N-terminal pro-B-type natriuretic peptide levels and early outcome after cardiac surgery: a prospective cohort study.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a powerful predictor of cardiovascular outcome in many circumstances. There are, however, limited data regarding the utility of NT-proBNP or BNP levels in patients undergoing cardiac surgery. The current study assesses the ability of NT-proBNP to predict early outcome in this setting. METHODS: One thousand and ten patients undergoing non-emergent cardiac surgery were recruited prospectively. Baseline clinical details were obtained and the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet score were calculated. Preoperative NT-proBNP levels were measured using the Roche Elecsys assay. The primary endpoint was 30 day mortality. RESULTS: Median NT-proBNP levels were 624 ng litre(-1) among patients who died within 30 days of surgery (n=29), compared with 279 ng litre(-1) in survivors [odds ratio (OR) 1.03 per 250 ng litre(-1), 95% confidence interval 1.01-1.05, P=0.001). NT-proBNP levels remained predictors of 30 day mortality in models including either the additive EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.01), the logistic EuroSCORE (OR 1.03 per 250 ng litre(-1), P=0.004), or the Parsonnet score (OR 1.02 per 250 ng litre(-1), P=0.04). Levels of NT-proBNP were also predictors of prolonged (>1 day) stay in the intensive care unit (OR 1.03 per 250 ng litre(-1), P<0.001) and of a hospital stay >1 week (OR 1.07 per 250 ng litre(-1), P<0.001). They remained predictive of these outcomes in regression models that included either the EuroSCORE or the Parsonnet score and in a model that included all study variables. CONCLUSIONS: NT-proBNP levels predict early outcome after cardiac surgery. Their prognostic utility is modest-but is independent of traditional indicators and conventional risk prediction scores.

Socio-economic status and early outcome from coronary artery bypass grafting.

OBJECTIVE: To determine the effects of socio-economic status (SES) on the outcome of coronary artery bypass grafting (CABG). DESIGN: Prospective cohort study. SETTING: Regional cardiac surgical unit. PATIENTS: 1994 consecutive patients undergoing non-emergency CABG. MEASURES: SES was determined from the patient's postcode using Carstairs tables. The primary end-point was all-cause mortality at 30 days. RESULTS: There were 50 deaths (2.5%) within 30 days of surgery. A higher Carstairs score demonstrated a trend towards increased 30-day mortality (odds ratio (OR) 1.09 per unit, 95% CI 1.00 to 1.20, p = 0.06). In a backward conditional model, including other predictors of early mortality, Carstairs scores were independently predictive (OR 1.12 per unit, 95% CI 1.01 to 1.24, p = 0.02). In a model including only Carstairs scores and the EuroSCORE, both were independent predictors of this outcome (OR for Carstairs score 1.11 per unit, 95% CI 1.00 to 1.22, p = 0.04). The 30-day mortality increases in each quartile of Carstairs scores, with patients in quartile 4 (most deprived) at significantly higher risk compared with quartile 1 (uncorrected OR 2.53 per unit, 95% CI 1.04 to 6.15; OR corrected for EuroSCORE, 2.56 per unit, 95% CI 1.03 to 6.34, p = 0.04 for both). Similarly, patients in the least affluent quartile were twice as likely to suffer a serious complication as those in the most affluent quartile (OR 2.14 per unit, 95% CI 1.32 to 3.46, p = 0.002). This increased risk was also independent of the EuroSCORE. CONCLUSIONS: Lower SES is associated with a poorer early outcome following CABG and is independent of other recognised risk factors.

Comparison of survival following coronary artery bypass grafting vs. percutaneous coronary intervention in diabetic and non-diabetic patients: retrospective cohort study of 6320 procedures.

