EuroSCORE overestimates the risk of cardiac surgery: results from the national registry of the German Society of Thoracic and Cardiovascular Surgery.

OBJECTIVE: The EuroSCORE risk stratification model has been developed in 1995 and is still widely used to assess individual patient risk prior to cardiac surgery. Furthermore, the score advanced to a decision tool to determine so-called "high-risk patients" and in consequence serves as an important selection criterion in new technologies, such as the catheter-based aortic valve replacement. Several studies with relatively small patient numbers showed a substantial overestimation of risk by the EuroSCORE. The aim of our study was to evaluate whether the nationwide data support this finding. METHODS: A subgroup of the registry of the German Society of Thoracic and Cardiovascular Surgery from 2006 and 2007, with 32,806 patients undergoing isolated coronary surgery and isolated aortic valve replacement was investigated. RESULTS: The overall hospital mortality in isolated coronary surgery in this patient cohort (n = 26,501 patients) was 2.6% (n = 695). The overall hospital mortality in isolated aortic valve replacement in this patient cohort (n = 6,305 patients) was 3.9% (n = 245). The logistic EuroSCORE predicted a proportion of 5.2% for patients with isolated CABG and 7.3% for patients with isolated aortic valve replacement. The area under the receiver operating characteristic curve was 0.77 for isolated CABG procedures and 0.69 for isolated valve procedures, supporting the substantial lack of predictive value of the EuroSCORE. CONCLUSION: The logistic EuroSCORE insufficiently evaluates the risk of the current patient population and therefore should be carefully used as a tool for important therapeutic decision-making.

Cardiac surgery in Germany during 2006: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.

All cardiac surgical procedures performed in 81 German cardiac surgical units throughout the year 2006 are presented in this report, based on a voluntary registry which is organized by the German Society for Thoracic and Cardiovascular Surgery. In 2006 a total of 97,123 cardiac surgical procedures (ICD and pacemakers procedures excluded) have been collected in this registry. More than 9.6 % of the patients were older than 80 years compared to 8.4 % in 2005. Hospital mortality in 51,273 isolated CABG procedures (10.1 % off-pump) was 3.1 %. In 20,028 isolated valve procedures a mortality of 4.9 % has been observed. This registry will continue to be an important tool of the German Society for Thoracic and Cardiovascular Surgery enabling a continuous and voluntary quality assurance and illustrating the development of cardiac surgery in Germany.

Cardiac surgery in Germany during 2005: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.

All cardiac surgical procedures performed in 79 German cardiac surgical units throughout the year 2005 are presented in this report, based on a voluntary registry, which is organized by the German Society for Thoracic and Cardiovascular Surgery. In 2005, a total of 98 860 cardiac surgical procedures (ICD and pacemaker procedures excluded) were collected in this registry. More than 8.4 % of the patients were older than 80 years, compared to 7.8 % in 2004. Hospital mortality in 54 126 isolated CABG procedures (9.7 % off-pump) was 2.9 %, while a mortality of 4.5 % was observed in 19 203 isolated valve procedures. This registry is an important tool of the German Society for Thoracic and Cardiovascular Surgery to ensure a continuous and voluntary quality assurance and illustrate the development of cardiac surgery in Germany.

Cardiac surgery in Germany during 2004: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery.

All cardiac surgical procedures performed in 79 German cardiac surgical units in the year 2004 are presented in this report, which is based on a voluntary registry organized by the German Society for Thoracic and Cardiovascular Surgery. A total of 100 830 cardiac surgical procedures (ICD and pacemaker procedures excluded) were reported to the registry for the year 2004, an increase by 1.1 % compared to the year 2003. More than 7.8 % of the patients were older than 80 years. Hospital mortality in 58 144 isolated CABG procedures (7.1 % off pump) was 2.8 %, and 4.5 % in 18 617 isolated valve procedures. This registry is an important tool of the German Society for Thoracic and Cardiovascular Surgery to allow a continuous and voluntary monitoring of quality and to illustrate the development of cardiac surgery in Germany.

Combined procedures using the extracorporeal circulation and urologic tumor operation--experiences in six cases.

