower just after cardiopulmonary bypass, and cardiac index was higher postoperatively in the 17beta-estradiol group as compared with controls. CONCLUSION: Pretreatment with 17beta-estradiol can limit leukocyte activation in men after CABG surgery.

Cytokine responses in patients undergoing coronary artery bypass surgery after ischemic preconditioning.

OBJECTIVE: The release of proinflammatory cytokines has been shown to be associated with the development of complications after coronary artery bypass grafting with cardiopulmonary bypass. The purpose of the present study was to establish whether ischemic preconditioning (IP) could limit inflammatory cytokines release in patients undergoing elective coronary artery bypass surgery. METHODS: Twenty-two patients with multiple-vessel coronary artery disease and stable angina admitted for first-time elective coronary artery bypass surgery were randomized into control or ischemic preconditioning groups. Patients in the IP group were exposed to two cycles of two-minute myocardial ischemia, followed by three minutes of reperfusion, at the beginning of the revascularization operation, before the cross-clamping and ischemic period used for coronary artery bypass graft anastomosis. Peripheral plasma levels of TNF-alpha, IL-6, IL-8 and IL-10 were measured perioperatively. RESULTS: Significant elevation of IL-6, IL-8 and IL-10 were observed in both groups after reperfusion. Ischemic preconditioning has no effect on cytokine release in the early stage after reperfusion. Arterial blood IL-6 levels in the preconditioning group were significantly lower than in controls at 20 h after declamping (52.93 +/- 9.79 vs 96.04 +/- 17.56 pg/ml, p < 0.05). CONCLUSIONS: The results indicate that ischemic preconditioning results in no effect on systemic inflammatory cytokine release in the early stage but a delayed reduction in IL-6 levels at 20 h after reperfusion.

Effect of ischaemic preconditioning, cardiopulmonary bypass and myocardial ischaemic/reperfusion on free radical generation in CABG patients.

OBJECTIVE: To investigate the free radicals (FR) generation after ischaemic preconditioning and cardiopulmonary bypass and during reperfusion in CABG patients, and the role of ischaemic preconditioning. METHODS: Forty-three CABG patients were randomised into an ischaemic preconditioning and a control group. The protocol for ischaemic preconditioning was two cycles of 2-min ischaemia followed by 3-min reperfusion. Free radicals were measured using electron spin resonance spectroscopy. Global and right heart functions were collected. RESULTS: The free radicals generation in coronary sinus blood in the ischaemic preconditioning group was 9.7 and 16.6% after the ischaemic preconditioning protocol and 10 min after declamping, 6.8 and 13.3% in the controls. The free radicals in arterial samples were, respectively, 21, 14, 10 and 9% at 10 min, 1, 2 and 24 h after reperfusion. Cardiac index (CI) and right ventricular ejection fraction (RVEF) were improved by ischaemic preconditioning. CONCLUSION: Both ischaemic preconditioning and cardiopulmonary bypass induced free radicals generation. Although ischaemic preconditioning had no effect on free radicals generation after the operation, it protected against postoperative stunning.

Pump prime aprotinin fails to limit proinflammatory cytokine release after coronary artery bypass surgery.

BACKGROUND: The purpose of this study was to establish whether pump prime aprotinin could limit the cytokine responses in patients undergoing elective coronary artery bypass surgery. METHODS: Twenty-one patients admitted for first-time elective coronary artery bypass surgery were randomized into control or aprotinin groups. Patients in the aprotinin group received 280 mg aprotinin in the pump prime. Leukocyte count, creatine kinase cardiac isoenzyme (CK-MB), cytokine production and postoperative blood loss were analyzed perioperatively and compared with preoperative values. RESULTS: The peak level of leukocyte count was lower in the aprotinin group than in controls (9.3 +/- 0.58 vs 11.2 +/- 0.68 x 10(9)/L, p = 0.01). Interleukin (IL)-6 and IL-8 did not differ significantly between the groups throughout the study period. Plasma IL-10 levels were higher in the controls than in the aprotinin group at 5 min (49.6 +/- 24.9 vs 8.13 +/- 2.8 pg/ml, p = 0.01) after reperfusion. CONCLUSION: Pump prime aprotinin fails to limit proinflammatory cytokine response in circulating blood.