AIM: To determine whether mortality following percutaneous coronary intervention vs. coronary bypass grafting varies according to whether or not patients have diabetes. METHODS: We used the Scottish Coronary Revascularization Register to identify all patients undergoing revascularization in Scottish NHS hospitals since 1997. We excluded single-vessel disease, left main stem stenosis, and bypass grafting performed at the same time as other operations. We used death certificate data from the Registrar General to identify all subsequent deaths. RESULTS: Of the 6320 eligible procedures, 5042 (80%) were bypass grafts and 1278 (20%) angioplasties. Overall 831 (13%) patients had diabetes with no significant difference by procedure (13% vs. 12%). A total of 382 deaths occurred over a mean follow-up of 2.3 years. Diabetic patients had a poorer prognosis following both surgery (adjusted hazards ratio (HR) 1.43, 95% confidence interval (CI) 1.08, 1.89) and percutaneous intervention (adjusted HR 2.58, 95% CI 1.43, 4.63). Among non-diabetic patients, no significant differences in mortality were detected between the two procedures. Among diabetic patients, no significant difference was detected in those with two-vessel disease. In those with impaired left ventricular function and triple-vessel disease, angioplasty was associated with a significantly higher risk of death (adjusted HR 3.58, 95% CI 1.40, 9.19). CONCLUSIONS: This is the first study to demonstrate statistically significant results that support the BARI trial findings. Our study demonstrated a significant difference for triple-vessel disease but not two-vessel disease. The former may be due to incomplete revascularization using percutaneous intervention. Our results require corroboration from randomized trials.

The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study.

Chronic pain after surgery is recognised as an important post-operative complication; recent studies have shown up to 30% of patients reporting persistent pain following mastectomy and inguinal hernia repair. No large-scale studies have investigated the epidemiology of chronic pain at two operative sites following coronary artery bypass grafting (CABG). This paper reports the follow-up of a cohort of 1348 patients who underwent cardiac surgery between 1996 and 2000 at one cardiothoracic unit in northeast Scotland. Chronic pain was defined as pain in the location of surgery, different from that suffered pre-operatively, arising post-operatively and persisting beyond 3 months. The survey questionnaire consisted of the short-form-36 (SF-36), Rose angina questionnaire, McGill pain questionnaire and the University of California and San Francisco (UCSF) pain service questionnaire. Of the 1080 responders, 130 reported chronic chest pain, 100 chronic post-saphenectomy pain and 194 reported pain at both surgical sites. The cumulative prevalence of post-cardiac surgery pain was 39.3% (CI(95) 36.4-42.2%) and mean time of 28 months since surgery (SD 15.3 months). Patients who reported pain at both sites had lower quality of life scores across all eight health domains compared to patients with pain at one site only and those who were pain-free. Prevalence of chronic pain decreased with age, from 55% in those aged under 60 years to 34% in patients over 70 years. Patients with pre-operative angina and those who were overweight or obese (BMI>/=25) at the time of surgery were more likely to report chronic pain. Chronic pain following median sternotomy and saphenous vein harvesting is more common than hitherto reported and that patients undergoing CABG should be warned of this possibility.

Metastatic pulmonary ameloblastoma. An unusual case.

We present a patient who had a large metastatic pulmonary ameloblastoma resected 25 years after removal of an apparently benign primary ameloblastoma of the jaw. It highlights three areas: problems with the histopathological diagnosis of pulmonary metastases using fine needle aspiration; a noted radiological improvement after a 5-year course of oral cyclophosphamide, in keeping with occasional patients who have responded to chemotherapy; and the technical difficulties of resection of a large pulmonary metastasis, particularly when it is adherent to the mediastinum.

The role of the intra-aortic balloon pump counterpulsation (IABP) in emergency surgery.

Elective surgical procedures are often delayed for up to six months in patients who have suffered a myocardial infarction (MI) because of the substantial risk of re-infarction and high peri-operative mortality. The optimal management of patients who have sustained a recent myocardial infarction and who require an emergency abdominal operation, however, has yet to be defined. The use of an intraaortic balloon pump (IABP) may play a role in such patients by improving the function of the injured heart. Three cases are presented in which IABP was used in patients who had recently sustained a myocardial infarction and who required emergency abdominal surgery. A review of the literature is presented and the application of IABP in such circumstances is discussed. Although clinical experience is limited, the use of the IABP may be useful in selected patients who have sustained a recent MI and who require emergency surgery.

Outcomes following coronary artery bypass grafting and percutaneous transluminal coronary angioplasty in the stent era: a prospective study of all 9890 consecutive patients operated on in Scotland over a two year period.

