Determinants of mortality after cardiac surgery: results of the registry of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) on 10 525 patients.

BACKGROUND: Mortality from cardiac surgery is an essential indicator of quality and forms the basis of treatment strategy decisions in eligible patients. No contemporary complete data on unselected adult cardiac surgery patients are available in Germany. METHODS AND RESULTS: A registry was started in June 1997 of all patients referred to surgery from 85 cardiology centres in Germany. The registry was intended to include 10 000 patients and this number was reached in March 1998. Follow-up of the patients was by simple questionnaire, reporting the date of surgery, major complications, and symptomatic improvement. If the questionnaire was not returned, a reminder letter was sent and, if necessary, further telephone investigations were performed. This resulted in 99.9% complete data. Of 10 525 patients operated on, 3.91% had died by 30 days after surgery. The overall operative mortality was 4.57%, which included 69 patients who died after more than 30 days from complications related to surgery. By multivariate analysis, the following predictors of mortality were identified: previous surgery, emergency or complex operation; age >75 years, female gender, cardiac failure, angina CCS class IV, and three-vessel coronary disease. An integral part of the registry was a pre-operative prediction of surgical risk in five categories. This risk estimate revealed a surprisingly correct prediction of the mortality observed. CONCLUSIONS: In a representative unselected group of cardiac surgery patients, operative mortality was 4.57%. Several procedural and clinical parameters were significantly correlated with mortality, but the risk increment by each of these factors was small. Unstructured clinical judgement reliably predicted the operative risk.

[Thrombolysis therapy and coronary angiography in acute myocardial infarct in the Augsburg region: results of the Augsburger Heart infarct register 1985-1987]. / Thrombolysetherapie und Koronarangiographie bei akutem Myokardinfarkt in der Region Augsburg: Ergebnisse des Augsburger Herzinfarktregisters 1985-1987.

In the years 1985-87, the Augsburg Coronary Event Register registered 1333 hospitalized patients who had survived an acute myocardial infarction (AMI) for at least 24 h. In 953 patients, data on time intervals in the prehospital phase were documented in addition to the medical records data in a standardized nurse interview. The time from onset of AMI until the patient called for medical attention constituted most of the prehospital time delay. Of the interviewed male and female patients, 67% were hospitalized within 6 h (= time limit). The differences, both in the number of thrombolyses and the number of coronary angiographies performed in men and in women are statistically significant. Thrombolysis was performed in 27% of the male and 12% of the female AMI patients who were admitted to hospital within the time limit. The rate of thrombolytic therapy decreased with increasing age and was less in patients with recurrent AMI (men: 20%, women: 0%) than in patients with first AMI (men: 29%, women: 15%). There was some time-of-day variation in the percentage of thrombolytic therapy which may be attributable to hospital organization. From 1985 to 1987, the coronary angiography rates performed in the medical center doubled, independent of the thrombolytic therapy rates. In this time, angiography rates in thrombolyzed patients increased from 49% to 75%, and from 14% to 31% in patients without thrombolysis. The 28-day case fatality was 4.8% in patients with thrombolysis and 13% in patients without thrombolytic therapy. Controlling for age, sex, and recurrent AMI, this difference is not statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical aortic valve replacement for acute Streptococcus viridans endocarditis with simultaneous moderate hemophilia A]. / Operativer Aortenklappenersatz wegen akuter Streptococcus-viridans-Endokarditis bei gleichzeitig bestehender mittelschwerer Hämophilie A.

This is a report of a 25-year-old patient with known aortic valve stenosis since early youth and hemophilia A, showing recurrent joint bleeding. Acute Streptococcus endocarditis induced aortic valve insufficiency resulting in cardiac failure. Aortic valve replacement was performed after substitution of factor VIII, during which intra- and postoperative bleeding was prolonged by pericardial adhesions. Heparin was administered during cardiopulmonary-bypass as usual, but usual postoperative cumarin therapy was not initiated due to prolonged PTT time. One year postoperatively, the patient was in an excellent condition and fully rehabilitated.

Prognostic implications of transient--predominantly silent--ischaemia in patients with unstable angina pectoris.