We investigated the question whether combined open heart surgery and urologic tumor operations may be helpful for patients with coincident diseases. From 8/1989 to 8/2000 six patients underwent combined open heart surgery and urologic tumor operation (61-76 years). Two patients suffered from aortic valve stenosis, four patients from ischemic heart disease. Concerning the kidney five patients had an adenocarcinoma, one patient a non-Hodgkin's lymphoma. In two patients we performed an aortic valve replacement and tumor nephrectomy (partial resection of the kidney), respectively. Four patients underwent myocardial revascularization and the corresponding tumor operation. The immediate postoperative course shows satisfactory results. In long-term follow-up one patient reported a low level of loading capacity, however, without typical ischemic symptoms. A clue for a tumor recidivism has not yet been observed. Two patients died 2.5 years after the operation, but the underlying reasons remain speculative because of missing autopsy. Patients suffering from both cardiovascular and kidney disease can be treated in only one setting with low risk. Remembering critically the limited number of cases, we conclude that combined procedures should take preference of operations in two settings, which is in agreement with the current data from the literature.

INR self-management permits lower anticoagulation levels after mechanical heart valve replacement.

BACKGROUND: The Early Self Controlled Anticoagulation Trial (ESCAT I) showed that anticoagulation self-management after mechanical heart valve replacement decreased complication rates by maintaining INR levels closer to the target range than International Normalized Ratio (INR) home doctor management. The therapeutic range for the INR in that study was between 2.5 and 4.5 for all positions of prosthetic valves. ESCAT II should find out whether lowering the target range for INR self-management would further reduce complication rates. METHODS: ESCAT II is a prospective controlled randomized (valves: St. Jude Medical Standard or Medtronic Hall, treatment: conventional/low-dose) multicenter study with 3,300 patients. We present interim results of 1,818 patients. 908 were categorized as having a low-dose target range, which was INR 1.8 to 2.8 for prostheses in aortic position and 2.5 to 3.5 for prostheses in mitral position or in combined valve replacement. The control group (conventional group) with 910 patients aimed at an INR of 2.5 to 4.5 for all valve positions. RESULTS: In the conventional group, 74% of INR values measured were within the therapeutic range. In the low-dose group, 72% of the values were within that range. The linearized thromboembolism rate (% per patient year) was 0.21% for both groups. The bleeding complication rate was 0.56% in the low-dose regimen group versus 0.91% in the conventional group. CONCLUSIONS: Early onset INR self-management under oral anticoagulation after mechanical heart valve replacement enables patients to keep within a lower and smaller INR target range. The reduced anticoagulation level resulted in fewer grade III bleeding complications without increasing thromboembolic event rates.

[Incidence and prevalence of postoperative acute confusion in heart surgery patients after coronary artery bypass and heart valve replacement surgeries]. / Inzidenz und Prävalenz postoperativer akuter Verwirrtheit kardiochirurgischer Patienten nach Bypassoperationen sowie Herzklappenersatz.

Compared to foreign countries, Germany does not have data about the occurrence of acute confusion following heart-surgery. However, the occurrence of acute confusion does extend the hospital length of stay for up to 13 days. Thus, this phenomenon is of high relevance to nursing. This prevalence/incidence study was implemented with the goal of obtaining exact information on the incidence rate of acute postoperative confusion after a heart surgery through a multicenter evaluation. The data evaluation took place in the form of a convenience sample survey in three different German clinics specializing on heart surgeries. The observation period lasted from the day of the surgery up to the fifth postoperative day. In the context of this prospective Cohort-study all patients aged 18 and older who had heart surgery between February 1st and April 30th, 2000, were considered suitable as participants in the study. In the end, 860 patients were included in this study. 152 patients (17.4%) showed symptoms of acute confusion (confidence interval 14-20%). Certain circumstances seemed to predispose patients to acute confusion. A widespread occurrence could be observed particularly at night. Patients aged 81-91 were mainly affected. A confusion rate of 43.5% could be determined for this group. These results confirm the clinical importance and suggest interdisciplinary approaches for solution.