Effect of ischemic preconditioning on myocardial protection in coronary artery bypass graft patients : can the free radicals act as a trigger for ischemic preconditioning?

OBJECTIVE: To investigate the interrelationship of free radicals (FRs), ischemic preconditioning (IP), and hemodynamic function in coronary artery bypass graft (CABG) patients. DESIGN: Prospective, randomized, and controlled clinical study. PATIENTS: Forty CABG patients were randomized into an IP group (n = 20) and a control group (n = 20). INTERVENTION: The IP group was preconditioned with two cycles of two-min ischemia followed by 3-min reperfusion before cross-clamping. MEASUREMENT AND RESULTS: FR content in coronary sinus blood was measured directly using alpha-phenyl-N-tert-butylnitrone-electron spin-trapped spectroscopy. A small amount of FRs was generated after the IP protocol (5.6% above the baseline) but not in control subjects. A larger amount was generated 10 min after declamping in both groups (8.4% in IP protocol and 7.7% in control subjects). Hemodynamic function recovered better in the IP group at 1 h and 6 h after declamping. There was a significant negative correlation between FR generation after declamping and left ventricular stroke work index (LVSWI) at 1 h and 6 h after declamping (r = -0.71 and - 0.59, respectively) in the control subjects but not in the IP group. There was a significant positive correlation between FR generation after the IP protocol and cardiac index at 1 h and 6 h (r = 0.50 and 0.61, respectively) and LVSWI at 1 h and 6 h (r = 0.56 and 0.54, respectively) after declamping in the IP group but not in the control subjects. CONCLUSION: FR generation after the operation correlates with ventricular functional depression in CABG patients. IP protects the stunning heart but does not alter FR generation. The association of better hemodynamic recovery after CABG with FR generation during the IP period suggests that FRs might act as one of the triggers for IP.

Radial artery graft inflow from the undetached, unharvested RIMA: a method to avoid proximal anastomosis to the aorta in CABG surgery.

Performing the proximal anastomosis of a free arterial graft to the ascending aorta is problematic, especially if the wall of the aorta is calcified or thickened. We describe a method, which makes it possible to avoid this procedure.

Beneficial effects of ischemic preconditioning on right ventricular function after coronary artery bypass grafting.

BACKGROUND: Preservation of right ventricular myocardium is unsatisfactory in patients with critical stenosis or occlusion of the right coronary artery. The aim of this study was to investigate whether ischemic preconditioning (IP) improved the recovery of right ventricular function after coronary artery bypass grafting. METHODS: Forty patients with three-vessel disease who had coronary artery bypass grafting were randomly assigned to the IP group (n = 20) or control group (n = 20). In the IP group, two cycles of two minutes of ischemia after three minutes of reperfusion were given before cross-clamping. Hemodynamic data were collected. Right ventricular ejection fraction was measured by thermodilution. RESULTS: Right ventricular ejection fraction and right ventricular systolic volume index were decreased post-operatively (lowest value at 6 hours postoperatively). The changes in right ventricular ejection fraction were significantly milder in the IP group postoperatively (p = 0.012). The decrease in right ventricular systolic volume index postoperatively was also less in IP patients (p = 0.002). Fewer inotropic drugs were used in the IP group compared with controls. CONCLUSIONS: Ischemic preconditioning had a myocardial protective effect on recovery of right ventricular contractility in patients who had coronary artery bypass grafting.

Ischaemic preconditioning has a beneficial effect on left ventricular haemodynamic function after a coronary artery biopass grafting operation.