The occurrence of unstable angina pectoris, despite medical treatment, is generally regarded as an ominous prognostic sign and an indication for invasive diagnosis and revascularization. We investigated 38 consecutive patients with severe unstable angina with a mean of 2.5 days of continuous two-channel, frequency modulated Holter monitoring for ST segment analysis. In 16 patients, transient ischaemic episodes (more than 0.1 mV lasting more than 1 min) occurred despite maximal medical treatment: 82% of the episodes were silent. Compared to the 22 patients without ischaemic episodes there were no significant differences in prevalence of risk factors, numbers of vessels diseased (69% vs. 74% triple-vessel disease) or ejection fraction (54 +/- 15% vs. 53 +/- 16%). The 30-day prognosis, however, varied: of 16 patients with ischaemic episodes, 14 (88%) had a subsequent cardiac event (death, AMI, PTCA or CABG) compared to only 10 of 22 patients (45%) without ischaemic episodes (P less than 0.02 for all events, P less than 0.1 for death/AMI only). Transient ischaemic episodes, predominantly silent, are frequent in patients with severe unstable angina. Objective evidence of ongoing ischaemia despite medical treatment has a guarded short-term prognosis. 'Stabilization' of unstable angina may be incomplete as long as transient ischaemia at rest can still be detected.

[Primary dissection of the left coronary artery with rupture of the ventricle in a 27-year-old patient]. / Primäre Dissektion der linken Koronararterie mit Ventrikelruptur bei einer 27jährigen Patientin.

This report of a 27-year-old patient describes an extensive infarction of the anterior wall due to primary dissection of the left coronary artery in the absence of the circumflex artery followed by rupture of the left ventricle. In earlier reports an aortocoronary bypass operation was usually performed in similar situations. Although the final outcome was lethal, this case report shows recanalization by methods of "interventional cardiology" to be a potentially successful alternative which may be of value when bypass operation is not available or contraindicated, as in developing cardiogenic shock. This case report demonstrates an initially successful treatment, which after a stable interval was followed by a lethal complication, namely, rupture of the ventricle due to hemorrhagic infarction.

[Intracoronary nifedipine--separation of drug specific and vehicle-induced effects]. / Nifedipin intrakoronar--Trennung wirkstoffspezifischer und lösungsmittelbedingter Effekte.

In 22 patients we studied the effects of 0.2 mg nifedipine given intracoronary during the course of routine PTCA. In 9 patients the effect of the nifedipine-free solvent was additionally tested. Injections were made through the guiding catheters or balloon catheters as pre- and poststenotic injections. We monitored frequency and character of pain, ECG changes (continuous recording of full 12-lead ECG) and pressure recordings from the left ventricle and pre- and poststenotic coronary artery. Short-lasting "stinging" pain sensations were described by 41% of the patients after nifedipine and 33% after solvent injection (n.s.). Patients described the pain as different from their usual angina pectoris. Pain was more frequent after poststenotic injections (through the balloon catheter) than after pre-stenotic injections (59% vs. 19%, p less than 0.01). ECG changes were peaking T waves, ST elevation and ST depression. They were recorded after pre-stenotic injections in 21 of 22 cases for nifedipine and 6 of 9 for solvent and after poststenotic injections in 22 of 22 cases for nifedipine and 8 of 9 cases for solvent. After nifedipine 0.2 mg i.c. the pressures decreased by 3.5% pre-stenotic and 9.7% post-stenotic. LVEDP increased by 10.7%. Our results show that pain sensations and electrocardiographic changes occur with similar character and frequency after i.c. injections of nifedipine or nifedipine-free solvent. Thus these effects do not seem to be caused by nifedipine. Hemodynamic effects were small and there was no disproportionate decrease of poststenotic pressure.

Physical activity decreases the number of beta-adrenergic receptors on human lymphocytes.

On intact human lymphocytes a specific binding site (BS) for 125I-Cyanopindolol (125I-CYP), a derivative of the beta-blocking drug pindolol, was characterized. Inhibition of binding for catecholamines in the following order of potency: l-isoprenaline greater than l-adrenaline greater than l-noradrenaline proves the BS as a beta 2-receptor subtype. In 77 healthy persons (36 females, 41 males) the number of BS amounted to 2,639 +/- 125 BS/cell without any significant correlation to age (17-86 years) or sex. The dissociation constant (KD) indicating the affinity of iodocyanopindolol to the BS on intact lymphocytes was KD = 1.9 +/- 1.1 X 10(-10) M. A change of the number of beta-adrenergic receptors on intact human lymphocytes has been measured previously in asthmatics and in the myocardium of patients with congestive heart failure. We investigated a possible change in the beta-receptors on lymphocytes by physical and mental activity ("stress") in physicians going about their daily routine work. Persons left alone in a hospital room reading or sleeping were defined as "inactive controls". The number of BS on intact lymphocytes was significantly higher in inactive persons at 8 a.m. (2,230 +/- 482 BS) compared to active persons (1,743 +/- 285 BS; P less than 0.05) and at 1 p.m. (2,394 +/- 253 BS vs 1,733 +/- 556; P less than 0.05) but not different at 6 p.m. (1,634 +/- 578 BS vs 1,768 +/- 588 BS; P less than 0.1). The KD remained unchanged under all conditions. The serum noradrenaline and adrenaline levels were also measured during the day.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac glycoside receptors in cultured heart cells--II. Characterization of a high affinity and a low affinity binding site in heart muscle cells from neonatal rats.