Online detection of myocardial ischemia by near infrared spectroscopy with a fiberoptic catheter.

BACKGROUND: The interruption of myocardial O2-supply in acute myocardial ischemia causes differences in coronary venous O2-content. In this study, the oxygenation status of coronary sinus blood is detected in myocardial ischemia by near infrared (NIR) spectroscopy. METHOD: For the intravascular application, a new fiberoptic catheter is developed. After calibration of the catheter by perfusion of blood with standardized gas mixtures in an in vitro experiment, the in vivo application was performed in 12 domestic pigs. The catheter was placed into coronary sinus and an anterior ischemia was induced by temporary occlusion of LAD. NIR graphs and hemodynamic data were obtained for 90 min ischemia and 90 min reperfusion time. RESULTS: Main NIR-spectroscopic differences between oxygenated and de-oxygenated hemoglobin took place in O2-concentrations less than 30%. Coronary sinus NIR spectra of hemoglobin-oxygen binding showed significant, reproducible differences between pre-ischemia, LAD-occlusion and reperfusion. NIR graphs also show variations related to CO2-concentration, pH and temperature. CONCLUSION: The intravascular application of NIR spectroscopy could be a reliable tool in detection and follow-up of acute myocardial ischemia and infarction.

Ectopic thyroid tissue in the left ventricular outflow tract.

Ectopic thyroid tissue in the heart (struma cordis) is rare. The only report from a hemodynamically significant obstruction of the left ventricular outflow tract (LVOT) by a heterotopic thyroid gland was published in 1988. In our patient, a 42-year-old woman with recurrent chest pain, two spheric cardiac tumors were diagnosed by transthoracal echocardiography. One of the tumors, obstructing the LVOT, could successfully be resected under cardiopulmonary bypass. The pathologic examination showed a colloid-filled ectopic thyroid gland. The second tumor, which was entirely located in the submembraneous part of the interventricular septum, had no hemodynamic influence, and was left in situ to avoid surgical damage of adjacent intraseptal structures. The midterm follow-up showed no recurrence.

Simultaneous carotid endarterectomy and coronary artery bypass grafting in 313 patients.

The coincidence of coronary and carotid artery disease (uni- or bilateral, with or without involvement of the supra-aortic branch) is still a problem with regards to surgical strategy. Since the opening of the Heart Centre Duisburg in 1989 the authors have favoured a simultaneous approach to lesions in both arterial systems in order to avoid myocardial infarction or stroke. The aim of this retrospective study was to review the early and late results of the combined procedures for the endpoints of death, myocardial infarction and stroke. During a 7-year period (1990-1997) a total of 18,050 patients underwent cardiac surgery and extracorporeal circulation. Simultaneous intervention in both arterial systems was performed in 313 patients (1.73%). All patients underwent preoperative ultrasonic diagnostics, digital subtraction angiography, neurological examination and cardiac catheterization. The principal indication was the need for myocardial revascularization, and symptomatic or asymptomatic carotid stenosis of 80% diameter reduction or more (with or without contralateral disease). The mean age was 66.4 +/- 6.9 years; 240 patients (76.7%) were male, 73 patients (23.3%) female; 243 patients (77.6%) had triple-vessel disease, 82 patients (26.2%) had left main stenosis and 94 patients (43.5%) had a reduced ejection fraction. A total of 171 patients (54.6%) had a previous myocardial infarction, 54 patients (17.3%) presented with unstable angina and nine patients (2.9%) had prior coronary artery bypass grafts. Eighty-seven patients (27.8%) had an internal carotid artery stenosis on the right side, 75 patients (24%) on the left side and 151 patients (48.2%) lesions in both carotid arteries. Prior carotid endarterectomy was performed in 14 patients (4.5%), and the contralateral carotid was occluded in 24 patients (7.7%). Fifty patients had a previous stroke (16%) and 185 patients (59.1%) were asymptomatic. During surgery, the the carotid artery was first exposed, followed by median sternotomy, systemic heparinization, cannulation and cardiopulmonary bypass. After achieving mild hypothermia (30 degrees C), endarterectomy was performed with a venous patch closure. An occluded contralateral carotid artery was always an indication for shunting. Coronary artery bypass grafting was carried out with intermittent cross-clamping under moderate hypothermia (22-27 degrees C). Ten patients suffered a myocardial infarction (3.2%), seven patients (2.2%) had an apoplectic insult perioperatively ( < 30 days) and one patient (0.3%) had an event during long-term follow-up. Early overall mortality was 28 (8.9%), of which 13 were cardiac related (4.2%). Overall late mortality was eight (2.6%), of which six were cardiac related (1.9%). Mean survival time was 6.18 years. Simultaneous carotid endarterectomy and myocardial revascularization can be justified as a routine surgical management of severe lesions in both arterial systems. The risk of myocardial infarction, apoplectic stroke or mortality was not significantly different than isolated procedures.