OBJECTIVE: Ischaemic preconditioning (IP) is the most effective procedure for endogenous myocardial protection. However, studies on the effects of IP in cardiac surgery are rare and controversial. The present aim was to investigate whether IP improves the haemodynamic recovery of CABG patients. DESIGN: The study included 40 stable CABG patients with 3-vessel disease, randomized into an IP group (n = 20) and a control group (n = 20). In the IP group two cycles of 2-min ischaemia following 3-min reperfusion before cross-clamping were induced. The haemodynamics of the patients were followed-up to the first postoperative morning. RESULTS: The cardiac index decreased at 1 and 6 h after surgery in the control group but increased in the IP group (-0.33 vs 0.09 l/min/m2, p = 0.02 and -0.15 vs 0.57 l/min/m2, p = 0.001, respectively). Depressions in the left ventricular stroke work index and the right ventricular stroke work index at 6 h after surgery were more severe in controls and were statistically significant (p = 0.049 and 0.007, respectively). Less inotropic support was used in the IP group. There were no differences in serum CK-MB, cardiac troponin I, myoglobin or lactate values between the two groups. CONCLUSION: IP has a beneficial effect on left ventricular haemodynamic recovery after a CABG operation.

Release of brain-specific creatine kinase and neuron-specific enolase into cerebrospinal fluid after hypothermic and normothermic cardiopulmonary bypass in coronary artery surgery.

BACKGROUND: Coronary artery bypass (CABG) surgery is successfully managed with normothermic cardiopulmonary bypass (CPB) using warm blood cardioplegia. The lack of the protective effect of hypothermia, however, might make the central nervous system vulnerable. METHODS: Thirty-six patients were randomized into normothermic CPB (36-37 degrees C) (NTCPB group, n=18) and hypothermic CPB (28 degrees C) (HTCPB group, n=18) in order to examine whether normothermic or hypothermic CPB induces the release of the intracellular brain enzymes, creatine kinase (CK), its brain-specific isoenzyme (CK-BB), and neuron-specific enolase (NSE) into cerebrospinal fluid (CSF). In addition, clinical neurologic examination and neuropsychologic assessment were done preoperatively, 5 d and 11-23 mo postoperatively. RESULTS: One patient in each group suffered a stroke after surgery. Two patients in the normothermic group had minor neurologic complications. The cognitive decline after operation was similar in the NTCPB and HTCPB groups. CSF enzymes from normothermic and hypothermic CABG patients without gross neurologic complications were not significantly higher than CSF enzymes from orthopaedic reference patients. CABG patients with neurologic complications had higher enzyme concentrations. Cognitive decline after the operation correlated statistically significantly with CSF enzyme concentrations in the NTCPB group, but not in the HTCPB group. CONCLUSION: CABG operation without major neurologic complication does not induce the release of CK, CK-BB or NSE enzymes into CSF, irrespective of whether the CPB is normothermic or hypothermic.

Protective effect of unstable angina in coronary artery bypass surgery.

OBJECTIVE: To test the hypothesis that recent ischaemic episodes in unstable cases have a protective effect on coronary artery bypass graft (CABG) patients. MATERIALS AND METHODS: Twenty unstable patients with ischaemic episodes within 3 days before operation were compared with 20 stable patients. Haemodynamic data were monitored up to the first postoperative day. Biochemical markers were measured up to the second postoperative day. RESULTS: The cardiac index decreased at 1 and 6 h after declamping in the stable group (89% and 97% of baseline) but increased in unstable patients (104% and 122%, p =0.038 and 0.036, respectively). The depression in the right ventricular stroke work index was significantly attenuated in the unstable group (58%, 67% and 83% in stable and 90%, 97% and 117% in unstable patients, p = 0.027, 0.010 and 0.049 at 1 and 6 h after declamping and 1st POD). The release of cardiac troponin I (CTnI) and CK-MB was significantly lower in the unstable group at 6 h after declamping (5.6 +/- 2.9 and 19.0 +/- 6.3 microg/l in unstable vs 17.4 +/- 9.6 and 25.8 +/- 12.3 microg/l in stable patients, p = 0.000 and 0.039, respectively). CONCLUSION: Recent unstable angina before CABG might act as an ischaemic preconditioning stimulus and could improve haemodynamic function and cellular viability. Delayed preconditioning most likely causes this protective effect.

Dopexamine unloads the impaired right ventricle better than iloprost, a prostacyclin analog, after coronary artery surgery.