The binding of [3H]ouabain has been studied in (Na+ + K+)-ATPase enriched cardiac cell membranes, as well as in cardiac muscle and non-muscle cells in culture--all obtained from hearts of neonatal rats. The binding has been correlated with ouabain-induced inhibition of (Na+ + K+)-ATPase (cardiac cell membranes) and the inhibition of active (86Rb+ + K+)-influx (cardiac muscle and non-muscle cells in culture). Furthermore, the effect of ouabain on the amplitude of cell-wall motion and contraction velocity has been studied in electrically driven cardiac muscle cells. In muscle and non-muscle cells, two classes of ouabain binding sites have been identified. In rat heart muscle cells, the high affinity binding site has a dissociation constant (KD) of 3.2 X 10(-8) M and a binding capacity (B) of 0.2 pmole/mg protein (80,000 sites/cell); the values for the low affinity binding site are: KD = 7.1 X 10(-6) M; B = 2.6 pmole/mg protein (10(6) sites/cell). The binding to both types of binding sites is depressed by K+ and abolished after heat denaturation of the cells. The kinetics of [3H]ouabain binding to rat heart muscle cells (association and dissociation rate constants, K+- and temperature-dependence of association and dissociation processes) have been characterized. In rat heart muscle and non-muscle cells, the binding of [3H]ouabain to the low affinity site results in inhibition of the (86Rb+ + K+)-influx (EC50 = 1.3 and 1.5 X 10(-5) M ouabain), a decrease in cell-K+ (EC50 = 1.9 and 1.4 X 10(-5) M) and an increase in cell-Na+ (10(-5)-10(-4) M). The ouabain-induced positive inotropic effect (increase in amplitude of cell-wall motion, increase in contraction velocity) in cardiac muscle cells is observed only at ouabain concentrations greater than or equal to 5 X 10(-6) M, and it is therefore probably attributed to occupation of the low affinity binding site. Coupling of occupation of the low affinity site by ouabain with drug-induced inhibition of the sodium pump and with drug-induced positive inotropic action is further substantiated by kinetic measurements. In contrast, occupation of the high affinity binding site does not produce any measurable inhibition of the sodium pump activity or positive inotropy.(ABSTRACT TRUNCATED AT 400 WORDS)

Influence of digitalis and diuretics on ouabain binding sites on human erythrocytes.

It has been reported that during chronic treatment with digitalis, the number of digitalis binding sites is increased in human erythrocytes [22]. From this finding a tachyphylaxis for cardiac glycosides has been postulated. We reinvestigated this problem in several groups of patients. The number of 3H-ouabain binding sites per erythrocyte in control persons (group I) was 214 +/- 60, n = 43 (means +/- SD). The dissociation constant (KD) was 1.8 +/- 0.5 nM. Thirteen patients (group II) taking cardiac glycosides only, for at least 6 months, had 281 +/- 99 (p less than 0.05) ouabain binding sites per single red cell, KD = 1.8 +/- 0.7 nM. Group III (34 patients) took digitalis for more than 6 months and diuretics for at least 3 months (352 +/- 126 (p less than 0.001), KD = 1.6 +/- 0.6). Twenty-three of these (group IV) were taking a combination with "K+-saving" diuretics (336 +/- 194 (p less than 0.01), KD = 1.6 +/- 0.5) and (group V, 11 patients) a combination with "K+-losing" diuretics (462 +/- 133 (p less than 0.001), KD = 1.4 +/- 0.4). Nine patients (group VI) had a chronic hypokalemia, mainly due to taking furosemide (437 +/- 98 (p less than 0.001), KD = 1.5 +/- 0.4). Four control persons took 50 mg hydrochlorothiazide daily for more than 4 months without measurable K+-losses and without changes in ouabain binding sites. It is concluded from these findings that diuretic treatment with chronic hypokalemia in addition to digitalis is accompanied by a significant increase in ouabain binding sites in human red cells.(ABSTRACT TRUNCATED AT 250 WORDS)