The value of procalcitonin as an infection marker in cardiac surgery.

BACKGROUND/OBJECTIVE: Cardiopulmonary bypass generally leads to an unspecific increase of inflammatory parameters after cardiac operations. Increased Procalcitonin (PCT)-levels in serum, particularly after contamination with bacterial endotoxines, can be used as a marker for specific infections. The objective of this prospective study was to evaluate the course of PCT after cardiac surgery for the differential diagnosis of infections/unspecific inflammatory reactions, compared to routine infection parameters. METHOD: Serum PCT levels were measured in 400 routine cardiosurgical patients preoperatively and at 1., 2., 4. and 6. postoperative days with a luminescence immunoassay. PCT-values were compared to the patient's clinical infection status, body temperature, leukocyte count and C-reactive protein (CRP). RESULTS: 364 patients had an infection-free postoperative course, 27 patients developed infections. All of these patients showed elevated infection parameters at 1-2. postoperative days. In patients without infection, these parameters decreased after 2. postoperative day. Patients predisposed to an infection had continuously high temperature, leukocytes, CRP and PCT until 4.postoperative day with leukocytes and CRP decreasing after 4.postoperative day. PCT however showed a divergent course with a second increase in these patients between 4.-6. postop day (p<0.001). At this time, no clinical sign of an infection was evident. The increase of PCT was independent of infection type, but most apparent in bacteriemia/sepsis. CONCLUSION: Based on its different course from other parameters in infection development between 4.-6. days, PCT can probably be used as a predictive marker in bacterial infections after cardiac surgery. The cost of the used immunoassay however will set the limits for a routine application.

[Coil embolization of an AV-fistula between the left thoracic artery and vein after coronary artery bypass surgery]. / Interventioneller Verschluss einer Fistel zwischen Arteria und Vena thoracica interna nach koronarer Bypassoperation.

We report a case of an artificial fistula between the internal thoracic artery and vein after coronary artery bypass surgery, anastomosing the left internal thoracic artery to the LAD. Because of symptomatic anterior wall ischaemia due to coronary steal a treatment was mandatory. Instead of surgical correction, this shunt was closed by coil embolization of the venous limb.

Cardiovascular operations in patients with dialysis-dependent renal failure.

BACKGROUND: Cardiac operations in patients with end-stage renal disease carry a significantly increased perioperative risk, and long-term functional results and survival are still purely defined. METHODS: Therefore, we performed a retrospective analysis of 45 consecutive patients with dialysis-dependent renal failure who underwent either coronary artery bypass grafting (n = 30), valve replacement or combined procedures (n = 13), or pericardiotomy (n = 2). Mean age of the patients was 59+/-10 years. RESULTS: There were two perioperative deaths (30-day mortality, 4.4%). Actuarial survival rates at 1, 2, 3, and 5 years were 0.90, 0.73, 0.67, and 0.67, respectively, after bypass operation and 0.77, 0.77, 0.77, and 0.39, respectively, after valvular or combined operation. Late deaths (n = 13) occurred 2 to 60 months after operation and were attributable to cardiac events in 7 patients. Of the long-term survivors after either bypass grafting (n = 20) or a valvular or combined procedure (n = 8), 15 and 7 patients had improved anginal status and New York Heart Association functional status, respectively, after 36+/-4 months (range, 21 to 66 months). Five patients underwent renal transplantation 32+/-9 months after cardiac operation. CONCLUSIONS: Cardiac operations in patients with endstage renal disease may be performed with a fairly low perioperative risk and the perspective of long-term functional improvement and acceptable long-term survival.