OBJECTIVE: To evaluate the ventricle-unloading properties of dopexamine and iloprost and to compare their effects on right ventricular (RV) function and oxygen transport in patients with low RV ejection fraction (RVEF) after cardiac surgery. DESIGN: A prospective, randomized, double-blind, cross-over, clinical study. SETTING: University hospital. PARTICIPANTS: Twenty patients with proximal total stenosis of the right coronary artery studied immediately after coronary artery surgery. INTERVENTIONS: Treatment drugs were administered in a random order in doses equipotent with respect to cardiac output response. Infusion rates were increased stepwise to induce a 25% increase in cardiac index. A washout period of 60 minutes was allowed between treatments. MEASUREMENTS AND MAIN RESULTS: Central hemodynamics, RV function assessed by the EF (fast-response thermodilution), end-systolic and end-diastolic volumes, and systemic oxygenation were measured before and after the first drug, after the washout period, and after the second drug. Central filling pressures remained constant during treatments. Both drugs decreased pulmonary vascular resistance index, but iloprost was more effective (p < 0.05). Iloprost decreased mean arterial and pulmonary artery pressure, which were unaffected by dopexamine. Dopexamine increased EF significantly more than iloprost (p < 0.001). End-systolic volume index decreased subsequent to dopexamine only (p < 0.001). Iloprost increased intrapulmonary shunt more than dopexamine (p < 0.001). Changes in oxygen delivery, consumption, and extraction were similar. CONCLUSION: The findings suggest that dopexamine is more effective than iloprost for support and unloading of the postoperatively disturbed RV in terms of RVEF and end-systolic volume. The reduction of pulmonary vascular resistance after administration of iloprost without a decrease in end-systolic volume might not be considered a reduction of RV afterload. Iloprost increases the pulmonary shunt fraction, however, more than dopexamine, indicating a more prominent vasodilator effect.

Stenosis of the right coronary artery and retrograde cardioplegia predispose patients to atrial fibrillation after coronary artery bypass grafting.

It is assumed that stenosis of the right coronary artery (RCA) predisposes CABG patients, by way of incomplete atrial myocardial protection, to postoperative atrial fibrillation (AF). Sixty patients with high-grade RCA lesion were randomized into four groups according to the technique of delivery of cold blood cardioplegia: antegrade, retrograde, retrograde without catheter cuff, and combined antegrade and retrograde. As controls, 34 patients without RCA lesion were randomized to receive antegrade or retrograde cardioplegia. Postoperative atrial fibrillation episodes were recorded. Patients with RCA lesion were more prone to develop AF; odds ratio (OR)=3.75 (95% confidence interval [CI]=1.22-11.5). Retrograde delivery in these patients was more often associated with AF, OR=4.97 (95% CI = 1.02-24.1). Other risk factors for AF were an increasing number of preoperative infarcts (p < 0.05) and more advanced coronary artery disease (p < 0.05). Prolonged stay in the intensive care unit (p < 0.001) and occurrence of postoperative ventricular tachycardia (p < 0.05) were associated with AF. RCA stenosis and retrograde cardioplegia delivery in RCA-affected patients were risk factors for postoperative atrial fibrillation. Retrograde cardioplegia may offer poorer protection at the atrial level.

High incidence and prevalence of adult coeliac disease. Augmented diagnostic approach.

BACKGROUND: The diagnosis of coeliac disease is easily overlooked as patients can present with mild or atypical symptoms, or the condition can even be clinically silent. Our aim was to detect coeliac disease patients with such atypical or no symptoms as well as those with typical features. METHODS: The incidence of adult coeliac disease in Tampere was calculated from 1975 to 1994 and the prevalence as of 31 December 1994. Open-access endoscopy was available for general practitioners, and small-bowel biopsy was done routinely. Serologic screening was applied to patients with an increased risk of coeliac disease. RESULTS: The incidence of coeliac disease increased tenfold, and the prevalence was 270 per 100,000 inhabitants in 1994. Twenty per cent were found by serologic screening and 10% as a result of routine biopsy; 24% had dermatitis herpetiformis. CONCLUSIONS: Our diagnostic approach gave a coeliac prevalence similar to that found in population screening studies. One-third had silent coeliac disease.