OBJECTIVE: To determine current outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). DESIGN: The Scottish coronary revascularisation register provided prospectively collected data on case mix and in-hospital complications for all revascularisation procedures between April 1997 and March 1999 (4775 PTCA; 5115 CABG). Linkage to routine hospital discharge and death data provided follow up information on survival and repeat revascularisation. RESULTS: Stents were used in 51% of PTCA procedures. CABG patients were older, had more severe coronary disease, and had greater comorbidity. PTCA was more likely to be undertaken as an urgent or emergency procedure. Perioperative death and urgent surgery followed 0.3% and 0.6% of PTCA procedures, respectively. Case fatality rates were higher following CABG, with 6.7% dead within two years compared with 3.4% following PTCA. PTCA was more often followed by readmission for ischaemic heart disease, repeat angiography, or revascularisation: 22.8% of patients had repeat revascularisation within two years, compared with 1.8% following CABG. CONCLUSIONS: The severity of coronary heart disease was greater than in previously published registry studies and randomised trials. Despite this, overall survival figures were comparable and repeat revascularisation rates lower, particularly following PTCA. Perioperative death and urgent surgery following PTCA were also lower. These favourable outcomes may be attributable, in part, to increased use of bail out and elective stenting.

Expression of CD44v6 but not E-cadherin or beta-catenin influences prognosis in primary pulmonary adenocarcinoma.

Primary pulmonary adenocarcinoma was studied, looking for relationships between the expression of cell adhesion molecules (CAMs) E-cadherin, beta-catenin and CD44v6, and clinicopathological tumour parameters and patient post-operative survival. Formalin-fixed, paraffin-embedded tissue from 120 primary lung adenocarcinomas, including 23 poorly differentiated tumours, 17 of probable bronchial origin, and 29 with a prominent bronchioloalveolar pattern, together with nodal metastatic tumour from 34 of these patients was stained using monoclonal antibodies and immunohistochemistry. Sections were scored either high level (>10% cells positive) or low level (<10% positive). High level expression of CD44v6 was retained in 28.4% (34/120) of tumours, while high levels of E-cadherin (57.5%, 69/120) and beta-catenin (80. 8%, 97/120) were more frequent. For all CAMs, staining levels did not correlate with nodal status, stage or tumour type. The apical or basal staining seen in normal bronchial and alveolar epithelium was often seen in papillary, glandular, and bronchioloalveolar areas of tumour, while solid invasive tumour more often showed pericellular staining. When the staining for each CAM in 34 nodal metastases was compared with that in the corresponding primary tumour, a high degree of concordance was found, with no tendency for metastases to show less staining than the primary tumour. Expression of E-cadherin and beta-catenin in the primary tumour had no influence on post-operative survival, but patients whose tumours had low level CD44v6 expression had a poorer post-operative survival than those with high levels of CD44v6 (p=0.0014 for all patients, p=0.0012 for stage I patients only). In primary pulmonary adenocarcinoma, the levels of expression of E-cadherin, beta-catenin, and CD44v6 are not associated with lymph node metastases or tumour stage but the staining pattern is associated with tumour morphology. Low levels of CD44v6 expression predict a poor post-operative survival, independently of stage, while there is no such relationship with the expression of E-cadherin or beta-catenin.

Quality of harvested autologous platelets compared with stored donor platelets for use after cardiopulmonary bypass procedures.

Platelet dysfunction has a major contribution in bleeding after cardiopulmonary bypass (CPB) and transfusion of platelets is frequently used to secure haemostasis. Allogeneic platelets prepared for transfusion are functionally impaired. Autologous platelets harvested preoperatively require a shorter storage time before transfusion and their use also avoids the risks associated with transfusion of allogeneic blood products. For the first time, we have compared the functional quality of autologous platelets with allogeneic platelets prepared by two methods, immediately before infusion. Platelet activation was assessed by P-selectin expression and fibrinogen binding using flow cytometry. We also monitored the effects of CPB surgery and re-infusion of autologous platelets on platelet function. Autologous platelet-rich plasma (PRP) contained a significantly lower (P < 0.05) percentage of P-selectin-positive and fibrinogen-positive platelets compared with allogeneic platelet preparations, and also contained a significantly higher (P < 0.05) percentage of responsive platelets. Allogeneic platelets prepared by donor apheresis were more activated and less responsive than those produced by centrifugation of whole blood. In patients' blood, the percentage of platelets expressing P-selectin or binding fibrinogen increased significantly after CPB (P < 0.05), while the percentage of platelets responsive to in vitro agonists was decreased (P < 0.05 in autologous transfusion patients), consistent with platelet activation during the procedure. The percentage of activated platelets decreased (statistically not significant) after re-infusion of autologous PRP. P-selectin expression had returned to pre-CPB levels 24 h post-operatively. Autologous platelet preparations display minimal activation, but remain responsive. Conservation of platelet function may contribute to the potential clinical benefits of autologous transfusion in cardiopulmonary bypass.