Tracheobronchial rupture after emergency intubation.

Iatrogenic injuries of the trachea are rare. We report a case of tracheobronchial rupture in a 77-year-old woman after emergency intubation. Early bronchoscopy showed a rupture of the posterior wall of the trachea into the right main bronchus with a total length of 9.5 cm. A right thoracotomy was performed and the tracheal rupture was managed successfully by primary suture. Surgical treatment and possible causes of this lesion are discussed with reference to the literature.

Evaluation of a porcine internal mammary artery (No-React II) as a small-diameter conduit.

BACKGROUND: The patency of biologic small-diameter vascular grafts in the aortocoronary position is still unsatisfactory. Most of the studies suggest that xenografts are to be avoided as an aortocoronary bypass. METHODS: The porcine internal mammary artery treated by the No-React II procedure was developed for use as an alternative coronary artery bypass conduit. The attempt of this study was to evaluate the patency and histologic changes of the porcine internal mammary artery in animals. Five calves underwent coronary artery bypass grafting with a porcine internal mammary artery graft to the right coronary artery. After euthanasia of the animals 103 days later, the samples of these grafts were studied morphologically for patency, structural changes, calcifications, and inflammatory and immunologic response. RESULTS: One animal died during the procedure as result of acute thrombosis of the porcine internal mammary artery graft. In the other 4 animals all grafts became occluded. In the histologic sections of the grafts we noted multiple calcifications and a host-graft immunologic reaction (severe chronic rejection). CONCLUSIONS: The present study demonstrates a very poor experience with the porcine internal mammary artery (No-React II) conduit. We do not recommend this prosthesis for clinical use in humans.

-Surgical occlusion of persistent ductus arteriosus in advanced age--determining indications based on 3 case reports-. / Operativer Verschluss des persistierenden Ductus arteriosus im höheren Lebensalter--Indikationsstellung anhand von 3 Fallbeispielen.

We present three cases of a surgical approach to close a patent ductus arteriosus in the elderly. In each case a transcatheter closure was not indicated for different reasons: Patient No. 1 had an extremely calcified aortic arch; Patient No. 2 was operated on under the erroneous diagnosis of an aortopulmonary window; Patient No. 3 concomitantly suffered a high-grade valvular aortic stenosis. The patent ductus arteriosus was closed transpulmonally via a median sternotomy under the conditions of extracorporal circulation in each of the three patients. Patient No. 3 additionally underwent an aortic valve replacement. We discuss the differential indications for a surgical closure of a patent ductus arteriosus in the elderly.

Internal mammary artery bypass grafting in left main stenosis.

Internal mammary artery grafting to the left anterior descending artery gives higher long-term patency and improved survival as compared with venous grafts. Few data exist on the operative mortality and infarction rate in coronary artery bypass surgery when using this type of graft in high-risk groups, such as patients with left main stenosis. In 19 months, we studied 81 consecutive patients with left main stenosis who received a mammary artery graft to the left anterior descending artery as well as vein grafts to other vessels and found no excessive mortality or infarction rate. We suggest that patients with left main stenosis should be treated with an internal mammary artery graft.

[Malignant hemangioendotheliosarcoma in the area of the right coronary artery: imaging by selective coronary angiography]. / Malignes Hämangioendotheliosarkom im Bereich der rechten Koronararterie: Darstellung durch selektive Koronarangiographie.

We report on a case of a malignant hemangioendotheliosarcoma in the right coronary artery. The first manifestation was a pericardial tamponade from a hemorrhagic pericardial effusion. The diagnosis was established only by selective coronary angiography of the right coronary artery, other imaging procedures did not lead to the diagnosis. During follow-up, multiple angiosarcoma developed in the liver, the spleen and, finally, in the lungs. Despite multichemotherapy, the patient died 7 months after the first manifestation.