Preoperative histological classification of primary lung cancer: accuracy of diagnosis and use of the non-small cell category.

AIMS: To compare the preoperative classification of lung carcinoma made on cytological and histological specimens with the postoperative classification made on the resected specimen. In addition, to find out how often the term "non-small cell lung cancer, not otherwise specified" (NSCLC) was used, and in such cases to note the final diagnosis. METHODS: Between 1991 and 1995, 303 patients had a lung resection in Aberdeen for primary carcinoma. For each patient, the departmental records were examined for preoperative specimens (cytological and histological). A note was made of whether each specimen was positive or negative for malignancy and, if positive, what the cell type was. Where patients had more than one sample submitted, the most specific result was taken. RESULTS: Fifty four per cent of patients had a correct specific preoperative diagnosis of malignancy, whereas 34% were labelled as NSCLC. Patients with squamous carcinoma were more likely to have a diagnosis of malignancy (88%) that was specifically correct (75%). Patients who had adenocarcinoma were less likely to have a preoperative diagnosis of malignancy (64%) that was specifically correct (35%). For those in whom a diagnosis of NSCLC was made, 55% turned out to have adenocarcinoma whereas 24% had squamous carcinoma. CONCLUSIONS: By adhering strictly to criteria, a high accuracy of diagnosis can be achieved for squamous carcinoma, but the diagnosis of adenocarcinoma seems to be more of a challenge. NSCLC is a useful and appropriate classification, the use of which reduces the rate of inaccurate specific diagnosis. There are occasions when pathologists can provide a more accurate diagnosis by being less precise.

Immune cell infiltrates and prognosis in primary carcinoma of the lung.

The prognostic significance of immune cell infiltrates in surgically resected human lung cancer was investigated in 710 patients. Lymphoid infiltrates were quantified on both standard H&E stained sections and, in a subset of 95 cases, using immunohistochemistry and antibodies to CD3, CD8, CD57, CD68, CD79a and S100 to identify various immune cell types. Subjective grading (low, moderate, high) of lymphoid cell infiltrates on H&E sections of tumour and measurement, using image analysis, of overall level of tumour infiltration by any of the immunohistochemically labelled specific immune cell types of the stained sections showed no prognostic significance. However, when a distinction between peritumoural and intratumoural infiltration by particular cell types was made, intratumoural infiltration by high levels of CD3+ and S100+ cells was associated with longer post-operative survival (P = 0.02 and P = 0.045, respectively). In lung cancer, subjective assessment of tumour lymphoid infiltration and overall levels of infiltration by particular immune cell types carries no prognostic significance. Intratumoural infiltration by relatively high numbers of CD3+ T-lymphocytes and Langerhans cells (S100+) is associated with a better patient outcome.

The Ultracor tilting disc heart valve prosthesis: a seven-year study.

BACKGROUND AND AIM OF THE STUDY: The Ultracor heart valve is a recent entry in the evolution of the tilting disc valve. This report summarizes the experience with the Ultracor valve from three European centers. METHODS: Between 1990 and 1996, 446 patients received 499 Ultracor heart valve prostheses in 450 procedures, including 225 (50.0%) aortic, 172 (38.2%) mitral and 49 (10.9%) double valve replacements. An additional four (1.0%) patients had mitral valve replacement (MVR) added to a previous aortic valve replacement (AVR) and were considered double valve replacement (DVR) patients. The total follow up was 751 patient-years (pt-yr) for AVR (mean 3.4), 440 pt-yr for MVR (mean 2.6) and 125 pt-yr for DVR (mean 2.4). Nine patients (one AVR, eight MVR) were lost to follow up, which was 98% complete. RESULTS: The actuarial survival rate, including operative mortality rate, at five years was 90% for AVR, 77% for MVR and 82% for DVR. The linearized complication rates (%/year) for AVR, MVR and DVR were: 2.1, 4.0 and 4.0 for late mortality; 0.1, 3.0 and 0.8 for thromboembolism; 0, 0.2 and 0 for thrombosis; 2.0, 1.6 and 1.6 for anticoagulant-related hemorrhage (ACH); 0.3, 0.5 and 1.6 for prosthetic valve endocarditis (PVE); and 0.5, 0.9 and 3.2 for reoperation, respectively. The actuarial rates of freedom from complications at five years were: thromboembolism, 99% for AVR and 88% for MVR; thrombosis, 100% for AVR and 99% for MVR; ACH, 91% for AVR and 94% for MVR; PVE, 99% for AVR and 97% for MVR; reoperation, 98% for AVR and 98% for MVR. No structural failure was observed. CONCLUSIONS: Seven years' experience showed the Ultracor heart valve prosthesis to be comparable with other currently used mechanical heart valves. Continued evaluation of this prosthesis is warranted in order to obtain a more extended clinical follow up.

p53, c-erbB-2 and nm23 expression have no prognostic significance in primary pulmonary adenocarcinoma.

OBJECTIVE: We analysed nm23, c-erbB-2 and p53 protein expression in lung adenocarcinoma in relation to clinicopathological status and patient survival, to elucidate any potential prognostic value. Published reports suggest that high p53 and c-erbB-2 protein expression and loss of nm23 protein expression are associated with poor prognosis. METHODS: A total of 162 pulmonary adenocarcinomas resected between 1980 and 1991 were stained using monoclonal antibodies to nm23 (NCL-nm23), c-erbB-2 (NCL-CB11) and p53 (DAKO Do7). Antigen retrieval was by microwave heating and bound antibody was visualised using standard immunohistochemical methods. Staining was scored by two observers blinded to tumour status and patient survival. RESULTS: Of the tumours, 101/162 (62.3%) exhibited high-level p53 expression, 30 (18.5%) showed high-level c-erbB-2 membrane staining, and 77 (47.5%) demonstrated loss of nm23 positivity. The influence of T and N status and disease stage on postoperative survival was as expected. The predicted effect on patient survival of nm23, c-erbB-2 or nm23 protein expression suggested by previous studies was not verified by our work. This was true both overall and for groups within the same T or N status or stage. CONCLUSION: Immunohistochemical assessment of the nm23, c-erbB-2 and p53 proteins using the above monoclonal antibodies does not have value as an independent prognostic indicator in pulmonary adenocarcinoma.

Intralobar bronchopulmonary sequestration: antenatal diagnosis.

A child with the antenatal diagnosis of pulmonary cystic adenomatoid malformation underwent thoracotomy and an intralobar bronchopulmonary sequestration was found. Histological examination of the resected specimen showed cystic adenomatoid malformation within the sequestered segment.

An adjunct to cerebral protection during circulatory arrest.

For surgery of dissecting ascending aortic aneurysms we have employed deep hypothermic circulatory arrest to permit construction of the distal aortic anastomosis in a bloodless field. The cerebral complications of circulatory arrest in deep hypothermia are well recognised. Many methods of cerebral protection have been suggested besides deep hypothermia including retrograde cerebral perfusion, administration of thiopentone and cerebroplegia. We report a supplementary technique that theoretically may provide improved cerebral protection, and present the results in four cases.

Pancoast syndrome: an unusual complication of pulmonary infection by Staphylococcus aureus.

Pancoast syndrome, which comprises a lower brachial plexus lesion and Horner's syndrome, usually results from local invasion beyond the confines of the lung by an apical lung carcinoma. Other causes are rare. We report the unusual occurrence of a case of Pancoast syndrome caused by a destructive sclerosing fibrosis after pulmonary Staphylococcus aureus infection.